Pelvic and acetabular fracture care in England: current workload and future directions.

INTRODUCTION: Fractures of the pelvis and acetabulum (PAFs) are challenging injuries, requiring specialist surgical input. Since implementation of the major trauma network in England in 2012, little has been published regarding the available services, workforce organisation and burden of PAF workload. The aim of this study was to assess the recent trends in volume of PAF workload, evaluate the provision of specialist care, and identify variation in available resources, staffing and training opportunity. METHODS: Data on PAF volume, operative caseload, route of admission and time to surgery were requested from the Trauma Audit and Research Network. In order to evaluate current workforce provision and services, an online survey was distributed to individuals known to provide PAF care at each of the 22 major trauma centres (MTCs). RESULTS: From 2013 to 2019, 23,823 patients with PAF were admitted to MTCs in England, of whom 12,480 (52%) underwent operative intervention. On average, there are 3,971 MTC PAF admissions and 2,080 operative fixations each year. There has been an increase in admissions and cases treated operatively since 2013. Three-quarters (78%) of patients present directly to the MTC while 22% are referred from regional trauma units. Annually, there are on average 37 operatively managed PAF injuries per million population. Notwithstanding regional differences in case volume, the average number of annual PAF operative cases per surgeon in England is 30. There is significant variation in frequency of surgeon availability. There is also variation in rota organisation regarding consistent specialist surgeon availability. CONCLUSIONS: This article describes the provision of PAF services since the reorganisation of trauma services in England. Future service development should take into account the current distribution of activity, future trends for increased volume and casemix, and the need for a PAF registry.

Effects of Cover Crops on Pratylenchus penetrans and the Nematode Community in Carrot Production.

Cover cropping is a common practice in U.S. Midwest carrot production for soil conservation, and may affect soil ecology and plant-parasitic nematodes-to which carrots are very susceptible. This study assessed the impact of cover crops-oats (Avena sativa), radish (Raphanus sativus) cv. Defender, rape (Brassica napus) cv. Dwarf Essex, and a mixture of oats and radish-on plant-parasitic nematodes and soil ecology based on the nematode community in Michigan carrot production systems. Research was conducted at two field sites where cover crops were grown in Fall 2014 preceding Summer 2015 carrot production. At Site 1, root-lesion (Pratylenchus penetrans) and stunt (Tylenchorhynchus sp.) nematodes were present at low population densities (less than 25 nematodes/100 cm3 soil), but were not significantly affected (P > 0.05) by cover crops. At Site 2, P. penetrans population densities were increased (P ≤ 0.05) by 'Defender' radish compared to other cover crops or fallow control during cover crop growth and midseason carrot production. At both sites, there were few short-term impacts of cover cropping on soil ecology based on the nematode community. At Site 1, only at carrot harvest, radish-oats mixture and 'Dwarf Essex' rape alone enriched the soil food web based on the enrichment index (P ≤ 0.05) while rape and radish increased structure index values. At Site 2, bacterivore abundance was increased by oats or radish cover crops compared to control, but only during carrot production. In general, cover crops did not affect the nematode community until nearly a year after cover crop growth suggesting that changes in the soil community following cover cropping may be gradual.

Experience of managing open fractures of the lower limb at a major trauma centre.

INTRODUCTION: In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. METHODS: From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. RESULTS: Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. CONCLUSIONS: Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.

Discovery of localized regions of excess 10-TeV cosmic rays.

The 7 year data set of the Milagro TeV observatory contains 2.2 x 10(11) events of which most are due to hadronic cosmic rays. These data are searched for evidence of intermediate scale structure. Excess emission on angular scales of approximately 10 degrees has been found in two localized regions of unknown origin with greater than 12sigma significance. Both regions are inconsistent with pure gamma-ray emission with high confidence. One of the regions has a different energy spectrum than the isotropic cosmic-ray flux at a level of 4.6sigma, and it is consistent with hard spectrum protons with an exponential cutoff, with the most significant excess at approximately 10 TeV. Potential causes of these excesses are explored, but no compelling explanations are found.

Evidence for TeV gamma-ray emission from a region of the galactic plane.

Gamma-ray emission from a narrow band at the galactic equator has previously been detected up to 30 GeV. We report evidence for a TeV gamma-ray signal from a region of the galactic plane by Milagro, a large-field-of-view water Cherenkov detector for extensive air showers. An excess with a significance of 4.5 standard deviations has been observed from the region of galactic longitude l E (40 degrees, 100 degrees) and latitude /b/ < 5 degrees. Under the assumption of a simple power law spectrum, with no cutoff in the EGRET-Milagro energy range, the measured integral flux is phi gamma(>3.5 TeV) = (6.4 +/- 1.4 +/- 2.1) x 10(-11) cm(-2) s(-1) sr(-1). This flux is consistent with an extrapolation of the EGRET spectrum between 1 and 30 GeV in this galactic region.

