Metastatic adenocarcinoma after intramedullary fixation of a tibial fracture: A report of two cases.

We present two cases of metastatic lung cancer which occurred at the site of a previously united tibial fracture. Both patients were treated with a locked intramedullary nail. The patients presented with metastases at the site of their initial fracture approximately 16 and 13 months after injury respectively. We discuss this unusual presentation and review the relevant literature. We are unaware of any previous reports of a metastatic tumour occurring at the site of an orthopaedic implant used to stabilise a non-pathological fracture. These cases demonstrate the similar clinical presentation of infection and malignancy: a diagnosis which should always be considered in such patients.

Risk factors for periprosthetic fractures of the hip: a survivorship analysis.

UNLABELLED: Periprosthetic fracture is an uncommon but typically complex complication of cemented THA usually treated operatively. It is a source of reduced function, subsequent morbidity, and increased mortality. Previous studies may have underestimated the incidence of fracture through loss to followup or failure to use survivorship methodologies. The primary aim of this study was to use survivorship methodology to investigate the incidence of, and risk factors for fracture following primary arthroplasty. We examined a cohort of 6458 primary cemented femoral prostheses implanted during a 17-year period. One hundred twenty-four patients sustained fractures at the tip or below the femoral prosthesis. The incidence of fracture was 0.8% at 5 years and 3.5% at 10 years after primary implant. Patients older than 70 years had a 2.9 times greater risk of sustaining a subsequent fracture. There was no association between fracture and gender or implant type. These rates are higher than those reported for cemented arthroplasties. Older patients should be counseled regarding their higher risk of periprosthetic fracture, and additional research is required to elucidate the biologic mechanisms involved. LEVEL OF EVIDENCE: Level II, retrospective prognostic study.

Total knee replacement in morbidly obese patients. Results of a prospective, matched study.

The results of 41 consecutive total knee replacements performed on morbidly obese patients with a body mass index > 40 kg/m(2), were compared with a matched group of 41 similar procedures carried out in non-obese patients (body mass index < 30 kg/m(2)). The groups were matched for age, gender, diagnosis, type of prosthesis, laterality and pre-operative Knee Society Score. We prospectively followed up the patients for a mean of 38.5 months (6 to 66). No patients were lost to follow-up. At less than four years after operation, the results were worse in the morbidly obese group compared with the non-obese, as demonstrated by inferior Knee Society Scores (mean knee score 85.7 and 90.5 respectively, p = 0.08; mean function score 75.6 and 83.4, p = 0.01), a higher incidence of radiolucent lines on post-operative radiographs (29% and 7%, respectively, p = 0.02), a higher rate of complications (32% and 0%, respectively, p = 0.001) and inferior survivorship using revision and pain as end-points (72.3% and 97.6%, respectively, p = 0.02). Patients with a body mass index > 40 kg/m(2) should be advised to lose weight prior to total knee replacement and to maintain weight reduction. They should also be counselled regarding the inferior results which may occur if they do not lose weight before surgery.

Does obesity influence the clinical outcome at five years following total knee replacement for osteoarthritis?

A total of 370 consecutive primary total knee replacements performed for osteoarthritis were followed up prospectively at 6, 18, 36 and 60 months. The Knee Society score and complications (perioperative mortality, superficial and deep wound infection, deep-vein thrombosis and revision rate) were recorded. By dividing the study sample into subgroups based on the body mass index overall, the body mass index in female patients and the absolute body-weight. The outcome in obese and non-obese patients was compared. A repeated measures analysis of variance showed no difference in the Knee Society score between the subgroups. There was no statistically-significant difference in the complication rates for the subgroups studied. Obesity did not influence the clinical outcome five years after total knee replacement.

Nanowires and nanoribbons of charge-density-wave conductor NbSe3.

We report synthesis of nanowires and nanoribbons of the charge-density-wave conductor NbSe(3) through direct reaction of Nb and Se powders. The transverse dimension of the obtained nanostructures, as identified with scanning/transmission electron microscopy, ranges from 20 to 700 nm. X-ray and selected area electron diffraction analyses indicate that these nanowires and nanoribbons are single crystalline. Four-probe resistivity measurements confirm the expected charge-density-wave transitions, and furthermore, we find significant enhancement in the depinning threshold fields, which we attribute to a confinement effect.

