Showing papers by "North Bristol NHS Trust published in 2009"

Pgp3 Antibody Enzyme-Linked Immunosorbent Assay, a Sensitive and Specific Assay for Seroepidemiological Analysis of Chlamydia trachomatis Infection

Abstract: Understanding of the burden of Chlamydia trachomatis infection and its clinical sequelae is hampered by the absence of accurate, well-characterized tests using serological methods to determine past exposure to infection. An "in-house" immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) based on the C. trachomatis-specific antigen Pgp3 was produced and evaluated against three commercial ELISAs derived from the major outer membrane protein: the Medac pELISA plus, the Savyon SeroCT-IgG ELISA, and the Ani Labsystems IgG enzyme immunoassay. Sensitivities and specificities were determined using sera from both male and female patients (n = 356) for whom C. trachomatis had been detected in the lower genital tract at least 1 month prior to the testing of the sample and from 722 Chlamydia-negative children aged 2 to 13 years. The Pgp3 ELISA was significantly more sensitive (57.9% [95% confidence interval {95% CI}, 52.7 to 62.9%]) than the Ani Labsystems (49.2% [95% CI, 44.0 to 54.3%]; P = 0.003), SeroCT (47.2% [95% CI, 42.1 to 52.4%]; P < 0.0005), and Medac (44.4% [95% CI, 39.3 to 49.6%]; P < 0.0005) ELISAs. The Pgp3, Ani Labsystems, and SeroCT assays, but not the Medac assay, had significantly higher sensitivity for female specimens than for male specimens (73.8 versus 44.2%, 59.8 versus 40.5%, 55.5 versus 40%, and 45.7 versus 43.7%, respectively). For female patients, the Pgp3 assay was 14.0% (95% CI, 5.5 to 22.5%) more sensitive than the next most sensitive ELISA, the Ani Labsystems assay (P = 0.001). There was no significant difference in specificity between the Pgp3 (97.6% [95% CI, 96.2 to 98.6%]), Ani Labsystems (99% [95% CI, 97.7 to 99.6%]), SeroCT (97.2% [95% CI, 95.7 to 98.2%]), and Medac (96% [95% CI, 94.3 to 97.2%]) ELISAs. None of the ELISAs showed evidence of cross-reactivity with antibodies to Chlamydia pneumoniae.

Impaction bone grafting of the acetabulum at hip revision using a mix of bone chips and a biphasic porous ceramic bone graft substitute

Abstract: Background and purpose One of the greatest problems of revision hip arthroplasty is dealing with lost bone stock. Good results have been obtained with impaction grafting of allograft bone. However, there have been problems of infection, reproducibility, antigenicity, stability, availability of bone, and cost. Thus, alternatives to allograft have been sought. BoneSave is a biphasic porous ceramic specifically designed for use in impaction grafting. BoneSave is 80% tricalcium phosphate and 20% hydroxyapatite. Previous in vitro and in vivo studies have yielded good results using mixtures of allograft and BoneSave, when compared with allograft alone. This study is the first reported human clinical trial of BoneSave in impaction grafting.Methods We performed a single-institution, multi-surgeon, prospective cohort study. 43 consecutive patients underwent revision hip arthroplasty using BoneSave and allograft to restore missing bone in the acetabulum. 9 patients had cemented acetabular components implanted and 3...

Shared decision making and its role in end of life care

Abstract: Currently, 'shared decision making', which involves the multi-disciplinary team, i.e. the patient, nurse and doctor making joint decisions is advocated in many governing policies to improve the care of the dying patient. The UK population is ageing at an ever-increasing rate, which means that more people are experiencing a progressive death typical of that associated with chronic disease. These patients are suitable for participation in end of life decision making due to the pre-existing knowledge of impending death. Health-care professionals can assist the patient to achieve a 'good death' based on the patient's preferences, wishes and needs. The aim of the literature review discussed in this article was to identify the extent to which shared decision making currently exists during end of life care in the acute/hospice setting. Particular attention is paid to patient participation, the nurse's role, and the doctor/nurse relationship - factors that may facilitate or prevent shared decision making. Eighteen qualitative research papers published between 1997-2007 were reviewed and analysed, and demonstrated a strong link between shared decision making and a 'good death'. However, the research reviewed identified that although shared decision making can exist within end of life care, there are a number of reasons why this is not being achieved throughout the secondary care setting.

