Transcatheter coil embolization of a complex pulmonary artery pseudoaneurysm with thyrocervical trunk-pulmonary arterial fistulization in a patient with cystic fibrosis and massive hemoptysis.

Pulmonary artery pseudoaneurysm (PAP) is a rare cause of life-threatening hemoptysis and tends to develop in the setting of infection, neoplasm, or trauma. Successful endovascular coil embolization has demonstrated effectiveness in treating PAPs and is now the treatment of choice for these patients. Vascular supply to PAPs is highly variable and often requires embolization of both the systemic and pulmonary feeding vessels. This is a case report of a successful transcatheter coil embolization of a complex PAP with a thyrocervical trunk-pulmonary arterial fistula in a patient with massive hemoptysis in the setting of advanced cystic fibrosis.

Medium- to long-term results of a randomized controlled trial to assess the efficacy of arthoscopic-subacromial decompression versus mini-open repair for the treatment of medium-sized rotator cuff tears.

BACKGROUND: We report on the medium- to long-term results of a randomized controlled trial (RCT) aiming to determine whether rotator cuff repair confers any advantage over arthroscopic sub-acromial decompression (ASAD) alone in the management of medium-sized rotator cuff tears. METHODS: Ethical approval was sought to follow-up patients previously enrolled in a completed and previously published RCT comparing the outcome of ASAD with mini-open cuff repair for the treatment of rotator cuff tear. Forty-two patients were enrolled in the original study, with a mean of 64 years (range 54 years to 77 years). RESULTS: Fifteen of the original 17 patients randomized to ASAD alone and 18 of the original 25 patients randomized to cuff repair were available for follow-up. Each patient underwent American Shoulder and Elbow Surgeons (ASES), Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scoring, and clinical and ultrasound examination. Mean duration of follow-up was 7 years (range 5 years to 11 years). There was no statistically significant difference in terms of ASES, DASH and Constant scores at follow-up between the two groups. Some 33% of patients in the cuff-repair group had a proven re-rupture on ultrasound. This patient subgroup had significantly worse Constant scores compared to patients where the repair remained intact. None of the patients from either group developed cuff-tear arthropathy requiring arthroplasty surgery. CONCLUSIONS: In this medium- to longer-term study, there is no demonstrable significant benefit of cuff repair over decompression alone for the treatment of medium-sized rotator cuff tears, in terms of ASES, DASH and Constant scores for pain, function and strength modules. The presence of cuff tear does not necessitate surgical repair. This conclusion should drive surgical strategies and shared decision-making between patients and surgeons.

A systematic review of human norovirus survival reveals a greater persistence of human norovirus RT-qPCR signals compared to those of cultivable surrogate viruses.

Human noroviruses (hNoV) are the single largest cause of acute gastroenteritis in the western world. The efficacy of hNoV control measures remains largely unknown, partly owing to the inability to grow the virus in vitro and partly to the large number of surrogate studies of unknown relevance. A systematic review of the persistence and survival of hNoV in foods and the environment was undertaken based upon PRISMA (preferred reporting items for systematic reviews and meta analyses) guidelines to answer the questions: (1) "What are the natural hNoV persistence characteristics in food and the environment?" and (2) "How can these properties be altered by applying physical and/or chemical treatments to foods or food contact surfaces?" Over 10,000 citations were screened using defined inclusion and exclusion criteria. One hundred and twenty-six (126) citations were identified for further evaluation and data were extracted based upon the conditions of study and treatment (e.g., treatment parameters, pH, and temperature, time, infectivity, and RT-qPCR results). Since the only markers for hNoV persistence and survival were RT-qPCR data and human challenge studies, citations for further analysis were restricted to only those that included data on hNoV behavior (using RT-qPCR) as compared directly to surrogate virus behavior (using both RT-qPCR and infectivity) in the same study, and clinical studies. Based on these criteria, a total of 12 independent studies (5 for thermal inactivation and 7 for available chlorine) and 3 human challenge studies were identified. RT-qPCR always underestimated reductions in surrogate virus titre as a function of treatment when compared to infectivity. The corresponding reductions in RT-qPCR signals for hNoV under comparable conditions were nearly always less than those observed for the surrogates. These relationships were statistically significant for heat when comparing persistence of hNoV RT-qPCR signals with surrogate MNV-1 RT-qPCR signals (P equal persistence=<0.07); and for free chlorine when comparing persistence of hNoV RT-qPCR signals to those of FCV F-9 (p=<0.01). Overall the data suggest that hNoV are frequently more resistant to typical food and environmental control measures compared with cultivable surrogate viruses, when basing data on comparative RT-qPCR results.

