Treatment of distal femur fractures in a regional Australian hospital.

AIM: To review our outcomes and compare the results of the Less Invasive Stabilization System (LISS) to other implants for distal femur fracture management at a regional Australian hospital. METHODS: The LISS is a novel implant for the management of distal femur fractures. It is, however, technically demanding and treatment results have not yet been assessed outside tertiary centres. Twenty-seven patients with 28 distal femur fractures who had been managed surgically at the Mackay Base Hospital from January 2004 to December 2010 were retrospectively enrolled and assessed clinically and radiologically. Outcomes were union, pain, Lysholm score, knee range of motion, and complication rates. RESULTS: Twenty fractures were managed with the LISS and eight fractures were managed with alternative implants. Analysis of the surgical techniques revealed that 11 fractures managed with the LISS were performed according to the recommended principles (LISS-R) and 9 were not (LISS-N). Union occurred in 67.9% of fractures overall: 9/11 (82%) in the LISS-R group vs 5/9 (56%) in the LISS-N group and 5/8 (62.5%) in the alternative implant group. There was no statistically significant difference between pain, Lysholm score, and complication rates between the groups. However, there was a trend towards the LISS-R group having superior outcomes which were clinically significant. There was a statistically significant greater range of median knee flexion in the LISS-R group with compared to the LISS-N group (P = 0.0143) and compared with the alternative implant group (P = 0.0454). CONCLUSION: The trends towards the benefits of the LISS procedure when correctly applied would suggest that not only should the LISS procedure be performed for distal femur fractures, but the correct principle of insertion is important in improving the patient's outcome.

Overaggressive stent expansion without intravascular imaging: impact on restenosis.

OBJECTIVE: Aggressive stent expansion is required for optimal strut apposition, but risk of stent deformation, fracture and subsequent restenosis is potentially greater when performed without intravascular imaging guidance. We investigated how frequently stents are 'overexpanded' and whether this correlates with restenosis. DESIGN AND SETTING: Single-centre prospective database study at a high-volume tertiary university hospital. PATIENTS: 243 patients undergoing single-vessel stenting for de novo stenosis in 277 lesions. Exclusion criteria were bifurcational, graft or left main disease and intravascular imaging use. All had ischaemia-driven repeat coronary angiography up to 48 months later. Degree of stent overexpansion was the difference between nominal and final stent size. RESULTS: Stents were expanded above nominal in 99% of cases and above rated burst pressure in 52%. Stents were expanded >20% above nominal in 12% of cases. Stents overexpanded by >20% were smaller (2.87 vs 3.19 mm), longer (24 vs 19 mm) and more often drug-eluting (53% vs 27%). Angiographic restenosis was observed in 80 lesions (29%). There was no correlation between degree of overexpansion and per cent angiographic restenosis across the whole group (R(2)=-0.01; p=0.09), in those with stent overexpansion >20% (p=0.31) or small stents <3 mm (p=0.71). Indeed, in the group with stent overexpansion >25%, the greater the overexpansion, the less the per cent angiographic restenosis (p=0.02). CONCLUSIONS: In this real-world population undergoing non-complex percutaneous coronary intervention without intravascular imaging, any tendency to overaggressive stent expansion did not predispose at all to restenosis.

Compliance charts to guide non-complex small artery stenting: validation by quantitative coronary angiography.

OBJECTIVE: To determine whether stent sizing derived from manufacturers' compliance charts provides a reasonable in vivo estimate of final minimum lumen diameter (MLD) when compared with quantitative coronary angiography (QCA). DESIGN: Single-centre measurement comparison study. SETTING: Tertiary referral university hospital. PATIENTS: Fifty cases receiving a single stent for non-complex de novo stenosis were randomly selected from the percutaneous coronary intervention database of our high-volume centre. Restenosis, stent thrombosis, bifurcational disease, rotablation, left main or graft stenting, intravascular ultrasound or kissing balloon inflations were exclusion criteria. MAIN OUTCOME MEASURES: Equality and limits of agreement (LOA) between compliance chart and QCA measurements of final MLD, especially focusing on patients with small stents<3 mm. The paired t test and Bland-Altman plots were used to compare measurements. RESULTS: There was no significant difference between compliance chart-derived and QCA final MLD (n=50; mean -0.034 mm, SD 0.35, 95% CI -0.132 to +0.064; p=0.49), with reasonable Bland-Altman LOA between the two methods of assessing final MLD in the overall group (LOA -0.72 to +0.66 mm), as well as in the group of particular interest with Derived final MLD <3 mm (n=30; mean 0.019 mm, SD 0.27, 95% CI -0.082 to +0.119; p=0.71; LOA -0.52 to +0.56 mm). CONCLUSIONS: Compliance charts provide an acceptable estimate of final MLD and are a reasonable guide to sizing during non-complex stenting, especially in small vessels <3 mm.