Acceptance and Commitment Therapy (ACT) with a learning disabled young person experiencing anxious and obsessive thoughts.

Abstract: This case study describes how the ACT model was adapted to treat anxious and obsessive thoughts in a young person with moderate/severe learning disabilities. Using mindfulness and ACT-based experiential activities, the client learned to notice her thoughts and distance herself from their literal content. The negative impact that the client's anxious thoughts had on her life was reduced and she was able to return to a part-time college course. The article describes how the client engaged with some ACT-based activities, such as mindfulness and defusion exercises. The outcome suggests that the experiential, activity-based nature of ACT may offer a more accessible intervention model for learning disabled people than traditional CBT models based on verbal reasoning skills. However, the intervention also required considerable individual adaptation and it is likely that this will be the case in work with people with learning disabilities.

Recognition and referral of girls with Attention Deficit Hyperactivity Disorder: case vignette study.

Abstract: Background Compared with boys, girls with Attention Deficit Hyperactivity Disorder (ADHD) are under-recognized. Parents commonly discuss concerns with teachers, who play an important role in the recognition and referral of children with ADHD. We investigated whether the predominating subtype of symptomatology influences teacher recognition of affected girls. Methods A total of 212 teachers from 40 randomly selected primary schools in England participated in a postal questionnaire study. The questionnaire consisted of a case vignette (based on DSM-IV criteria) describing a girl with either combined or predominantly inattentive subtype ADHD. Each school received an equal number of each type of vignette for distribution. Further questions elicited teachers' conceptualization of the girl's difficulties and need for specialist referral, their views on treatment modalities and demographic data. Results Most (98%) teachers recognized the presence of a problem but mainly conceptualized the girl's behaviour as reflecting attentional (89%) or emotional (62%) difficulties. Teachers were less likely to correctly identify a girl with inattentive than combined subtype ADHD (14% vs. 43%) or recommend clinical referral (50% vs. 59%) for her. Few (15%) teachers thought that medication might be helpful for a girl meeting diagnostic criteria for ADHD. Conclusions Teachers are able to recognize ADHD-related behaviours and impairments but conceptualize these as reflecting attentional or emotional difficulties rather than as relating to a disorder (ADHD). Teachers' conceptualization of ADHD and views about medication are important factors that could affect accurate recognition and referral. Improving teachers' knowledge about ADHD, especially the inattentive subtype, could assist in tackling gender-related barriers to care.

Vascular Endothelial Growth Factor (VEGF) isoform expression and activity in human and murine lung injury.

Abstract: Background The properties of vascular endothelial growth factor (VEGF) as a potent vascular permogen and mitogen have led to investigation of its potential role in lung injury. Alternate spliced VEGF transcript generates several isoforms with potentially differing functions. The purpose of this study was to determine VEGF isoform expression and source in normal and ARDS subjects and investigate the expression and regulation of VEGF isoforms by human alveolar type 2 (ATII) cells.

Heterogeneous breakpoints in patients with acute lymphoblastic leukemia and the dic(9;20)(p11~13;q11) show recurrent involvement of genes at 20q11.21

Abstract: The dic(9;20)(p11~13;q11) is a recurrent chromosomal abnormality in patients with acute lymphoblastic leukemia. Although it results in loss of material from 9p and 20q, the molecular targets on both chromosomes have not been fully elucidated. From an initial cohort of 58 with acute lymphoblastic leukemia patients with this translocation, breakpoint mapping with fluorescence in situ hybridization on 26 of them revealed breakpoint heterogeneity of both chromosomes. PAX5 has been proposed to be the target gene on 9p, while for 20q, FISH analysis implicated the involvement of the ASXL1 gene, either by a breakpoint within (n=4) or centromeric (deletion, n=12) of the gene. Molecular copy-number counting, long-distance inverse PCR and direct sequence analysis identified six dic(9;20) breakpoint sequences. In addition to the three previously reported: PAX5-ASXL1, PAX5-C20ORF112 and PAX5-KIF3B; we identified three new ones in this study: sequences 3’ of PAX5 disrupting ASXL1, and ZCCHC7 disrupted by sequences 3’ of FRG1B and LOC1499503. This study provides insight into the breakpoint complexity underlying dicentric chromosomal formation in acute lymphoblastic leukemia and highlights putative target gene loci.

