Patients undergoing hip hemiarthroplasty who require early return to theatre have early increased mortality and worse functional outcomes at short term follow-up.

BACKGROUND: Re-operation following hip hemiarthroplasty is potentially devastating due to a frail, co-morbid surgical cohort. We aimed to assess the outcomes of patients who required early return to theatre (RTT) within 30 days of index operation in a high-volume hip fracture unit. METHODS: A retrospective review of a prospectively maintained database was undertaken. All hip hemiarthroplasties performed between 1st January 2010 and 31st December 2019 was included. Demographic details, complications including reason for return to theatre, length of stay, discharge destination, functional outcome and mortality were collected and reviewed. RESULTS: 4340 hip hemiarthroplasty procedures were performed, of which 64 patients (1.47%) required early RTT within 30 days of index procedure and 4276 patients did not require early-RTT. The most common reasons for RTT were infection (n = 47) and dislocation (n = 15). There were no cases of peri­prosthetic fracture requiring RTT within 30 days. Patients requiring early RTT had a significantly increased rate of mortality within 120 days; 32.8% (21 of the 64 patients) versus 13.6% (580 out of the 4276) not requiring early RTT (p < 0.001). The median length of acute inpatient admission for patients who required early RTT was significantly longer at 31 days (range 6-185 days) compared to 10 days (range 3-171 days, p < 0.001) for those without early RTT. Early RTT was associated with a poorer functional mobility outcome at 120 days post-operatively, with a significantly greater reduction in Barthel score compared to the non-RTT cohort (p < 0.05). CONCLUSION: Patients requiring early RTT following hip hemiarthroplasty had a significantly increased length of stay, mortality and worse functional outcome compared to patients who did not require early RTT within 30 days.

Peculiar covalent bonding of C60/6H-SiC(0 0 0 1)-(3 × 3) probed by photoelectron spectroscopy.

High resolution photoemission with synchrotron radiation was used to study the interface formation of a thin layer of C60 on 6H-SiC(0 0 0 1)-(3 × 3), characterized by protruding Si-tetramers. The results show that C60 is chemisorbed by orbital hybridization between the highest-occupied molecular orbital (HOMO) and the p z orbital of Si adatom at the apex of the tetramers. The covalent nature of the bonding was inferred from core level as well as valence band spectra. The Si 2p spectra reveal that a large fraction (at least 45%) of the Si adatoms remain unbound despite the reactive character of the associated dangling bonds. This is consistent with a model in which each C60 is attached to the substrate through a single covalent C60-Si bond. A binding energy shift of the core levels associated with sub-surface Si or C atoms indicates a decrease of the SiC band bending caused by a charge transfer from the C60 molecules to the substrate via the formation of donor-like interface states.

Fixation of unstable ankle fractures using a long hindfoot nail.

BACKGROUND: Management of fragility fractures of the ankle is challenging. Non-operative treatment often requires significant periods of reduced weight bearing. Operative fixation is difficult due to osteoporotic bone and poor soft tissues. The aim of this study was to review the initial experience of treating unstable ankle fractures with a retrograde femoral nail used as a long tibiotalocalcaneal nail. PATIENTS AND METHODS: Sixteen patients were treated from January 2014 until November 2017. Mean age was 73 (50-96) and twelve of the sixteen patients were female. All patients had three or more co-morbidities and an American Society of Anaesthesiologists score of 3. All patients had unstable ankle fracture configurations and were classified using the AO classification. RESULTS: All patients regained baseline mobility by final follow-up (mean 21 months follow-up). Four of the sixteen patients died within 12 months of surgery. There were no wound complications or deep infections. There were no cases of metalwork failure or peri-prosthetic fracture. DISCUSSION: Use of a retrograde femoral nail has been shown to be a safe and effective option in the management of unstable ankle fractures in elderly and frail patients. This technique may lead to lower wound complications compared to traditional fixation techniques and allows earlier mobilisation.

The mechanism of light emission from a scanning tunnelling microscope operating in air.