The effects of music on cardiac patients on bed rest.

Hospitalizations that require invasive cardiac procedures or support with an intra-aortic balloon pump can be unsettling. This study was undertaken to measure the effect of a music intervention on physiologic and psychological responses of patients on bed rest due to procedural sheaths or an intra-aortic balloon pump. A randomized, two-group, pretest/post-test design was utilized to measure the effect of a 30-minute music intervention on heart rate, blood pressure, respiratory rate, skin temperature, pain perception, and mood states. One hundred forty subjects participated, 65 in the control group and 75 in the treatment group. There were no significant differences between the groups in demographic, clinical, or baseline variables, except for respiratory rate. After the music intervention, there were reductions in blood pressure, respiratory rate, and psychological distress, as measured by the Profile of Mood States (p < 0.05). Music appeared to affect selected physiologic responses and reduce psychological distress in patients on bed rest.

Electronic home monitoring of congestive heart failure patients: design and feasibility.

The efficacy of electronic monitoring in the home care of heart failure (HF) patients has not been widely reported. We developed a Vital Sign System (VSS) monitoring device capable of measuring the weight, blood pressure, and heart rate of congestive heart failure (CHF) patients in the home and transmitting these measurements via modem to a World Wide Web server. In this study of 22 CHF patients, we tested the reliability of the VSS electronic measurements compared to manual measurements taken by visiting home care nurses and ease of use of the VSS units as rated by both patients and home care nurses. The correlation of electronic to manual measurements was high (weight r=0.99; systolic blood pressure [SBP] r=0.84; diastolic blood pressure [DBP] r=0.54; heart rate [HR] r=0.88). The mean difference between electronic and manual measurements was within an acceptable range for clinical surveillance and care of CHF patients (weight 1.6 lbs; SBP 8.8 mm Hg; DBP 9.2 mm Hg; HR 0.7 bpm) The devices were rated favorably by both nurses and patients. The VSS monitoring device is a reliable, feasible, and favorably rated technology for home surveillance of CHF patients. (c)1999 by CHF, Inc.

Cat-scratch disease in Hawaii: etiology and seroepidemiology.

OBJECTIVE: To study the etiology and seroepidemiology of cat-scratch disease (CSD) in Hawaii. METHODS: Blood and fine-needle aspirate (FNA) from the lymph nodes of 39 consecutive patients with clinical CSD were cultured for Bartonella henselae, and blood samples from index cats, stray cats, and dogs were cultured and their sera were tested by indirect fluorescence antibody test for antibodies to B. henselae and Afipia felis. Sera from age- and sex-matched human subjects without cat exposure served as controls. RESULTS: Warthin-Starry staining showed positive results in only 4 of 32 FNAs, and B. henselae was isolated from only one FNA specimen. All of 38 patients who had two or more sera tested had elevated titers of antibody to B. henselae. Only 1 of 48 human control sera had antibody to B. henselae. Of 31 kittens, 21 had positive blood culture results and elevated antibody titers to B. henselae. Of three adult cats, all had negative blood culture results, but they had serologic evidence of past infection. Of 23 adult stray cats, 18 had elevated titers of antibody to B. henselae, but in only one was the blood culture result positive. Results of IFA tests were marginally positive for A. felis in 1 of 29 patients with CSD and in one adult stray cat and one dog. CONCLUSIONS: This study shows that the B. henselae IFA test is both highly sensitive and specific for the detection of infection caused by B. henselae and for the laboratory diagnosis of CSD, and that FNA is seldom helpful in confirming the diagnosis. We further demonstrated that CSD in Hawaii is due to B. henselae and that infection is directly linked to the scratch or bite of a kitten. Older cats seldom have bacteremia but often have serologic evidence of past infection. Our study fails to implicate dogs in the epidemiology of CSD in Hawaii, and A. felis was not etiologically implicated in CSD in the human subjects and animals we studied.

An electromechanical spinal injury technique with dynamic sensitivity.