The early migration of a partially cemented fluted pegged glenoid component using radiostereometric analysis.

BACKGROUND: Radiostereometric analysis measures the position of rigid bodies in 3 dimensions with very high precision and can be used to measure early micromotion of glenoid implants. MATERIALS AND METHODS: Radiostereometric analysis was used to measure migration of 11 partially cemented fluted pegged glenoid components in patients with osteoarthritis who underwent shoulder arthroplasty during a 2-year period. Patients were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores and by a computed tomography (CT) scan at the 2-year follow-up. RESULTS: Migration patterns could be classified into 2 groups: The first group showed little if any migration, the second group rotated by 4° or more as early as 3 months after operation. The maximum total point motion reached up to 2 mm by the 6-month follow-up. At 12 months, the 2 groups could be identified by the presence or absence of focal lucency around the central peg. At the end of 2 years, CT scans were able to classify the same 2 migration patterns by the presence or absence of osseointegration around the cementless central peg of the glenoid implant. The clinical effect of the absence of osseointegration in this novel glenoid component is unknown because both groups had similar clinical results at 2 years. CONCLUSION: Rapid early migration associated with focal lucency and absence of osseointegration was observed in 6 of 11 components. We postulate that lack of initial fixation leads to early movement of the glenoid component and failure of osseointegration.

Excision arthroplasty following shoulder replacement.

Excision arthroplasty of the shoulder is a rarely performed procedure used in cases where replacement of a failed arthroplasty is not feasible. We report four cases of excision arthroplasty following a shoulder replacement, one performed for infection and three for instability. Excision arthroplasty resulted in very poor function with pain improvement in only two cases.

A new modality of treatment for non-united fracture of the humerus in a patient with osteopetrosis: a case report.

INTRODUCTION: Osteopetrosis introduces technical limitations to the traditional treatment of fracture management that may be minimised with specific pre-operative planning. Extreme care and caution are required when drilling, reaming, or inserting implants in patients with osteopetrosis. Caution must be exercised throughout the postoperative course when these patients are at greatest risk for device failure or further injury. CASE PRESENTATION: We present our experience of treating such a fracture where a patient presented with a non-united fracture of the humerus. The bone was already osteoporotic. We successfully used a new technique which has not been described in the literature before. This included the use of a high-speed drill to prepare the bone for screw fixation. Bone healing was augmented with bone morphogenic protein. CONCLUSION: This technique can give invaluable experience to surgeons who are involved in treating these types of fracture.

A study of the micromovement of pegged and keeled glenoid components compared using radiostereometric analysis.

In a prospective, randomized study between 2000 and 2004, 20 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with radiostereometric analysis, 10 with keeled and 10 with pegged glenoid components. The relative movement of the glenoid component with respect to the scapula was measured over a 24-month period. Three keeled and five pegged glenoids needed reaming for erosion. The largest translations occurred along the longitudinal axis (mean of 1.35 mm for keeled eroded components) (P = .017 for keeled vs pegged components and P = .013 for eroded vs non-eroded components). Both of the other translation axes showed no significant differences. The highest maximum total point movement at 24 months was 2.57 mm for keeled eroded components and 1.64 mm for pegged eroded components (P = .029 for keeled vs pegged components and P = .023 for eroded vs non-eroded components). The largest rotation was anteversion, with mean values of 5.5 degrees for keeled eroded components and 4.8 degrees for pegged eroded components (P = .658 for keeled vs pegged components and P = .90 for eroded vs non-eroded components). The mean varus tilt was 4.5 degrees for keeled eroded components compared with 2.3 degrees for pegged eroded components (P = .004 for keeled vs pegged components and P = .016 for eroded vs non-eroded components), and finally, anterior-posterior rotation mean values were 3.5 degrees for keeled eroded components and 1.1 degrees for pegged eroded components (P = .022 for keeled vs pegged components and P = .04 for eroded vs non-eroded components). In conclusion, whereas all components moved, radiostereometric analysis revealed increased migration with keeled components, exacerbated by glenoid erosion. Furthermore, a distinctive pattern of migration was identified over the 2-year period.

Biostimulation for the treatment of an oil-contaminated coastal salt marsh.

