Long-term outcomes after high-energy open tibial fractures: Is a salvaged limb superior to prosthesis in terms of physical function and quality of life?

PURPOSE: The aim of this study was to describe complication rates and long-term functional outcomes among patients with amputated versus reconstructed limb after high-energy open tibial fractures. METHODS: Patients treated operatively for a high-energy open tibial fracture, classified as Gustilo-Anderson (GA) grade 3, at our hospital in the time period 2004-2013 were invited to a clinical and radiographic follow-up at minimum 2 years after injury. Eighty-two patients with 87 GA grade 3 fractures were included. There were 39 type GA 3A, 34 GA 3B, and 14 GA 3C. RESULTS: The GA 3A reconstruction group had the lowest complication rate and the best long-term outcome scores at mean 5 years (range 2-8 years) after injury. Within the group of GA 3B and 3C fractures, we found no significant differences in long-term outcomes among patients with reconstructed versus amputated limbs. The mean physical component summary score of the SF-36 in the reconstruction versus amputation group was 54.2 (95% CI 46.3-62.1) versus 47.7 (95% CI 32.6-62.2), respectively (p = 0.524), while the mean mental component summary score was 63.7 (95% CI 50.6-71.8) versus 59.2 (95% CI 48.8-68.0), respectively (p = 0.603). On the 6-minute walk test, the reconstruction group walked on average 493 m (95% CI 447-535 m) versus 449 m (95% CI 384-518 m) in the amputation group. The return to work rate was 73% (16 of 22) in the reconstruction group versus 50% (7 of 14) in the amputation group (p = 0.166). The mean patient satisfaction score (VAS 0-100) was 67 (95% CI 67-77) in the reconstruction group versus 65 (95% CI 51-76) in the amputation group (p = 0.795). Regardless of the treatment strategy, the complication rate was high. CONCLUSIONS: Amputation should be considered as a viable treatment option, equal to limb salvage, after high-energy open tibial fracture with severe vascular damage or soft tissue loss.

Long-term survival and risk factors for failure of the native hip joint after operatively treated displaced acetabular fractures.

AIMS: Our aim in this study was to describe the long-term survival of the native hip joint after open reduction and internal fixation of a displaced fracture of the acetabulum. We also present long-term clinical outcomes and risk factors associated with a poor outcome. PATIENTS AND METHODS: A total of 285 patients underwent surgery for a displaced acetabular fracture between 1993 and 2005. For the survival analysis 253 were included, there were 197 men and 56 women with a mean age of 42 years (12 to 78). The mean follow-up of 11 years (1 to 20) was identified from our pelvic fracture registry. There were 99 elementary and 154 associated fracture types. For the long-term clinical follow-up, 192 patients with complete data were included. Their mean age was 40 years (13 to 78) with a mean follow-up of 12 years (5 to 20). Injury to the femoral head and acetabular impaction were assessed with CT scans and patients with an ipsilateral fracture of the femoral head were excluded. RESULTS: A total of 36 patients underwent total hip arthroplasty (THA). The overall ten-year survival of the hip joint was 86% (95% confidence interval (CI) 81% to 90%) and the 20-year survival was 82% (95% CI 76% to 87%). Injury to the femoral head and acetabular impaction were the strongest predictors of failure, with the long-term survival rate falling towards 50% in these patients. The survival fell to 0% at three years when both these risk factors were present in patients aged > 60 years. CONCLUSION: The long-term survival of the native hip joint after acetabular fractures was good, but the presence of injury to the femoral head and acetabular impaction proved to be strong predictors of failure, especially in patients aged > 60 years. These patients may be better treated with a combination of open reduction and internal fixation and primary arthroplasty. Cite this article: Bone Joint J 2017;99-B:834-40.

[Norwegian medical students abroad--background, effort and satisfaction]. / Norske medisinstudenter i utlandet--bakgrunn, studieinnsats og tilfredshet.

BACKGROUND: More than 30% of Norwegian physicians have graduated from medical schools outside Norway, and the number of Norwegian students that attend medical schools abroad is increasing, particularly in Hungary, Poland and the Czech republic. It is of interest to know more about these future Norwegian doctors: where they come from, and how they cope with studying abroad. MATERIAL AND METHODS: A postal survey was carried out among all 1,198 Norwegian medical students that were in the files of the State Education Loan Fund by August 1998. There were 756 responses (63%). The questions covered reasons for going abroad, academic and non-academic outcome, satisfaction, specialty and job preferences, possible motives for career choices, personality traits, smoking status and alcohol use. Comparable data were available from previous studies of medical students in Norway. RESULTS: The social background of students abroad is similar to that of students at home, and their high school grade level is only slightly below. The main reasons for studying abroad is that they were not admitted at a Norwegian university and have a strong wish of becoming a doctor. Language, financial situation, and a number of pragmatic reasons determine which country to go to, choice of university is often incidental. Students abroad spend more time on their studies than students at home do. They are generally satisfied with the academic quality, but satisfaction with how the study is organised is lower in Central and Eastern-European countries. INTERPRETATION: Norwegians who are highly motivated but excluded from Norwegian universities increasingly attend medical schools abroad and are by and large satisfied with the quality of the curriculum.