The scanning tunnelling microscope (STM) may be used as a low-energy, electrical nanosource of surface plasmon polaritons and light. In this article, we demonstrate that the optimum mode of operation of the STM for maximum photon emission is completely different in air than in vacuum. To this end, we investigate the emission of photons, the variation in the relative tip-sample distance and the measured current as a function of time for an STM operating in air. Contrary to the case of an STM operating in vacuum, the measured current between the tip and sample for an STM in air is very unstable (rapidly fluctuating in time) when the applied voltage between the tip and sample is in the ∼1.5-3 V range (i.e., in the energy range of visible photons). The photon emission occurs in short (50 µs) bursts when the STM tip is closest to the sample. The current instabilities are shown to be a key ingredient for producing intense light emission from an STM operating in air (photon emission rate several orders of magnitude higher than for stable current). These results are explained in terms of the interplay between the tunnel current and the electrochemical current in the ubiquitous thin water layer that exists when working in air.

Audit of a Services to Improve Access project to improve access for skin cancer surgery.

Like many general practices in low decile communities with a high percentage of elderly patients, the Paeroa Medical Centre was relying heavily on secondary care to provide skin cancer surgical services, which led to delays in treatment and under-utilisation of the skills available in primary care. A new system utilising Services to Improve Access (SIA) funding was developed to provide partially funded skin cancer surgery within primary care. A 6-month period of this work by one general practitioner (GP) was audited. This has demonstrated that the majority of minor dermatological surgery can be successfully managed in primary care, with more timely and convenient treatment and substantial cost savings to the health system.

The effect of a dedicated Ponseti service on the outcome of idiopathic clubfoot treatment.

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity.

Spilled gallstones during laparoscopic cholecystectomy.

INTRODUCTION: Incidental gallbladder cancer is found in 0.6-2.1% of patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. Patients with Tis or T1a tumours generally undergo no further intervention. However, spilled stones during surgery may have catastrophic consequences. We present a case and suggest aggressive management in patients with incidental gallbladder cancer who had spilled gallstones at surgery. CASE HISTORY: A 37-year-old woman underwent a laparoscopic cholecystectomy for symptomatic gallstones, during which some stones were spilled into the peritoneal cavity. Subsequent histological examination confirmed incidental pT1a gallbladder cancer. Hepatopancreatobiliary multidisciplinary team discussion agreed on regular six-monthly follow-up. The patient developed recurrent pain two years after surgery. Computed tomography revealed a lesion in segment 6 of the liver. At laparotomy, multiple tumour embedded gallstones were found on the diaphragm. Histological examination showed features (akin to the original pathology) consistent with a metastatic gallbladder tumour. CONCLUSIONS: This case highlights the potential for recurrence of early stage disease resulting from implantation of dysplastic or malignant cells carried through spilled gallstones. It is therefore important to know if stones were spilled during original surgery in patients with incidental gallbladder cancer following a laparoscopic cholecystectomy. Aggressive and early surgical management should be considered for these patients.

Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre.

BACKGROUND: Displaced paediatric supracondylar humeral fractures pose a significant risk of neurovascular injury and consequently have traditionally been treated as a surgical emergency. Recently, the need for emergency surgery has been questioned. We wished to analyse our experience at a large UK tertiary paediatric trauma centre. METHODS: A retrospective case note review was performed on patients with Gartland Grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. We divided children into those treated before 12 h (early surgery) and after 12 h (delayed surgery). Analysis was undertaken using Fisher's exact test. RESULTS: Of the 137 patients, 115 were included in the study; median time-to-surgery was 15:30 (range 2:45-62:50); thirty-nine children were treated before 12 h and 76 patients after. In the early surgery group, three children (7.7%) developed a superficial pin-site infection, four children (10.3%) required open reduction, five children (12.8%) sustained an iatrogenic nerve injury, and two children (5%) required reoperation. In the delayed surgery group, one child (1.3%) had a superficial pin-site infection, four children (5.3%) required open reduction, seven children (9.2%) sustained an iatrogenic nerve injury, and two children (2.6%) reoperation. Bivariate analysis of our data using Fisher's exact t test revealed no statistically significant difference between early and delayed surgery groups with regard to infection rates (p = 0.1), iatrogenic nerve injury (p = 0.53) or need for open reduction (p = 0.44). CONCLUSION: Our results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis. These results indicate that patient transfer to a specialist paediatric centre, often with consequent surgical delay, is a safe management option and also negates the obligation to carry out these procedures at night.

Combined AFM and STM measurements of a silicene sheet grown on the Ag(111) surface.

In this paper, we present the first non-contact atomic force microscopy (nc-AFM) of a silicene on a silver (Ag) surface, obtained by combining non-contact atomic force microscopy and scanning tunneling microscopy (STM). STM images over large areas of silicene grown on the Ag(111) surface show both (√13 × âˆš13)R13.9° and (4 × 4) superstructures. For the widely observed (4 × 4) structure, the observed nc-AFM image is very similar to the one recorded by STM. The structure resolved by nc-AFM is compatible with only one out of two silicon atoms being visible. This indicates unambiguously a strong buckling of the silicene honeycomb layer.

