Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates.

BACKGROUND: Grade III open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. This paper reviews the outcomes in patients treated in an orthoplastic unit where the emphasis was on undertaking the definitive orthopaedic and plastic surgical procedures in a single stage, following initial debridement and temporary stabilisation as necessary. METHODS: We reviewed medical notes of 73 consecutive patients with 74 Grade III open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had (a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and (b) those who had definitive treatment completed in <72h vs. >72h. RESULTS: (a) Combined Single-stage Orthoplastic Fixation and Coverage: 48 fractures were managed with definitive orthopaedic fixation and plastic surgical coverage performed at the same time, whilst 26 had these performed at separate stages. Of those subjects that had definitive fixation and coverage in one procedure 2 (4.2%) developed deep infections, compared with 9 (34.6%) deep infections (p<0.001) in those who underwent definitive fixation and coverage at separate operations. (b) Timing of surgery: Of the fractures that had definitive fixation and coverage completed within 72h of injury, 5 (20%) developed deep infections, compared with 6 (12.2%) deep infections (p=0.492) in those whose definitive fixation/coverage was completed at later than 72h. CONCLUSION: Joint orthoplastic operating lists facilitate simultaneous definitive fixation and cover that greatly reduces infection rates. Based on our experience presented in this paper, we believe that emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic procedure to achieve definitive fixation and soft tissue coverage and optimal outcomes.

Use of tranexamic acid to reduce bleeding in burns surgery.

We describe, for the first time, the use of topical tranexamic acid as an adjunct to traditional methods in the control of bleeding in burns surgery. We illustrate our use with a case example and continue to discuss the reasons we believe it is a useful, effective and safe means of achieving haemostasis.

Parallel diversification of Australian gall-thrips on Acacia.

The diversification of gall-inducing Australian Kladothrips (Insecta: Thysanoptera) on Acacia has produced a pair of sister-clades, each of which includes a suite of lineages that utilize virtually the same set of 15 closely related host plant species. This pattern of parallel insect-host plant radiation may be driven by cospeciation, host-shifting to the same set of host plants, or some combination of these processes. We used molecular-phylogenetic data on the two gall-thrips clades to analyze the degree of concordance between their phylogenies, which is indicative of parallel divergence. Analyses of phylogenetic concordance indicate statistically-significant similarity between the two clades. Their topologies also fit with a hypothesis of some degree of host-plant tracking. Based on phylogenetic and taxonomic information regarding the phylogeny of the Acacia host plants in each clade, one or more species has apparently shifted to more-divergent Acacia host-plant species, and in each case these shifts have resulted in notable divergence in aspects of the phenotype including morphology, life history and behaviour. Our analyses indicate that gall-thrips on Australian Acacia have undergone parallel diversification as a result of some combination of cospeciation, highly restricted host-plant shifting, or both processes, but that the evolution of novel phenotypic diversity in this group is a function of relatively few shifts to divergent host plants. This combination of ecologically restricted and divergent radiation may represent a microcosm for the macroevolution of host plant relationships and phenotypic diversity among other phytophagous insects.

Inbreeding ancestors: the role of sibmating in the social evolution of gall thrips.

We used microsatellite data to estimate levels of inbreeding in four species of solitary gall thrips that are in the same clade as the six species with soldier castes. Three of the four species were highly inbred (Fis 0.54-0.68), and the other apparently mated randomly (Fis near zero). These estimates, combined with previous data from species with soldiers, suggest that inbreeding is a pervasive life-history feature of the gall-inducing thrips on Australian Acacia. Mapping of inbreeding estimates onto the phylogeny of the gall inducers showed that the ancestral lineage that gave rise to soldiers was apparently highly inbred, and therefore, inbreeding could have played a role in the origin of sociality within this group. Moreover, there was a trend from high levels of inbreeding at the origin of soldiers to low levels in the most derived species with soldiers, which exhibits the highest levels of reproductive division of labor and soldier altruism. These patterns are consistent with considerations from population genetics, which show that the likelihood of the origin of soldier altruism is higher in inbreeding populations but that, once soldiers have evolved, a reduction in inbreeding levels may facilitate the evolution of enhanced division of labor and reproductive skew.

A simple technique for defatting morsellised bone graft in revision hip arthroplasty.

A method for producing fat-free, non-saline laden morsellised bone graft for use in revision hip arthroplasty is described. The method is easily performed, requires inexpensive and readily available equipment and, we believe, reduces loss of bone graft compared with alternative techniques. (Hip International 2002; 4: 403-4).