[Norwegian medical students abroad--career plans, personality, smoking and alcohol use]. / Norske medisinstudenter i utlandet--karriereplaner, personlighet, røyking og alkoholbruk.

BACKGROUND: More than 30% of Norwegian physicians have graduated from medical schools outside Norway, and the number of Norwegian students that attend medical schools abroad is increasing, particularly in Hungary, Poland and the Czech republic. There is a need to know more about these future Norwegian doctors, what their motives and plans are, and how they differ from students at home. MATERIAL AND METHODS: A postal survey was carried out among all 1,198 Norwegian medical students that were in the files of the State Education Loan Fund by August 1998. The questions covered reasons for going abroad, academic and non-academic outcome, satisfaction, specialty and job preferences, possible motives for career choices, personality characteristics, smoking status and alcohol use. Comparable data were available from previous studies of medical students in Norway. RESULTS: There were 756 responses (63%). Surgery, internal medicine and paediatrics were the most popular specialties. Family medicine and psychiatry seem to be less likely specialties for students abroad than for students at home. Traditional gender differences, e.g. interest in aiming for a leadership position, were present and did not differ from those seen among students in Norway. Students abroad were more oriented towards leadership and prestigious specialties, less preoccupied with the possibility of making medical mistakes, and less interested in medico-policial issues than their counterparts at home. Their personality profiles seemed more robust than those of students in Norway. On the other hand, they smoked much more frequently and had a higher risk of alcohol-related problems. INTERPRETATION: Norwegian medical students abroad do not particularly prefer specialties like general practice and psychiatry, where the demand for medical manpower is highest. They seem to have quite traditional preferences according to gender.

[Changes in career plans of medical students during the first half of medical school]. / Endring i medisinstudenters karrierepreferanser under første del av studiet.

A cohort of Norwegian medical students was followed through the pre-clinical part of medical school to study the development of specialty and leadership preferences. A questionnaire was sent to medical students immediately after they started their medical training in 1993, and again early in 1997 when the students had just started their clinical curriculum. 283 of 415 (68%) responded at both points in time. In order to investigate the relationship between various motivational variables and specialty and leadership preferences, five latent variables were identified through factor analysis: defensive, active, comprehensive, career-oriented and detached. Based on previous research in Norway, an index of prestige was constructed, where medical specialties and subspecialties were ranked according to the opinions of physicians and other health personnel. The intention was to explore the possible impact of prestige on specialty preferences. Career preferences were unstable on the individual but stable on the aggregate level. Interest in psychiatry, public health and laboratory medicine decreased during the first years of medical school, and high-prestige specialties became more appealing. Gender differences in career plans were distinct, stable and traditional. For future hospital physicians, leadership ambitions were much higher among men at both points in time. Our findings were that factors with bearing on choice of career are different for women and men, and preferences half-way through medical school are clearly related to such factors.

Motivation for medical school: the relationship to gender and specialty preferences in a nationwide sample.

OBJECTIVES: Motivation for going to medical school and career plans of a 1 year cohort of students entering medical school in Norway (n = 420 response rate: 90%, 54% women, mean age: 22 years) were surveyed by a postal questionnaire the first month after they had started. DESIGN: Motives for choosing medicine were categorized into three indexes: 'people orientated', 'status/security orientated' and 'natural science orientated' motives. SETTING: University of Oslo. SUBJECTS: Medical students. RESULTS: Students picked out which they preferred among 53 specialties. The highest motivational scores were on the 'person orientated' index, female students scoring higher than men. Female students were, however, nearly as highly motivated by status/security and interests in natural science as were men. 'Person orientated' and 'natural science orientated' motives exerted the strongest influence on specialty preferences. Those who preferred family medicine were more person orientated and less natural science orientated, while those who preferred internal medicine were more natural science orientated. Father being a physician did not influence the motivational pattern, but increased the preference for laboratory and internal medicine. Frequently repeated upper secondary school exams for acceptance into medical school were negatively related to natural science motivation, and to increased preference for becoming a surgeon. CONCLUSIONS: In this first month of the curriculum students regarded person oriented motives as the most important for becoming a doctor.

[Career plans of future physicians. Level of ambition and plans for specialization among medical students]. / Kommende legers karriereplaner. Ambisjonsnivå og spesialiseringsplaner blant medisinstudenter.