STM imaging, spectroscopy and manipulation of a self-assembled PTCDI monolayer on epitaxial graphene.

Scanning Tunneling Microscopy (STM), Scanning Tunneling Spectroscopy (STS), and manipulation studies were performed on an ordered self-assembled monolayer (SAM) of N,N'-bis(1-hexylheptyl)perylene-3,4:9,10-bis(dicarboximide) molecules on epitaxial graphene on hexagonal silicon carbide - SiC(0001). Four novel aspects of the molecular SAM on graphene are presented. Molecules adsorb in both armchair and zig-zag configurations, giving rise to six orientations of the molecular layer with respect to the underlying substrate. The interaction between the molecules and the graphene surface shifts the LUMO towards the Fermi level, inducing a charge transfer and the opening of a band gap in the graphene, with the LUMO inside. This decouples the LUMO from the surface rendering it invisible in the dI/dV spectroscopy. The HOMO only becomes visible at short tip-surface distances, as its energy lies within the band gap of the SiC substrate. Finally, the observed molecular defects are very particular, being composed exclusively of molecular dimers. These molecular dimers have a stronger interaction with the graphene than other molecules.

[Prospective trial comparing Airtraq and Glidescope techniques for intubation of obese patients]. / Étude prospective comparant la technique de l'Airtraq et du Glidescope lors de l'intubation chez les patients obèses.

OBJECTIVES: Videolaryngoscope techniques are more and more in use and tend to modify our approach for patients difficult to intubate. We compared two techniques, Airtraq and Glidescope with direct laryngoscopy, with special emphasis on ease of access to airway (Intubation Difficulty Score - IDS score, duration and success of intubation) and the impact on hemodynamic variables among patients with a BMI of more than 30. STUDY DESIGN: Prospective study randomised with minimisation technique. MATERIAL AND METHODS: Eighty patients have been allocated by minimisation to four groups: two groups being intubated with Airtraq, each one with a different investigator, and two with Glidescope videolaryngoscope technique. Induction of anesthesia was standardly performed with total intravenous anesthesia with remifentanil, propofol in TCI mode and rocuronium in bolus. Following parameters were recorded : intubation success based on intubation time and desaturation level, its duration, its impact on hemodynamic variables, IDS score and possible dental lesions. RESULTS: Intubation success was 100% for Glidescope and 80.6% for Airtraq (P=0.009). Airtraq allowed a better visualisation of the vocal cords (lower Cormack and Lehane score) than Glidescope. In contrast, alternative intubation techniques were significantly more often used in the Airtraq group. No difference could be detected between both systems on hemodynamic parameters. CONCLUSIONS: In obese patients, Glidescope allows intubation relatively easily without rescue techniques.

The paradox of an insulating contact between a chemisorbed molecule and a wide band gap semiconductor surface.

Controlling the intrinsic optical and electronic properties of a single molecule adsorbed on a surface requires electronic decoupling of some molecular orbitals from the surface states. Scanning tunneling microscopy experiments and density functional theory calculations are used to study a perylene molecule derivative (DHH-PTCDI), adsorbed on the clean 3 × 3 reconstructed wide band gap silicon carbide surface (SiC(0001)-3 × 3). We find that the LUMO of the adsorbed molecule is invisible in I(V) spectra due to the absence of any surface or bulk states and that the HOMO has a very low saturation current in I(z) spectra. These results present a paradox that the molecular orbitals are electronically isolated from the surface of the wide band gap semiconductor even though strong chemical bonds are formed.

[Guide for the use of jet-ventilation during ENT and oral surgery]. / Guide d'utilisation de la jet-ventilation en chirurgie ORL, trachéale et maxillo-faciale.