The fate of anastomotic sinuses after total mesorectal excision for rectal cancer.

Abstract: Objective Chronic anastomotic sinus is a recognizedcomplication of total mesorectal excision (TME) surgery.We observed two patients who developed new tumourswithin chronic anastomotic sinuses 6 and 19 years afterinitialsurgery.Theaimofthisstudywasthereforetoreportthe incidence and outcome of anastomotic sinuses, thusidentifying those at potential risk of malignant change.Method We retrospectively reviewed patient records andradiology reports to identify potentially curative rectalcancer cases between 1998 and 2005.Results In a consecutive series of 100 TMEs withileostomy, there were 70 males and 30 females, aged 66(33–88) years. Anastomosis was by double staple tech-nique. A policy of instant enema was used prior toileostomy closure. Eighty-six patients had instant enemas.Of the 14 that did not, four died prior to enema, onereturned to theatre for sepsis, three had their anastomosesassessed by sigmoidoscopy alone. Six had incompleterecords. Of the 86 patients, eight presacral sinuses wereidentified. Three sinuses closed spontaneously. Fivepersisted of whom two required further surgery.Conclusion Persistent anastomotic sinuses occurred in5% after curative TME. Malignant transformation canoccur. Active treatment for chronic sinuses should,therefore, be considered.Keywords Rectal, cancer, surgery, anastomotic, sinus

Mid-term outcome of GSB-III total elbow arthroplasty in patients with rheumatoid arthritis and patients with post-traumatic arthritis.

Abstract: Introduction We reviewed the mid-term outcome of GSB-III semi-constrained total elbow arthroplasty (TEA) and compared the results of patients with rheumatoid arthritis (RA) and those suffering from post-traumatic arthritis (PTA).

An initial evaluation of post-cardiopulmonary bypass acute kidney injury in swine.

Abstract: Objective: Acute kidney injury (AKI) post-cardiac surgery is associated with mortality rates approaching 20%. The development of effective treatments is hindered by the poor homology between rodent models, the mainstay of research into AKI, and that which occurs in humans. This pilot study aims to characterise post-cardiopulmonary bypass (CPB) AKI in an animal model with potentially greater homology to cardiac surgery patients. Methods and results: Adult pigs, weighing 50—75 kg, underwent 2.5 h of CPB. Pigs undergoing saphenous vein grafting procedures servedas controls.Pre-CPBmeasuresof porcinerenalfunctionwere withinnormalranges foradulthumans.TheeffectofCPB onrenalfunction;a 25%reductionin 51 Cr-EDTAclearance(p = 0.068),anda33%reductionincreatinineclearance(p = 0.043),wassimilartothosereportedinclinical studies. CPB resulted in tubular epithelial injury (median NAG/creatinine ratio 2.6 u mmol � 1 (interquartile range (IQR): 0.81—5.43) post-CPB vs 0.48 u mmol � 1 (IQR: 0.37—0.97) pre-CPB, p = 0.043) as well as glomerular and/or proximal tubular injury (median albumin/creatinine ratio 6.8 mg mmol � 1 (IQR: 5.45—13.06) post-CPB vs 1.10 mg mmol � 1 (IQR: 0.05—2.00) pre-CPB, p = 0.080). Tubular injury scores were significantly higher in kidneys post-CPB (median score 2.0 (IQR: 1.0—2.0) relative to vein graft controls (median score 1.0 (IQR 1.0—1.0), p = 0.019). AKI was associated with endothelial injury and activation, as demonstrated by reduced DBA (dolichos biflorus agglutinin) lectin and increased endothelin1 and vascular cell adhesion molecule (VCAM) staining. Conclusions: The porcine model of post-CPB AKI shows significant homology to AKI in cardiac surgical patients. It links functional, urinary and histological measures of kidney injury and may offer novel insights into the mechanisms underlying post-CPB AKI. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Analgesia in conjunction with normalisation of thermal sensation following deep brain stimulation for central post-stroke pain.