A field study was conducted on a coastal salt marsh in Nova Scotia, Canada, during the summer of 2000. The objective of the study was to assess the effectiveness of biostimulation in restoring an oil-contaminated coastal marsh dominated by Spartina alterniflora under north-temperate conditions. Three remediation treatments were tested with two additional unoiled treatments, with and without added nutrients, serving as controls. This research determined the effectiveness of nitrogen and phosphorus addition for accelerating oil disappearance, the role of nutrients in enhancing restoration in the absence of wetland plants, and the rate at which the stressed salt marsh recovered. Petroleum hydrocarbons were analyzed by gas chromatography/mass spectrometry (GC/MS). Statistically significant treatment differences were observed for alkanes but not aromatics in sediment samples. No differences were evident in above-ground vegetation samples. GC/MS-resolved alkanes and aromatics degraded substantially (>90% and >80%, respectively) after 20 weeks with no loss of TPH. Biodegradation was determined to be the main oil removal mechanism rather than physical washout.

Depression in burn reconstruction patients: symptom prevalence and association with body image dissatisfaction and physical function.

OBJECTIVE: This study investigated the prevalence and the clinical correlates of symptoms of depression among burn reconstruction patients. METHOD: A sample of 224 burn reconstruction patients completed the Beck Depression Inventory (BDI), the SF-36 Health Survey and the Satisfaction with Appearance Scale. RESULTS: The prevalence of at least mild to moderate symptoms of depression (BDI > or =10) was 46%. Female patients were disproportionately represented in this burn reconstruction population (46%) compared to all survivors from the burn center (29%; P<.001) and compared to a national sample of burn survivors (27%; P<.001). Compared to males, female patients presented for consultation much longer after a burn injury (P<.001), tended to have smaller burns (P=.06) and were less likely to have facial burns (P=.08). Depressive symptoms were largely predicted by body image dissatisfaction (beta=.58; P<.001), with additional variance predicted by physical function (beta=-.13; P=.07). The effect of patient and burn injury variables on depressive symptoms was mediated by body image dissatisfaction and physical function. CONCLUSION: The high prevalence of significant symptoms of depression in burn reconstruction patients and their relationship with body image suggest the importance of the routine psychological screening of patients seeking reconstruction services.

Laboratory evaluation of oil spill bioremediation products in salt and freshwater systems.

Ten oil spill bioremediation products were tested in the laboratory for their ability to enhance biodegradation of weathered Alaskan North Slope crude oil in both freshwater and saltwater media. The products included nutrients to stimulate inoculated microorganisms, nutrients plus an oil-degrading inoculum, nutrients plus compounds intended to stimulate oil-degrading activity, or other compounds intended to enhance microbial activity. The product tests were undertaken to evaluate significant modifications in the existing official United States Environmental Protection Agency (EPA) protocol used for qualifying commercial bioremediation agents for use in oil spills. The EPA protocol was modified to include defined formulas for the exposure waters (freshwater, saltwater), a positive control using a known inoculum and nutrients, two negative controls (one sterile, the other inoculated but nutrient-limited), and simplified oil chemical analysis. Three analysts conducted the product test independently in each type of exposure water in round-robin fashion. Statistical tests were performed on analyst variability, reproducibility, and repeatability, and the performance of the various products was quantified in both exposure media. Analysis of variance showed that the analyst error at each time-point was highly significant (P values ranged from 0.0001 to 0.008, depending on water type and oil fraction). In the saltwater tests, six products demonstrated various degrees of biodegradative activity against the alkane fraction of the crude oil and three degraded the aromatic hydrocarbons by >10%. In the freshwater tests, eight products caused >20% loss of alkane hydrocarbons, of which five degraded the alkanes by >50%. Only four products were able to degrade polycyclic aromatic hydrocarbons (PAHs) by >20%, one of which caused 88% removal. However, when the variability of the analysts was taken into consideration, only one of the ten products was found to yield significant percent removals of the PAH fraction and only in freshwater. Viable microorganism population analysis (most-probable-number method) was also performed on every sample by each operator to measure the changes in aromatic and alkane hydrocarbon-degrading organism numbers. In general, little evidence of significant growth of either alkane- or PAH-degraders occurred among any of the ten products in either the saltwater or freshwater testing.

Toxicity of metals and metal mixtures: analysis of concentration and time dependence for zinc and copper.