The aim of this synthesis was to give recommendations on the use of jet-ventilation during ENT surgical and endoscopy procedures. Literature was collected from PUBMED and analysed by the members of French association of anaesthesiologists in ENT surgery, all skilled in this field. Presentation of these recommendations was given during the general assembly held in Reims, the 15th May 2009. Jet-ventilation is especially indicated during upper airway endoscopy and laryngeal invasive endoscopic surgery. Furthermore, transtracheal jet ventilation is included on most of difficult oxygenation and difficult intubation algorithm. The main risk of jet-ventilation is pulmonary barotrauma when expiration of injected gas is impeded by an upper airway obstruction. Failure and complications of tracheal puncture are rare when performed by experimented operators. Clinical use of jet ventilation requires a dedicated device. Practice of jet ventilation without intubation may be dangerous when applied without control of driving pressure and end expiratory tracheal pressure. Every anaesthetist should be familiar with transtracheal ventilation since they may face a "cannot ventilate cannot intubate" situation. Upper airway endoscopy and laryngeal surgery are the ideal field for training jet ventilation, even more so as this technique offers perfect operative conditions. To apply this project, jet ventilation should be used more frequently in routine practice. To maintain skill, regular use of these techniques is required.

Theoretical simulations of the tip-induced configuration changes of the 4,4(')-diacetyl-p-terphenyl molecule chemisorbed on Si(001).

We have investigated from a theoretical point of view modifications of the 4,4(')-diacetyl-p-terphenyl molecule chemisorbed on Si(001) induced by the scanning tunneling microscope (STM). In previous experiments, these modifications were observed to occur preferentially at the end of the molecule after a +4.0 V voltage pulse and at the center after a +4.5 V voltage pulse. In the framework of ab initio simulations, we have realized a systematic energetic study of the dissociative chemisorption of one, two, or three phenyl rings of the substituted p-terphenyl molecule. Charge densities were then calculated for the investigated configurations and compared to the STM topographies. Before manipulation with the STM tip, the substituted p-terphenyl molecule is preferentially adsorbed without phenyl ring dissociation, allowing a partial rotation of the central phenyl ring. Our results show that the STM induced modifications observed at the end of the molecule might originate from the dissociation of two phenyl rings (one central and one external ring), while the modifications occurring at the central part of the molecule can be interpreted as a dissociation of the two external rings.

Germanium adsorption on Ag(111): an AES-LEED and STM study.

The adsorption of germanium on Ag(111) has been investigated using Scanning Tunneling Microscopy, Auger Electron Spectroscopy and Low Energy Electron Diffraction. From the shape of the Auger peak-to-peak versus time curves, we deduce that at room temperature the growth mode is nearly layer-by-layer at least for the first two layers. In the sub-monolayer range, the growth starts by the formation of a (mean square root of 3 x mean square root of 3)R30 degrees surface superstructure which is complete at 1/3 monolayer coverage. Beyond this coverage a rectangular c(mean square root of 3 x 7) superstructure is observed. STM images reveal that this last reconstruction is formed by an ordered arrangement of self-assembled Ge tetramers giving rise to a surprising undulation of the surface.

Difficulty for oxygen to incorporate into the silicon network during initial O2 oxidation of Si(100)-(2x1).

First principles calculations and scanning tunneling microscopy studies of the oxidation of Si(100)-(2x1) surfaces by molecular oxygen reveal that the surface silanone (O)(Si=O) species is remarkably stable, constituting the key intermediate for initial oxidation. The propensity for oxygen to remain within the top surface layer as opposed to incorporating within Si-Si backbonds is surprisingly high. This resistance to incorporation into a cubic lattice even at higher coverages could be a factor to facilitate surface amorphization in subsequent steps.

The utility of thrombo-elastography in the monitoring of aspirin therapy.

To assess the utility of the thrombo-elastogram in monitoring of aspirin therapy 25 healthy volunteers were selected and given low-dose aspirin therapy. Thrombo-elastography and platelet aggregometry were conducted at baseline and 1 week later. After 1 week of aspirin therapy, thrombo-elastogram data failed to demonstrate a significant change in the clotting profile. Platelet aggregometry identified significant changes in the clotting profile in response to stimulation with arachidonic acid, adrenaline and ADP. We conclude that thrombo-elastography may not have utility in monitoring of response to aspirin.

Atomic-scale STM experiments on semiconductor surfaces: towards molecular nanomachines.

The electronic or quantum control of individual molecules with the scanning tunnelling microscope offers exciting perspectives on operating molecular nanomachines. This implies the use of semiconductor surfaces rather than metallic surfaces which would rapidly quench the electronic excitations. We review recent results illustrating the state of the art and the main problems which need to be solved: the choice, design and properties of functionalized organic molecules on semiconductor surfaces; the control of the inelastic electronic channels through a single molecule; and the search for well-controlled atomic-scale wide-band-gap semiconductor surfaces.