Percutaneous management of ununited femoral fracture.

We describe a percutaneous technique used for the management of non-union in a complex diaphyseal femoral fracture treated initially with intramedullary nailing. Seven months after the initial fixation, a proximal fracture gap failed to progress to union. A percutaneous procedure involving fracture gap freshening and supplementation with bone morphogenetic protein and demineralised bone matrix resulted in a satisfactory progression to union. The percutaneous procedure allowed less soft tissue insult around the fracture site, a short hospital stay, a fast return to the preoperative level of mobility and fracture union.

Rapid westernization of children's blood cholesterol in 3 countries: evidence for nutrient-gene interactions?

The aim of this study was to examine potential factors that modify blood cholesterol among children in countries in which dietary and lifestyle habits are becoming westernized. Population data on serum total and lipoprotein cholesterol, anthropometric indexes, and dietary intake were reviewed and compared for children aged 1-18 y from Japan, Spain, and the United States. The data show that total serum cholesterol in Japanese and Spanish children recently exceeded the 75th percentile for US children, primarily reflecting LDL cholesterol, although both LDL and HDL cholesterol contributed. Adiposity indexes do not explain the trends observed. Total and saturated fat intakes increased substantially in both Japan and Spain but in Japan are still lower than intakes in the United States. The Hegsted equation was used to relate differences in serum cholesterol to dietary fat intake. Changes in total serum cholesterol followed established dietary correlations among children in Spain, but not in Japan. Serum cholesterol in Japanese children was predicted to be 0.20-0.32 mmol/L lower than in US children; actual concentrations were considerably higher. These results suggest that a rapid westernization of children's blood cholesterol concentrations has occurred in Japan and Spain. Changes in fat intake predict changes in blood cholesterol in Spain, but not in Japan. Differences in genetic response to diet in certain populations, such as the Japanese, may explain higher blood cholesterol concentrations with lower fat intakes compared with the United States.

The BWM spinal fixator system. A preliminary report of a 2-year prospective, international multicenter study in a range of indications requiring surgical intervention for bone grafting and pedicle screw fixation.

STUDY DESIGN: A prospective, international, multicenter study of 400 patients who received the BWM fixator system. OBJECTIVES: To assess the effectiveness and safety of the system in the management of various conditions requiring spinal fixation and bone grafting. SUMMARY OF BACKGROUND DATA: The BWM system was developed for the management of spinal instability of all etiologies occurring in the thoracic, thoracolumbar, and lumbosacral spine. METHODS: Patients with fracture, tumor, spondylolisthesis, spondylitis, failed back, or other degenerative conditions of the spine received the BWM instrumentation as described in the study literature and were regularly reviewed for 2 years. RESULTS: The results from the first 200 patients to complete the study showed an overall graft fusion rate of 94% (95% confidence interval: 91.3%-97.6%). There were marked improvements in measures of functional ability (P < 0.001, Wilcoxon test). Before surgery, less than half the patients were capable of outdoor activity. At 2 years, 80% were able to undertake outdoor activity. There were few perioperative difficulties reported. Postoperative complications associated with major surgery were seen in 18% patients. There were 23 (2.6%) pedicle screw failures, including two loosenings, and 13 (2.5%) spacer element failures, including three loosenings. CONCLUSIONS: Clinical failure was not necessarily a consequence of component failure. The BWM fixator provided excellent stabilization during the process of bone graft consolidation. The risks of complication or component failure were no higher than those associated with similar devices.

Snacking habits of senior Americans.

This study evaluated snacking behavior among 335 non-institutionalized Americans aged 55 years and older. Respondents were randomly selected from the fifty states excluding Hawaii and Alaska and questioned by trained telephone interviewers using the CATI system. The study found that the majority of seniors snacked at least once daily with only 2.1% reporting that they never snack. Morning is the least common and evening is the most common time for snacking. Almost all snacking occurs at home. When selecting snacks, taste outranks nutrition as selection criteria. Fruits were popular but were chosen less often than other snacks. Findings suggest that snacking should be targeted with specific nutrition education messages that address the influences of time of day, location, and qualities of foods upon the choices made when snacking.

Snacking patterns among 1,800 adults and children.

OBJECTIVE: To study snacking behavior, including frequency, time of day, location, and qualities sought in snack choices. DESIGN: A survey questionnaire was designed for use by trained telephone interviewers to interview adults and for self-administration by students in the fifth and sixth grades. SETTING: A national random sample was drawn of 1,510 adults, and a nonrandom sample was drawn of 290 fifth and sixth graders attending schools in four states. SUBJECTS: Adults were randomly selected by a computerized telephone directory system from 48 states (Hawaii and Alaska were excluded). The five schools surveyed were selected to represent a major inner city (Atlanta, Ga), a suburban area (Englewood, NJ), a midsize city (two schools in St Louis, Mo), and a rural area (Hickman, Calif). RESULTS: The majority of children in all age groups snacked at least once daily. Morning was the least common and afternoon was the most common time for snacking. Almost all snacking occurred at home. In the selection of snacks, taste outranked nutrition as the most important characteristic of a snack. Fruits were popular with all age groups, but overall they were chosen less often at snacktime than foods from other categories. APPLICATIONS: Snacking should be targeted with specific nutrition education messages that address the influences of time of day, location, and qualities of foods on snack choices.