The toxic effects of heavy metals, zinc and copper, in unary and binary solutions were studied using the Microtox acute toxicity test which relies upon the attenuation of light intensity emitted by Vibrio fischeri. The toxic effect Gamma (ratio of the light intensity lost at time t to the light intensity remaining at time t) of zinc could be related to its concentration [X] by a two-parameter equation Gamma=a(1-exp(-b[X])), where parameter a was a function of time and b equal to 0.88L/mg. The toxic effect of zinc asymptotically approached a maximum with respect of to concentration at all times. The toxic effect of copper was fundamentally different from that of zinc, and increased exponentially with concentration without any limiting maximum value. It could also be described by a two-parameter equation, however, the equation had the form Gamma=aexp(b[X]), where parameter a was a constant and b a function of time. The different functional dependencies (of the toxic effect on the metal concentration) of zinc and copper indicate that different toxicity/inhibition mechanisms were possibly responsible for the attenuation of light intensity for the two metals. The toxic effects of binary mixtures were substantially higher than those expected on the basis of additivity of individual metals. No simple correlations were obtained that could relate the toxic effect of binary mixture to those of individual metals. A better understanding of metal-microbe interactions is needed for achieving predictive capability for toxic effect of mixtures.

Least possible fixation of fractures of the proximal humerus.

The purpose of this study was to assess the clinical outcome of an unreported technique of the least possible fixation for valgus-impacted fractures. Using an open technique without any sharp deep soft tissue dissection, the split between the tuberosities is opened to allow elevation of the impacted humeral head fragment. The tuberosities are reduced and repaired with absorbable sutures between the rotator cuff insertions. No bone grafting, Kirschner wire or other fixation device was used. For 11 patients, with an average age of 55 years, who were operated between 1989 and 1998, the mean follow-up period was 69 months. The patients were assessed radiologically and clinically using the Constant-Murley score. As a percentage of the normal side, the Constant-Murley scores ranged from 55 to 100% (mean 86%); there were eight patients with scores >80%, two patients with scores between 70 and 79% and one patient with score <70%. One patient (9%) showed avascular necrosis (AVN). This fixation allows preservation of the soft tissues in an open approach and avoids the dangers of other fixation methods. There is a low risk of AVN and it allows a good functional result.

Quantification of toxic and inhibitory impact of copper and zinc on mixed cultures of sulfate-reducing bacteria.

The adverse effects of copper and zinc on an acetate-utilizing mixed cultures of sulfate-reducing bacteria (SRB) at concentrations below the toxic concentration (minimum metal concentration at which no sulfate reduction is observed) are reported in this paper. Mathematical models were developed to incorporate the toxic and inhibitory effects (defined as the reduction in bacterial population upon exposure to the metal and the decrease in the metabolic rate of sulfate reduction by the SRB, respectively) into the sulfate-reduction biokinetics. The characteristic toxicity and inhibition constants were obtained from the measurements of bacterial populations and dissolved metal concentrations in serum bottle studies conducted at 35 degrees C and pH 6.6. Both copper and zinc had toxic and inhibitory effects on SRB. The toxicity constants for copper and zinc were 10.6 and 2.9 mM(-1), respectively, indicating that exposure to copper resulted in a higher mortality of SRB than did exposure to zinc. The values of the inhibition constants were found to be 17.9 +/- 2.5 and 25.2 +/- 1.0 mM(-1) for copper and zinc, respectively. This implies that dissolved zinc was slightly more inhibitory to SRB than copper. The models presented in the paper can be used to predict the response of a sulfate-reduction bioreactor to heavy metals during acid mine drainage treatment.

Inhibition of sulfate-reducing bacteria by metal sulfide formation in bioremediation of acid mine drainage.

Acid mine drainage (AMD) containing high concentrations of sulfate and heavy metal ions can be treated by biological sulfate reduction. It has been reported that the effect of heavy metals on sulfate-reducing bacteria (SRB) can be stimulatory at lower concentrations and toxic/inhibitory at higher concentrations. The quantification of the toxic/inhibitory effect of dissolved heavy metals is critical for the design and operation of an effective AMD bioremediation process. Serum bottle and batch reactor studies on metal toxicity to SRB indicate that insoluble metal sulfides can inhibit the SRB activity as well. The mechanism of inhibition is postulated to be external to the bacterial cell. The experimental data indicate that the metal sulfides formed due to the reaction between the dissolved metal and biogenic sulfide act as barriers preventing the access of the reactants (sulfate, organic matter) to the necessary enzymes. Scanning electron micrographs of the SRB cultures exposed to copper and zinc provide supporting evidence for this hypothesis. The SRB cultures retained their ability to effect sulfate reduction indicating that the metal sulfides were not lethally toxic to the SRB. This phenomenon of metal sulfide inhibition of the SRB has to be taken into account while designing a sulfate-reducing bioreator, and subsequently an efficient biotreatment strategy for AMD. Any metal sulfide formed in the bioreactor needs to be removed immediately from the system to maintain the efficiency of the process of sulfate reduction.