Dual aetiology hip pain requiring total hip arthroplasty in hereditary multiple exostoses: A case report and review of the literature.

We report a case of hereditary multiple exostoses (HME) presenting with avascular necrosis of the femoral head and mechanical impingement of an exostosis treated by total hip replacement. (Hip International 2002; 4: 397-9).

Reproductive division of labour coevolves with gall size in Australian thrips with soldiers.

An analysis of multiple species of Australian gall-inducing thrips with soldiers reveals a significant negative correlation between the size of gall produced and the reproductive division of labour. This correlation suggests that the evolution of smaller galls limited the available space and feeding sites for the offspring of female soldiers, and was a major factor that led to the evolution of an altruistic caste in the gall-inducers. We argue that high levels of inbreeding by singly mated foundresses and incestuous mating by her soldier offspring are key to this evolutionary relationship because they make the relatedness of a female soldier to her daughters and sisters approximately equal. Evidence that relatedness plays an important role is strengthened by the observation of outbred multiply mated foundresses and unbiased sex ratio of dispersers in Oncothrips waterhousei, and the inference that both gall volume and skew decreased along this lineage.

High relatedness and inbreeding at the origin of eusociality in gall-inducing thrips.

Within the haplodiploid eusocial gall-inducing thrips, a species-level phylogeny combined with genetic data for five eusocial species enables an inference of levels of relatedness and inbreeding values for lineages at the origin of eusociality. Character optimization using data from five eusocial species indicates that the lineage or lineages where eusociality is inferred to have originated exhibit relatedness of 0.64-0.92, and F(IS) of 0.33-0.64. The high inbreeding coefficients found in these eusocial thrips have increased relatedness among and within both sexes and have reduced the haplodiploidy-induced relatedness asymmetries [Hamilton, W. D. (1964) J. Theor. Biol. 7, 1-52]. These results indicate that unusually high relatedness is associated with the origin of eusociality, and they suggest a role for inbreeding in the evolution of bisexual helping.

Do the right thing. When it comes to your community, do you know what that is? Roundtable discussion.

What is the health care organization's responsibility to maintaining a healthy community, and how does the board fit into that role? Has the field's understandable fixation on costs and the penetration of managed care into most markets affected that role? Leaders of both for-profit and not-for-profit organizations often believe that they are fulfilling their community obligations as long as they provide uncompensated care to the indigent and the uninsured. But is that really being accountable to the community? And if it's not, then what is community accountability? The American Hospital Association's Division of Trustee Leadership and Trustee magazine posed these questions to 13 health care and community leaders last December. Their different perspectives provide for some surprising answers.

Ecology and evolution of galling thrips and their allies.

About 300 species of thrips belonging to 57 genera are known to form galls. Galls are caused by feeding, usually by one or more adults, on actively growing plant tissue. Most thrips genera with galling capabilities exploit multiple plant families, but there are several possible cases of thrips tracking the speciations of their host-plants. Gall morphology in thrips reflects insect phylogenetic relationships rather than those of plants. Galling species and their nongalling allies on Acacia in Australia exhibit a range of complex social behavior, including soldier castes, pleometrosis (i.e. joint colony founding), group foraging, and group defense, that is directly related to the nature of their domiciles. Galling thrips, by virtue of their haplodiploid genetic system and their ecological relationships with plants and natural enemies, are useful for analyzing a wide range of ecological, evolutionary, and behavioral questions.

CEO summit, Part 4. Brain teasers.

Physician issues are at the heart of today's debate on how to reconfigure the delivery and financing system. Leaders agree that you can't live without doctors, but it can be difficult to live with them. In this fourth and final CEO Summit series planned by McMannis Associates and cosponsored by Hospitals & Health Networks, CEO leaders dissect some of the trickier physician issues.

CEO summit, Part 3. Loading the ark.

There's a flood of change coming, and health care executives are quickly building and loading big boats to sail to the future. But what do you take--and what do you leave behind? What will be needed in the new world--and what won't? In the third of an exclusive four-part series planned by McManis Associates and co-sponsored by Hospitals & Health Networks, some top CEOs talk about their travel plans.

CEO summit. A new breed.

A new breed is evolving in health care. A provider sponsored network i s part insurance function and part provider function. But no one knows exactly how it will behave. In the second entry of the exclusive four-part CEO Summit series planned by McManis Associates and cosponsored by H&HN, some top leaders in health care discuss some of the conflict in this changing delivery system.