Thromboprophylaxis in patients undergoing total hip replacement.

Venous thromboembolism is a common complication following a hip replacement. It was the authors' impression that prophylaxis of deep vein thrombosis has changed in recent years. The authors felt that it was important to repeat a survey, done in 1997, on the use of thromboembolism prophylaxis among British orthopaedic surgeons.

The role of angiography in the management of haemorrhage from major fractures of the pelvis.

In a series of 150 consecutive patients with unstable fractures of the pelvis, angiography was performed in 23 (15%) who had uncontrolled hypotension. There were three anteroposterior compression (APC), eight lateral compression (LC) and 12 vertical shear (VS) injuries. Arterial sources of haemorrhage were identified in 18 (78%) patients and embolisation was performed. Angiography was required in 28% of VS injuries. The morphology of the fracture was not a reliable guide to the associated vascular injury. Ten (43%) patients died, of whom six had had angiography as the first therapeutic intervention. Five of these had a fracture which was associated with an increase in pelvic volume (APC or VS) which could have been stabilised by an external fixator. Based on our findings we recommend skeletal stabilisation and, if indicated, laparotomy to deal with sources of intraperitoneal blood loss before pelvic angiography. Embolisation of pelvic arterial bleeding is a worthwhile procedure in patients with hypotension which is unresponsive to these interventions.

Near-field magnetophotoluminescence spectroscopy of composition fluctuations in InGaAsN.

The localization of excitons on quantum-dot-like compositional fluctuations has been observed in temperature-dependent near-field magnetophotoluminescence spectra of InGaAsN. Localization is driven by the giant bowing parameter of these alloys and manifests itself by the appearance of ultranarrow lines (half-width <1 meV) at temperatures below 70 K. We show how near-field optical scanning microscopy can be used for the estimation of the size, density, and nitrogen excess of individual compositional fluctuations (clusters), thus revealing random versus phase-separation effects in the distribution of nitrogen.

Late fracture of the hip after reamed intramedullary nailing of the femur.

In a consecutive series of 498 patients with 528 fractures of the femur treated by conventional interlocking intramedullary nailing, 14 fractures of the femoral neck (2.7%) occurred in 13 patients. The fracture of the hip was not apparent either before operation or on the immediate postoperative radiographs. It was diagnosed in the first two weeks after operation in three patients and after three months in the remainder. Age over 60 years at the time of the femoral fracture and female gender were significantly predictive of hip fracture on bivariate logistic regression analysis, but on multivariate analysis only the location of the original fracture in the proximal third of the femur (p = 0.0022, odds ratio = 6.96, 95% CI 2.01 to 24.14), low-energy transfer (p = 0.0264, odds ratio = 15.56, 95% CI 1.38 to 75.48) and the severity of osteopenia on radiographs (p = 0.0128, odds ratio = 7.55, 95% CI 1.54 to 37.07) were significant independent predictors of later fracture. Five of the 19 women aged over 60 years, who sustained an osteoporotic proximal diaphyseal fracture of the femur during a simple fall, subsequently developed a fracture of the neck. Eleven of the hip fractures were displaced and intracapsular and, in view of the advanced age of most of these patients, were usually treated by replacement arthroplasty. Reduction and internal fixation was used to treat the remaining three intertrochanteric fractures. Three patients developed complications requiring further surgery; five died within two years of their fracture.

Rapid detection of acute appendicitis with Tc-99m-labeled intact polyvalent human immune globulin.

BACKGROUND: Acute appendicitis remains problematic for emergency clinicians. A rapid and definitive test is needed for detecting acute appendicitis before surgical intervention. The purpose of this clinical trial was to determine the efficacy of Tc-99m-labeled intact polyvalent human immune globulin (Tc-99m IgG) in the evaluation of acute appendicitis. STUDY DESIGN: Thirty-five patients with clinically suspected acute appendicitis were evaluated with Tc-99m IgG. After the intravenous injection of 25 mCi (92.5 MBq) of Tc-99m IgG, anterior flow, single photon emission computerized tomography (SPECT) and planar delayed images of the abdomen were obtained. Any abnormal focal uptake of Tc-99m IgG in the right lower quadrant was considered to be a positive scan. RESULTS: Twenty-one patients with a positive Tc-99m IgG scan underwent laparotomy and were found to have acute appendicitis. Of the 14 patients who had negative scans, 7 underwent surgery. In this series, Tc-99m IgG study yielded 21 true-positive, 12 true-negative, and 2 false-negative results with a sensitivity, specificity, and accuracy of 91%, 100%, and 94%, respectively. The positive and negative predictive values were 100% and 86%, respectively. There were no false-positive results. CONCLUSIONS: Tc-99m IgG scintigraphy can provide the clinicians a simple, rapid, and definitive test for the diagnosis of acute appendicitis.