Intramedullary locking nails for femoral shaft fractures in elderly patients.

Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient.

Three-dimensional kinematics of the human back.

This study examined the use of a new device, the 3space isotrak, to measure the kinematic behaviour of the backs of normal subjects and of patients from two orthopaedic practices. The device was shown to measure angles with a root mean square error of less than 0.2° and individuals showed a maximum standard deviation from the mean of movements repeated five times of less than 4°. Eighty normal subjects both male and female in four age ranges 20-29, 30-39, 40-49 and 50 years and over were measured. The three-dimensional kinematic patterns were similar for all groups, showing normals to have clearly identified patterns of movement. A general trend for decreasing mobility with age and some sex differences were also demonstrated. The clinical series showed widespread disruption to the primary and coupled movements of all the patients. When grouped together by clinical diagnosis the patient groups showed evidence of discrete and identifiable alterations from the normal kinematic patterns. However, further studies of homogeneous patient groups are required in order to demonstrate whether the measurements are of actual clinical use. The clinical studies also demonstrated that clinical subjective assessment of back mobility bore little relation to the true movements and therefore the clinical measurement of back movements should be reassessed. This study has shown the 3space isotrak to be an effective tool in the clinic for the three-dimensional kinematic measurement of low back mobility.

Legal requirement of private practice medical records.

The hospital medical record is a critical communication vehicle for the numerous health professionals who provide care to each patient. It is also an essential evidentiary tool in malpractice suits. Even though the medical record is not the sole information upon which the courts will rely in determining negligence liability, it can serve as an important chronology of care. Dietitians entering private practice, whether with a physician or not, should establish a system of record keeping. Although specific standards have not been set for private patient records, it is argued that records kept must meet many of the requisite guidelines for medical records in institutional settings. Additionally, the records must provide documentation that may be absent and difficult to obtain in the private setting. Discussed are legal issues surrounding patient records of the dietitian in private practice.

Malpractice liability in private practice of nutrition.

To date, no dietitian has been successfully sued in a malpractice case. However, as the number of dietitians in private practice increases, the risk of such suits increases proportionally. What is malpractice law and how does it apply to dietitians? What tests do the courts apply to determine whether injuries a patient has suffered were the fault of the health professional caring for that patient? What circumstances might ameliorate the patient's claims and limit the liability of the dietitian? Even though each case will be decided independently on the basis of the evidence presented in court, general principles and guidelines govern the courts' decision-making process. Among the elements that must be proved by a patient seeking legal redress are actual injury, a relationship of duty between the parties, breach of that duty, and a cause-and-effect relationship between the breach of duty and the injury suffered. Awareness of those principles can assist dietitians in conforming their conduct to practices that minimize their risk of liability.

USDA's strategies for the 80s: nutrition education.

In 1969, the White House Conference on Food, Nutrition and Health made recommendations to government to improve the nation's posture relating to nutriture. Among these were specific calls for improved nutrition education programs, including the use of the mass media, and improvement in ways of meeting the food needs of low-income families. Congress has since passed legislation addressing some of the recommendations, and the USDA has expanded and initiated new programs to implement them. These include the Expanded Food and Nutrition Education Program (EFNEP), Special Supplemental Feeding Program for Women, Infants and Children (WIC), the Food Stamp program, Commodity Supplemental Food program, and the Nutrition Education and Training program (NET). The USDA has set forth eight objectives to be met in the 1980s as it moves ahead as the "lead" agency for nutrition research, Extension, and nutrition education.

Nutrition legislation: strategy for success.

The decision to sponsor legislation should be carefully considered. Participation in the legislative process requires a major commitment of your organization's time and resources. You will need first to define short- and long-term legislative goals and then to draft these concepts into a bill and estimate its cost. You will need to select a sponsor, considering the commitment, staff interest, committee assignment, political party, and connections of the legislator. Next, a coalition of groups must be formed to support your bill and maintain media coverage to ensure public interest in it. Testimony and appearances during committee hearings must be made. Grassroots lobbying and letter-writing campaigns will further consume your organization's energies. A strategy for nutrition legislation can yield satisfying results. In a relatively short time, you can literally turn the tide of nutrition programs and funding within your state. But the price is high. Participation in the legislative process is not for the weak-hearted, the meek, the indecisive, or the uncommitted. You will get out of it what you put into it. Plant a turnip, get a turnip!