Abstract: The aetiology of central post-stroke pain (CPSP) is poorly understood and such pains are often refractory to treatment. We report the case of a 56-year-old man, who, following a temporo-parietal infarct, suffered from debilitating and refractory hemi-body cold dysaesthesia and severe tactile allodynia. This was associated with thermal and tactile hypoaesthesia and hypoalgesia on his affected side. Implantation of a deep brain stimulating electrode in his periventricular gray (PVG) region produced an improvement in his pain that was associated with a striking normalisation of his deficits in somatosensory perception. This improvement in pain and thermal sensibility was reversed as stimulation became less effective, because of increased electrode impedance. Therefore, we postulate that the analgesic benefit may have occurred as a consequence of the normalisation of somatosensory function and we discuss these findings in relation to the theories of central pain generation and the potential to engage useful plasticity in central circuits.

Concentration and bioavailability of ciprofloxacin and teicoplanin in the cornea.

Abstract: Purpose To investigate the concentration and bioavailability of ciprofloxacin and teicoplanin in the cornea. Methods A biological assay was developed with corneal tissue used as a carrier for the antimicrobial. Concentration and biological activity were determined with a chemical assay and zone of inhibition (ZOI) around corneal samples with epithelial and endothelial surfaces in contact with the indicator organism. Patients undergoing penetrating keratoplasty received ciprofloxacin 0.3% or teicoplanin 1%. Results There were good correlations between antimicrobial concentration and ZOI, when either filter paper or corneal discs were used (R(2) > 92%). Of 33 patients, the mean (median) concentration of ciprofloxacin in the cornea was 1.37 mg/L (0.46 mg/L) and 1.89 mg/L (1.44 mg/L; bioassay) in the epithelial and endothelial orientations, respectively, and 14.87 mg/L (7.41) in the cornea and 0.51 mg/L (0.42) in the aqueous (chemical assay). For teicoplanin, the mean (median) concentration in the cornea was 9.58 mg/L (0 mg/L) in the epithelial and 4.78 mg/L (0 mg/L) in the endothelial orientations (bioassay). In the chemical assay, teicoplanin could not be detected in the cornea or aqueous at the lower limit of detection of 3.6 mg/L. Conclusions The ZOI produced by corneal tissue provides a potential bioassay of antimicrobial activity and concentration. Although in contrast to teicoplanin ciprofloxacin shows good corneal penetration, with high endothelial-to-epithelial levels, only approximately 10% of measured levels in a chemical assay are available, according to a bioassay. Teicoplanin shows relatively poor corneal penetration through intact epithelium. These methods may be useful in evaluating the biological activity across the cornea of antimicrobials introduced into ophthalmic practice to deal with changing bacterial resistance.

Cervical range of movement in relation to neck dimension

Abstract: The authors investigated the effect of neck dimension upon cervical range of motion. Data relating to 100 healthy subjects, aged between 20 and 40 years, were recorded with respect to age, gender and range of motion in three planes. Additionally, two widely used methods of measuring neck motion, chin-sternal distance and uniplanar goniometer, were assessed against a validated measurement tool, the ‘CROM goniometer’. Using multiple linear regression analysis it was determined that sagittal flexion (P = 0.002) and lateral rotation (P < 0.0001) were most closely related to neck circumference alone whereas lateral flexion (P < 0.0001) was most closely related to a ratio of circumference and length of neck. Hence, assessing cervical range of motion as outcome variable or as a measure at posttreatment follow-up, neck circumference was shown to be one of the factors influencing total neck motion, particularly sagittal flexion and lateral tilt. Comparison of cervical range of motion assessed with a validated measurement tool, the CROM goniometer, with results of both frequently applied clinician’s instruments, the uniplanar goniometer and measurement of chin-sternal distance, showed low reliability with the latter techniques, and motion values measured with these techniques should be interpreted with caution if using them for comparison of cervical range of motion of alike groups. We demonstrated that neck dimension should be incorporated into cervical functional outcome assessment and one should be wary about recorded values for neck motion from non-validated measurement tools.

Surgical safety checklists.