The effective pharmacy-nursing committee.

The Saint Joseph's Hospital Pharmacy-Nursing Committee sees a long list of pharmacy-nursing and drug distribution system problems still to be addressed and has no worry about running out of new business. In fact, increasing controlled substances accountability, creating a more reliable and timely process for moving intravenous fluid pumps through the inpatient system, and implementing a pharmacy-based, patient-controlled analgesia program across all of the hospitals' wards are three major issues now being addressed by the committee. At Saint Joseph's Hospital there is not a lot of unnecessary handwringing or undue stress over major pharmacy-nursing issues. Issues do exist, but there is also an experienced Pharmacy-Nursing Committee with a good track record of being able to resolve major issues. The committee takes on problems in a healthy and confident atmosphere of trust in both profession's skills and competencies. There is a respectful knowledge of each discipline's professional responsibilities and a full awareness that a quality patient drug system requires pharmacy and nursing elements working closely together. Wrestling with the heavy, modern-day, hospital pharmacy-nursing drug distribution system issues at this facility actually can be fun as a result of the confidence, camaraderie, and empathy that exists within the Pharmacy-Nursing Committee.

Auricular microelectrostimulation: naloxone-reversible attenuation of opiate abstinence syndrome.

This study evaluated the effects in rats of very low amplitude (10 mu amp) charge-balanced 10-Hz stimulation delivered bilaterally to low impedance points on the outer ear. This microelectrostimulation markedly and significantly reduced the number of opiate abstinence signs observed following a week of continuous morphine infusion. This effect was prevented by subcutaneous injection of 3 mg/kg naloxone, suggesting that stimulation of endogenous opioid activity plays a major role in the actions of auricular microelectrostimulation.

Formaldehyde: a comparative evaluation of four monitoring methods.

The performances of four formaldehyde monitoring devices were compared in a series of laboratory and field experiments. The devices evaluated included the DuPont C-60 formaldehyde badge, the SKC impregnated charcoal tube, an impinger/polarographic method and the MDA Lion formaldemeter. The major evaluation parameters included: concentration range, effects of humidity, sample storage, air velocity, accuracy, precision, interferences from methanol, styrene, 1,3-butadiene, sulfur dioxide and dimethylamine. Based on favorable performances in the laboratory and field, each device was useful for monitoring formaldehyde in the industrial work environment; however, these devices were not evaluated for residential exposure assessment. The impinger/polarographic method had a sensitivity of 0.06 ppm, based on a 20-liter air sample volume, and accurately determined the short-term excursion limit (STEL). It was useful for area monitoring but was not very practical for time-weighted average (TWA) personal monitoring measurements. The DuPont badge had a sensitivity of 2.8 ppm-hr and accurately and simply determined TWA exposures. It was not sensitive enough to measure STEL exposures, however, and positive interferences resulted if 1,3-butadiene was present. The SKC impregnated charcoal tube measured both TWA and STEL concentrations and had a sensitivity of 0.06 ppm based on a 25-liter air sample volume. Lightweight and simple to use, the MDA Lion formaldemeter had a sensitivity of 0.2 ppm. It had the advantage of giving an instantaneous reading in the field; however, it must be used with caution because it responded to many interferences. The method of choice depended on the type of sampling required, field conditions encountered during sampling and an understanding of the limitations of each monitoring device.

Raymond lindeman and the trophic-dynamic concept in ecology.

Lindeman's classic paper on energy flow in ecosystems was initially rejected for publication in Ecology. Reviewers felt there were insufficient data to support the theoretical model and that theoretical essays were inappropriate for Ecology. The paper was subsequently accepted by Thomas Park, the zoological editor, after correspondence with G. Evelyn Hutchinson who indicated the importance of theory in the development of ecology.