This nation-wide study inquiry concerned the intended future careers of medical students at the end of their studies and those of a cohort of first-year students. More first-year than final-year students hoped to obtain a position as a hospital physical or surgeon with management responsibility and twice as many men as women wanted such a position in both cohorts. High self esteem, having a doctor as father and successful examinations at medical school were associated with a high level of ambition. Compared with first-year students, more final-year students preferred family medicine and internal medicine, and less preferred surgery, psychiatry and social medicine. Plans for specialisation were influenced by the father's education level, successful examinations at medical school, whether they had children or not, and the university of graduation. More women preferred gynaecology, more men preferred surgery. The interest for surgery among female students is high compared with the low share of female surgeons. Assuming that these trends persist, psychiatry, laboratory medicine and social medicine risk insufficient recruitment. The share of women holding clinical professorships will probably remain low, even in a generation with more female than male medical students.

[Repetition and private exams--the road to medical studies. Extent, financing and social consequences of collecting of grades for medical studies in Norway]. / Repetisjon og privatisteksamener--veien til det medisinske studium. Omfang, finansiering og sosiale konsekvenser ved poengsamling til medisinstudiet i Norge.

This article is based on a survey of Norwegian freshmen medical students in autumn 1993. Norwegian medical students are selected mainly by grades from the upper secondary school, and the purpose of this study is to shed light on the extent of repetition of exams among the entrants, emphasizing differences by gender and social background. A wide range of activities are associated with improvement of grades, including a high rate of attendance at private school. Most students are recruited from the upper social strata, and children of physicians are remarkably overrepresented. The unintended consequences of the selection mechanisms are discussed.

Comparisons of four in vitro cytotoxicity tests: The MTT assay, NR assay, uridine incorporation and protein measurements.

Four different in vitro cytotoxicity tests were compared: the MTT assay, the NR assay, the uridine incorporation assay and the measurement of total cellular protein. The comparison was done using the BHK-21 cell line and nine selected test chemicals (colchicine, amitriptyline, cycloheximide, 2,5-hexandione, mercury chloride, cadmium chloride, copper chloride, 2,4-dinitrophenol and chloroquine diphosphate). The concentration that induced 50% inhibition relative to the controls (IC(50)) was calculated for each test and chemical. The results from the cytotoxicity tests were generally in good agreement. However, for some chemicals the IC(50) values varied significantly between two assays. The largest variation was found for chloroquine diphosphate, where the IC(50) value for the NR assay was approximately eight times lower than the IC(50) value for the protein measurement.

Acute toxicity of toluene determined using glioma cells contained in sealed rolling bottles, with controlled vapour concentration.

A rolling bottle system containing glioma (C6) cells was used to test the toxicity of toluene, using mitochondrial activity (MTT assay), neutral red uptake and cell growth as indicators of toxicity. Toluene was shown to have toxic effects only at gas concentrations above 12,000 ppm. Because tests showed that as much as 30% of toluene leaked out of sealed tubes filled with toluene gas, the concentrations of toluene gas in the tubes were monitored by gas chromatography.

Effects of high pressure and vanadium on cell growth.

We have investigated the effects on cultured cells of high pressure separately and combined with vanadate. Growth of Chinese hamster ovary cells was reduced at pressure above 75 bar; the reduction was 31.6% at 185 bar. Vanadate inhibited cell growth at 5 microM and abolished growth at 100 microM. Combined exposure to vanadate and high pressure changed the toxicity of vanadate: at 5 microM, the toxicity decreased for pressure up to 100 bar; above 100 bar, 5 microM vanadate was more toxic to the cells than at normobaric pressure.

High hydrostatic pressure potentiation of the toxic effects of chromate in cell culture.

Development of hyperbaric welding has created the need for new occupational health standards. We have used cell cultures to investigate effects of high pressure chromate on the toxicity of the welding-fume component, chromate. The results indicate that pressure caused rounding-up of cells and changes in F-actin filaments, and that these effects were related to the extent of high pressure and independent of exposure duration. When exposing the Flow 5000 cells to chromate (1-5 microM) the amount of disrupted F-actin fibers was found to depend on the concentration applied and the duration of exposure. The amount of cell-associated chromate was the same for 1 h exposure at 1 and 150 bar. The fraction of rounded cells after exposure to 1 microM chromate and 100 bar for 18 h was higher than would be expected if the effects were purely additive.

High hydrostatic pressure and chromate-induced effects on cell cycle kinetics.

Cell cycle kinetics was studied using the quenching of 33258 Hoechst fluorescence by bromodeoxyuridine incorporation to investigate effects of high pressure on the toxicity of a welding fume component--chromate. When exposing the glioma cells to 1 microM K2Cr2O7 at 1 bar, we observed a prolongation of DNA-synthesis phase, whereas cells exposed to 5 microM K2Cr2O7 did not pass through mitosis. Cells exposed to 1 or 5 microM chromate during the last part of DNA synthesis and during mitosis were not delayed in passing through mitosis. High pressure (100 bar) or pretreatment with pressure did not cause changes of cell cycle parameters. The combined exposure of 1 microM K2Cr2O7 and high pressure caused the same effect as observed for 1 microM K2Cr2O7 at 1 atm. However, an extra delay was observed in passing through mitosis for cells exposed to 100-bar pressure during the early part of their cell cycle.