Abstract: Improve collaborative teamwork, minimise surprises, and reduce harm to patients Surgical deaths and complications are a global public health problem. The World Health Organization estimates that each year half a million deaths related to surgery could be prevented.1 2 In England and Wales, the National Patient Safety Agency’s national reporting and learning system recorded 129 419 surgery related events in 2007.3 In the United States, the state of Minnesota (with less than 2% of the US population) reported 21 surgeries in the wrong site during one year (October 2007 to October 2008) . 4 The real situation is probably even worse though, because most safety incidents are not reported.5 In June 2008, WHO launched the Safe Surgery Saves Lives campaign.2 This included a “surgical safety checklist” (www.who.int/patientsafety/safesurgery/en/) to ensure that the entire operating theatre team has a common understanding of the patient and the surgical procedure, and that evidence based interventions such as antibiotic prophylaxis or deep vein thrombosis prophylaxis are reliably given.2 The 19 item checklist is completed in three stages—before induction of anaesthesia (sign in), just before skin incision (time out), and before the patient leaves the operating theatre (sign out). Items on the checklist must be verbally confirmed with the patient and other team members. The WHO Safe Surgery Saves Lives Study Group has published a study of 3733 patients before implementation and …

Pharmacokinetic evaluation of linezolid in patients with major thermal injuries

Abstract: AIMS: To evaluate the pharmacokinetics of linezolid following its administration in patients with major thermal injuries and in a group of healthy volunteers. METHODS: In an open-label, multicentre design with two parallel groups, a group of patients with major thermal injuries (>20% body area) and a group of age-, sex- and weight-matched healthy volunteers, subjects received a single 600 mg intravenous dose of linezolid. Serial blood and urine collections were made and the concentrations of linezolid in these samples were determined by HPLC. Non-compartmental analyses were used to describe the pharmacokinetic disposition of linezolid. RESULTS: C(max) concentrations and the volume of distribution at steady state (V(ss)) were not statistically different (P > 0.05) between the two groups of subjects. In contrast, values describing clearance [elimination rate constant (k(el)), t(1/2) and mean residence time (MRT)] were significantly different (P < 0.05) in patients with thermal injuries compared with volunteers, which lead to an approximate reduction by half in AUC(0-infinity) from 98.1 mg.h/L (volunteers) to 42.5 mg.h/L (patients). Although renal clearance was similar in the two groups (24.7 +/- 23 versus 30.6 +/- 14.3 mL/min; P = 0.156), non-renal clearance was substantially increased (323 +/- 191 versus 80.4 +/- 27.5 mL/min) in the patients with thermal injuries, though this difference did not achieve statistical significance (P = 0.063). CONCLUSIONS: The pharmacokinetics of linezolid are altered in patients with major thermal injuries, mainly as a result of increased non-renal clearance. These changes are of sufficient magnitude that linezolid concentrations may be sub-therapeutic in some patients and we suggest that the dosage interval may need to be decreased in this patient population.

CYP2B6 G516T genotyping in a UK cohort of HIV-positive patients: polymorphism frequency and influence on efavirenz discontinuation.

Abstract: Objectives The nonnucleoside reverse transcriptase inhibitor (NNRTI) efavirenz undergoes phase I metabolism by the cytochrome P450 enzyme, CYP2B6. Previous studies outside of the United Kingdom have shown associations between the CYP2B6 polymorphism G516T and increased toxicity. This study aimed to develop a CYP2B6 G516T genotyping assay to identify individuals at risk of efavirenz toxicity. The frequency of this polymorphism in a UK HIV-infected population and its prevalence in individuals who had discontinued efavirenz were also to be assessed. Methods Genomic DNA from HIV-positive patients (n=206) attending clinic at Southmead Hospital, North Bristol NHS Trust was extracted from spare blood taken for CD4 monitoring. An allele-specific polymerase chain reaction (PCR) method for the CYP2B6 G516T polymorphism was used to assign patients' genotypes. Patients' age, sex, ethnicity and drug history were also recorded. Results The G516T polymorphism was more prevalent in Blacks (16%; n=10/63) than Caucasians (6%; n=9/143). No significant difference in the distribution of genotypes between individuals who had discontinued efavirenz (n=31) and individuals who had continued efavirenz (n=74) was observed (χ2; P=0.63). Conclusions A genotyping method for the CYP2B6 G516T method was used to assess the polymorphism frequency in a UK cohort of HIV-infected patients. The polymorphism was not more prevalent in individuals who had discontinued efavirenz. Reasons for drug discontinuation are likely to be multifactorial and as this study showed cannot be explained by this genetic difference alone. For this reason we do not advocate testing for this polymorphism in routine clinical practice at present.

Myocardial infarction associated with the administration of intravenous ephedrine and metaraminol for spinal-induced hypotension.