Over the past decade, our laboratory has attempted to create a simple, accurate device that could be used to produce reliable and quantifiable spinal cord injuries in the rodent. We report here on our latest of several modifications of a spinal cord impactor that has allowed us to meet these design criteria. The impactor uses the dynamic capacity of an electromagnetic driver (Ling shaker) and a unique pattern generator to briefly compress the dorsal surface of the spinal cord at velocities that may mimic compression injuries seen in the human. Calibrated, independent transducer systems provide open-loop output of the precise movement (displacement) of the impactor probe and the force necessary to achieve a given displacement. Touch sensitivity is accomplished by vibrating the probe slightly as it approaches the dural surface. This also allows a known biomechanical starting point. This combination of improvements in sensitivity and ability to measure all components of the dynamic compression has allowed us to determine detailed biomechanical descriptors of these impact injuries with low coefficients of variation. Furthermore, such descriptors correlate highly with histopathologic and behavioral outcome measures in animal populations with a variety of injury severities.

Intraoperative radiation therapy of pancreatic carcinoma: a report of RTOG-8505. Radiation Therapy Oncology Group.

The Radiation Therapy Oncology Group in 1985 began a study of IORT plus external beam radiation therapy for patients with locally unresected, non-metastatic pancreatic cancer. Patients were treated with a combination of 2000 cGy of IORT and postoperative external beam radiation therapy to 5040 cGy in combination with IV 5-FU (500 mg/m2/day on the first 3 days of the external beam treatment). As patients were registered on study prior to exploration, it was expected that a number of patients would be excluded from further analysis at the time of surgery. Eighty-six patients were entered on study through 6/1/88 and analyzed through 4/90. Fifty-one patients were fully analyzable. Median survival time of the 51 patients was 9 months with an 18-month actuarial survival rate of 9%. Local control could not be adequately evaluated in this multi-institutional study. Major postoperative complications were not excessive and occurred in 12% of patients. Two patients had major late morbidity leading to death, one from duodenal bleeding and the second from biliary obstruction. Although this study does demonstrate the feasibility of IORT in a multi-institutional setting, it does not demonstrate any advantage of IORT over conventional therapy for this disease.

Correlation between parameters of spinal cord impact and resultant injury.

It is difficult and expensive to produce and maintain animals with experimental spinal cord injuries. In order to reduce the expenditure of time, money, and animals, a method of predicting the final neurologic deficit from the mechanical parameters of the initial injury is needed. An attempt was made to ascertain the mechanical parameter(s) of a spinal cord injuring impact which best predict(s) the extent of the subsequent injury. Twelve rats were laminectomized and the spinal cords contused with an impactor which recorded force and cord surface displacement. Spinal cord lesion volume was measured after killing at 21 days. The records of displacement and force were used to generate velocity, momentum, power, and energy. The maximum values of the six descriptors of the impact were checked for linear statistical correlation with lesion volume. The nonparametric correlations of the impact descriptors with gait scores from other work were also examined. All descriptors correlated at the 1% level many times; force and displacement correlated at the 1% level most of the time. The displacement of one cord surface with respect to the other was judged to be the most useful parameter because it correlated very nearly as well as force with the subsequent measures of trauma and better than the others (but perhaps not significantly better), and because it is technically easier to measure and control.

A behavioral and anatomical analysis of spinal cord injury produced by a feedback-controlled impaction device.

In order to provide a reproducible experimental spinal cord injury with immediate feedback on the mechanical properties of the impact, we have developed an electro-mechanically driven, feedback-controlled impaction device. The device is sensitive to the characteristics of the injured tissue and allows continuous manipulation of impact force or tissue displacement. The current study describes the anatomical and behavioral outcomes of a range of impacts and examines the ability of the device to produce a consistent traumatic injury. Rats were subjected to spinal cord trauma at the midthoracic level. Group II received a wide range of impacts that were preset at a desired force level and group III received impacts preset for a constant displacement of the spinal cord surface. Group I served as laminectomy controls. Behavioral testing included assessments of general and fine locomotor skills (open field and grid walking) and postural adjustment to displacement (inclined plane). Lesion volumes and percentage area of the cord occupied by the lesion were assessed postmortem. For group II, significant correlations between the physical descriptors of the impact and the behavioral measures were observed early during the postoperative period for open field and inclined plane performance and later in the recovery period for grid walking. Lesion measures correlated significantly with impact descriptors and with behavioral measures as well. Group III showed consistent behavioral deficits which partially recovered in the postoperative interval. The behavioral results correlated well with the lesion measures for this group also. The results indicate that it is possible to produce an intermediate lesion in the rat which results in consistent recovery with a residual deficit 3 weeks postoperatively, using a device that allows for immediate assessment of the physical descriptors of impact trauma.

Cysts of the tunica albuginea testis: a report of 3 cases with a review of the literature.

We report 3 cases of cysts of the tunica albuginea. A review of the literature yielded only 12 similar cases. In all cases described testicular neoplasm was suspected preoperatively and orchiectomy was planned. We used a conservative surgical approach that permitted preservation of the testes.