Perioperative considerations in orthopaedic patients with diabetes mellitus: a review.

Patients with diabetes mellitus are predisposed to a host of orthopaedic problems which may require surgery and many patients with orthopaedic conditions may have unrecognised hyperglycaemia presenting for the first time at surgery. This group of patients are also prone to adverse surgical outcomes like post-operative infections and poor wound healing. The control of hyperglycaemia in orthopaedic patients with diabetes mellitus is the key in optimising surgical outcome in these patients. Peri-operative insulin is the main antihyperglycaemic agent of use. The risk of hypoglycaemia with tighter peri-operative glucose control outweighs its potential benefits. Blood glucose control with insulin infusion is better than sliding scale insulin. Control of infections and promotion of wound healing are necessary adjuncts in the management to optimise surgical outcome.

A review of obesity and orthopaedic surgery: the critical issues.

Obesity is a growing concern in the health community because of the morbidities associated with it. There is a higher occurrence of many orthopaedic conditions among obese individuals than their non-obese counter parts. Obesity also worsens the progression of many of these orthopaedic conditions. Studies have shown that obesity may have negative impact on bone metabolism and may be implicated in the pathophysiology of some orthopaedic conditions like osteoporosis, fractures, osteoarthritis and many soft tissue ailments by both reduction in bone mass and elaboration of proinflammatory cytokines. These contribute to preponderance of musculoskeletal co-morbidities among obese patients. Critical peri-operative issues which include increased cardiopulmonary risks, issues of special equipment, instrumentation, surgical approach, patients' positioning and adjustments in medication should be acknowledged and meticulously addressed in operative management of orthopaedic conditions in obese patients. Surgeries in obese patients are fraught with operative challenges and post-operative complications than in the non-obese and a good knowledge of the critical issues in surgical management of obese patients is necessary to facilitate decision making as well as rendering of effective and efficient orthopaedic care.

Chronic recurrent multifocal osteomyelitis: a case report and review of literature.

BACKGROUND: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare condition of largely unknown aetiology and pathogenesis with variable clinical and radiological features. There are no reports on CRMO to the best of our knowledge; in the West African sub region. OBJECTIVE: To present a case and review the literature on chronic recurrent multifocal osteomyelitis. METHODS: A 13-year-old male presented with a three-year history of recurrent discharging right thigh sinus and an 11-day history of a left shoulder swelling with discharging sinus. Detailed history was obtained and physical examination and radiological and microbiological tests carried out before treatments. RESULTS: There were periodic exacerbations of pain, swelling and discharge over affected areas. He had a short limb gait and shoulder asymmetry. His left shoulder was warm, erythematous and there was decreased range of movement in all directions. Investigations revealed an erythrycyte sedimentation rate (ESR) of 150mm/hr. Wound swabs taken at different times from the right thigh and shoulder sinuses revealed no growth. Radiographs of the left arm, right thigh and hip showed features consistent with chronic osteomyelitis. There were associated destruction of the left hip and soft tissues welling in the left shoulder. He was principally treated with non-steroidal anti-inflammatory drugs (NSAIDs) , antibiotics and dressing of sinuses for three months and had only mild relief of clinical features but no improvement in radiological picture. CONCLUSION: Chronic recurrent multifocal osteomyelitis is a diagnosis of exclusion which is usually under diagnosed because amongst other things, not much is known about it. Successful treatment is difficult to achieve, though some authors have reported good results with combined medical and surgical treatment.

Community acquired pneumonia in Port Harcourt Rivers State of Nigeria.

BACKGROUND: Community acquired pneumonia (CAP) is a major cause of death world wide. Knowledge of the likely pathogens and their sensitivity/resistance pattern can help in the choice of antibiotic therapy and improve outcome. OBJECTIVE: To identify the seasonal variation; age and sex distribution; bacteriology; antimicrobial sensitivity pattern of isolates; haematological data; radiology and clinicaloutcome of community-acquired pneumonia (CAP) in adult patients admitted to hospital in Port Harcourt, Nigeria. DESIGN: Prospective study. SETTING: University of Port Harcourt Teaching Hospital, and Braithwaite Memorial Hospital, Port Harcourt, Rivers State. PATIENTS: Adults admitted to the hospitals with CAP between 1 May 2002, and 30 April 2003. INTERVENTIONS: A diagnostic strategy using regular collection of sputum samples for gram stain, bacteriological culture and chest radiography were done. Blood cultures were done in severe cases. Antibiotic sensitivity testing was done on the positive cultures. RESULTS: During a 12 month period, 54 patients aged 16 to 82 years (mean 38.1 years) were evaluated. A total of 944 medical admissions were seen during the same period. This gives a prevalence rate of 5.7%. Twenty six classes of bacteria were isolated from the sputum of 23 patients (yield, 42.6%). Streptococcus pneumoniae, the most common pathogen, was isolated in nine cases (34.6%), followed by Klebsiella pneumoniae which was present in eight (30.8%). Other isolates included, Escherichia coli, four cases (15.4%), Pseudomonas aeruginosa, three cases (11.5%), and Staphylococcus aureus, two cases (7.7%). The commonest radiological pattern was lobar consolidation (49.9%) with no Distinct pattern associated with any conventional bacterial pathogen. The isolates showed good sensitivity to the newer and more expensive antibiotics (quinolines and cephalosporines) with marked resistance to the older and cheaper ones. However, clinical responses to benzyl penicillin and gentamycin were found to be good. Out of 54 patients evaluated, four (7.4%) died. CONCLUSION: Streptococcus pneumoniae and Klebsiella were common aetiological organisms of CAP in Port Harcourt. Treatment of CAP with benzyl penicillin remains an appropriate first line choice in this environment while the more expensive quinolines and cephalosporines can be used as backups.