The implementation of a gastroenteritis education program.

PURPOSE: The objective of this study is to determine if intensive gastroenteritis education results in greater caregiver knowledge and a reduction in future emergency department (ED) visits. METHODS: This was a concurrent control, prospective, single-blind trial. One hundred five children aged 3 to 48 months were assigned to receive an ED-based educational intervention and a home nursing education visit or neither. In the ED and 1 and 6 months postvisit, caregivers completed a 38-item Caregiver Gastroenteritis Knowledge Questionnaire. RESULTS: One month postintervention, the scores in the intervention group had risen compared with controls (3.3 vs 0.9, P = .11). At 6 months, the difference was negligible. At 1-year follow-up, 37% of children in both groups had an ED any-cause visit; gastroenteritis visits occurred in 27% and 13%. CONCLUSION: An intensive ED and home gastroenteritis education program did not result in a long-term increase in disease-specific caregiver knowledge or a reduction in future ED visits.

Cytokine array comparisons of plasma from cycling fertile women on cycle day 5 and ovulation.

PROBLEM: To identify plasma immuno-regulatory molecules up or down regulated between the follicular phase and ovulation of the human menstrual cycle. METHOD OF STUDY: RayBio cytokine arrays were used to screen 174 immuno-regulatory molecules in plasma collected during the follicular phase at menstrual cycle day 5 and at ovulation from five healthy, non-smoking, fertile women of reproductive age not using hormonal contraception. RESULTS: A total of 23 differentially expressed molecules were found: 10 molecules were differentially up-regulated and 13 down-regulated at ovulation compared with that at the follicular phase (alpha = 0.05, false discovery rate of 0.45). CONCLUSION: Circulating immuno-regulatory molecules fluctuate over the menstrual cycle in healthy women. The combination of differentially expressed molecules suggests roles in cyclical regulation of angiogenesis and immune cell trafficking.

Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation.

OBJECTIVE: The goal was to determine, in children with myocarditis, the frequency of various presenting symptoms and the sensitivity of clinical and laboratory investigations routinely available in the emergency department. METHODS: We performed a retrospective review of all patients < 18 years of age who were diagnosed as having myocarditis at our institution between May 2000 and May 2006 and who initially presented to an emergency department. Patients were categorized as having definite myocarditis (positive endomyocardial biopsy results) or probable myocarditis (diagnosis assigned by a pediatric cardiologist on the basis of history, physical examination, and investigation results in the absence of an endomyocardial biopsy or in the presence of negative biopsy results). All patients were assigned a predominant category of symptoms at presentation on the basis of criteria defined a priori. RESULTS: There were 16 cases of definite myocarditis and 15 cases of probable myocarditis. The age distribution was nonnormal, with peaks among children < or = 3 years and > or = 16 years of age. Of 14 patients who were seen by a physician before being diagnosed with myocarditis, 57% were originally diagnosed as having pneumonia or asthma. Thirty-two percent of patients presented with predominantly respiratory symptoms, 29% had cardiac symptoms, and 6% had gastrointestinal symptoms. Although evidence of cardiac dysfunction was frequently present in the form of respiratory distress, only a minority of children had evidence of hepatomegaly or abnormal cardiac examination results. The sensitivities of electrocardiograms and chest radiographs as screening tests were 93% and 55%, respectively. Among laboratory tests studied, aspartate aminotransferase measurement was the most sensitive (sensitivity: 85%). CONCLUSIONS: Children with myocarditis present with symptoms that can be mistaken for other types of illnesses; respiratory presentations were most common. When clinical suspicion of myocarditis exists, chest radiography alone is an insufficient screening test. All children should undergo electrocardiography. Aspartate aminotransferase testing may be a useful adjunctive investigation.