Abstract: A 31-year-old female with no risk factors for cardiac disease suffered a peri-operative myocardial infarction during an elective gynaecological procedure under spinal anaesthesia. The timing and nature of cardiac symptoms suggest that the myocardial infarction was caused by coronary artery vasospasm secondary to ephedrine and/or metaraminol, which were administered to treat spinal-induced hypotension. We review the recent literature and case reports on myocardial infarction attributed to sympathomimetic drugs, and recommend the use of sublingual or intravenous nitrates when signs or symptoms of coronary arterial vasospasm become evident during their use.

Emergency treatment of anaphylaxis in adults: concise guidance

Abstract: Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction characterised by rapidly developing life-threatening airway, breathing and/or circulation problems usually associated with skin and mucosal changes. Updated guidance on the recognition, acute management and follow up of adults with anaphylaxis has recently been published. This is a concise version of the full guidelines published by the Resuscitation Council (UK) in 2008. The use of an airway, breathing, circulation, disability and exposure approach to recognise and treat anaphylaxis is emphasised.

CSF spectrophotometry for bilirubin--why and how?

Abstract: In patients presenting with a possible subarachnoid haemorrhage (SAH), a negative CT scan of the head does not exclude SAH and further investigations are therefore required. Cerebral angiography identifies aneurysms but does not inform on whether they have ruptured and is resource intensive. Examination of the CSF for blood cannot distinguish between an in-vivo bleed and a traumatic lumbar puncture. Visual inspection of the CSF supernatant fluid for xanthochromia is insensitive and should not be used on any account. The most appropriate investigation is spectrophotometry of the CSF for the haemoglobin breakdown products, oxyhaemoglobin and bilirubin. Guidelines for the performance of spectrophotometry and interpretation have been produced, modified and are reviewed here. From 5 years' data involving 2302 scans, 92% did not support the occurrence of SAH, 4% indicated the need for angiography to identify a possible aneurysm, while 4% were equivocal due to the presence of oxyhaemoglobin in sufficient concentrations to interfere with the ability to identify bilirubin reliably.

A double-blind randomised clinical trial of the treatment of otitis externa using topical steroid alone versus topical steroid–antibiotic therapy

Abstract: The objective of the study was to determine if the addition of topical antibiotic increases the efficacy of topical steroid in controlling otitis externa. A double-blind randomised controlled trial was performed from February 2003 to April 2005 in an otolaryngology emergency clinic (acute urban teaching hospital) in the United Kingdom. Patients were followed up for 2 weeks. Forty-five adults with otitis externa based on the presence of oedema, discharge or debris in the outer ear canal were recruited. The patients were randomised to one of the two treatment groups, namely using betamethasone sodium phosphate 0.1% (Vista-Methasone) or betamethasone sodium phosphate 0.1% with neomycin sulphate 0.5% (Vista-Methasone N), and were instructed to use the trial medication at three drops three times a day for 2 weeks. Subjects’ visual analogue symptom scores (blockage, pain, discharge, and itching) for otitis externa pre-treatment (day 0) and post-treatment (day 15), percentage changes in visual analogue symptom scores as a result of treatment, proportion of patients whose symptom scores failed to improve or deteriorated on treatment were analysed. The two experimental arms demonstrated statistically similar presenting symptom scores at recruitment (mean symptom scores of 19.2 for betamethasone group and 28.7 for betamethasone-neomycin group). The mean symptom score change in response to treatment was 82.8 and 47.8% in the betamethasone–neomycin and betamethasone-alone groups, respectively. There was no statistically significant difference between the groups in median percentage symptom score change in response to treatment. All patients in the betamethasone–neomycin group showed symptom improvement but in the betamethasone alone group, five patients got worse (Fishers exact, P = 0.05). Topical antibiotic–steroid combination therapy is superior to steroid-alone treatment for symptomatic control of otitis externa.

Surgical management of tibial tubercle fractures in association with tibial plateau fractures fixed by direct wiring to a locking plate.

Abstract: Tibial tubercle fractures disrupting the extensor mechanism of the knee can occur in association with complex tibial plateau fractures (AO type 41A, B, C). The management of these fractures can be difficult; a stable repair of the tibial tubercle fragment is essential if the extensor mechanism is to be reconstituted. There are few reported techniques described to manage tibial tubercle fractures in conjunction with complex proximal tibial injuries. Traditionally, tibial tubercle fractures have been repaired by lagging the tubercle fragment to the posterior cortex of the tibia using 1 or more screws. However, the cortex of the posterior tibia does not always offer good purchase for screw fixation, particularly in osteopenic bone. Additionally, in complex proximal tibial fractures, comminution often extends posteriorly, further complicating stable lag screw fixation. Placement of an anteroposterior lag screw can also be complicated by "screw traffic" if there are a large number of screws fixing the primary fracture. In this article, we report a novel surgical approach for the management of tibial tubercle fracture fragments occurring in association with complex proximal tibial fractures. Using this technique, the tibial tubercle fragment is stabilized by wiring it directly to the screws of a locking plate. It allows for reduction and fixation of the tibial tubercle fragment that is stable enough to allow immediate full active range of motion. Over the past 5 years, we have applied this technique in 16 patients. Our preliminary results using this new technique have demonstrated a high rate of clinical and radiographic union with near normal return of extensor mechanism function.

The diagnosis and management of an expanding post-traumatic soft tissue cyst of the hip and groin

Abstract: A post-traumatic cyst is a rare complication of significant soft tissue trauma. It occurs at the junction between the subcutaneous fat and underlying fascia, when a large, subcutaneous haematoma fails to resolve, developing into a chronic, fluid-filled cyst, lined with fibrous tissue. This results in a swelling that persists for years, gradually increasing in size, often without causing significant discomfort to the patient. Clinically and radiologically these swellings may be mistaken for neoplastic lesions. They can be difficult to treat, are refractory to conservative management and have a high rate of recurrence following surgical excision. Careful monitoring and early treatment of persistent postoperative seroma is advocated.

Bacterial Strain-to-Strain Variation in Pharmacodynamic Index Magnitude, a Hitherto Unconsidered Factor in Establishing Antibiotic Clinical Breakpoints

Abstract: Antibiotic pharmacodynamic modeling allows variations in pathogen susceptibility and human pharmacokinetics to be accounted for when considering antibiotic doses, potential bacterial pathogen targets for therapy, and clinical susceptibility breakpoints. Variation in the pharmacodynamic index (area-under-the-concentration curve to 24 h [AUC24]/MIC; maximum serum concentration of drug in the serum/MIC; time the serum concentration remains higher than the MIC [T > MIC]) is not usually considered. In an in vitro pharmacokinetic model of infection using a dose-ranging design, we established the relationship between AUC24/MIC and the antibacterial effect for moxifloxacin against 10 strains of Staphylococcus aureus. The distributions of AUC24/MIC targets for 24-h bacteriostatic effect and 1-log, 2-log, and 3-log drops in bacterial counts were used to calculate potential clinical breakpoint values, and these were compared with those obtained by the more conventional approach of taking a single AUC24/MIC target. Consideration of the AUC24/MIC as a distribution rather than a single value resulted in a lower clinical breakpoint.

The use of capsaicin in loin pain-haematuria syndrome.

Abstract: OBJECTIVE To highlight the implications of the use of capsaicin in managing loin pain-haematuria syndrome (LPHS). PATIENTS AND METHODS Between February 2002 and February 2007, three patients (one male and two females; mean age 31.7 years) with LPHS were managed with capsaicin and followed up for a period of 8–48 months. All were diagnosed with LPHS after negative urological investigations including urine culture, urine cytology, renal tract ultrasonography, intravenous urography and flexible cystoscopy; and nephrological work-ups including normal blood pressure measurements, creatinine clearance, urinary protein estimation and serum urea/creatinine. Five original papers were reviewed in detail for this article. Including our own experience, a total of 52 (including five bilateral) cases of LPHS treated with capsaicin are reviewed. RESULTS Our patients received a total of four capsaicin instillations producing an average duration of pain relief per instillation of 17 weeks. There was evidence of renal deterioration in one, while another had worsened symptoms. The third patient continued his pain management within the pain clinic. The former two patients eventually underwent nephrectomy for poor function and extreme symptoms. CONCLUSION Intrarenal capsaicin at best produces only short-term pain relief in more than half of patients with LPHS. It produces significant side-effects, i.e. UTI, bladder pain, and in up to half of patients, deteriorating symptoms. Further loss of functional renal tissue and a nephrectomy rate of 20–67% should be weighed against the benefits. We have therefore abandoned its use in treating LPHS or renal pain, and recommend that patients should be adequately counselled on its potential side-effects, including nephrotoxicity and increased nephrectomy rate.