Cycling and spinal trauma: A worrying trend in referrals to a national spine centre.

INTRODUCTION: Cycling has seen a large increase in popularity worldwide over the last number of years. This has been linked to an increase in the number of road traffic accidents involving cyclists. Participation in cycling as part of competitive sport and endurance events has seen particular growth. AIM: To examine patients referred with spinal trauma related to cycling and to assess whether the growing popularity of cycling and particularly competitive cycling is linked to an increase in spinal trauma. METHODS: A retrospective analysis was carried out of a prospectively maintained database of referrals to a national referral centre for spinal trauma over a 4-year period (2010-2013). Data were further analysed for years 2012-2013, as there were incomplete data for years 2010-2011. RESULTS: Spinal injuries involving cyclists increased by 200% from 2010 to 2013. In comparison those involving cars only increased by 29% and motorcycles reduced by 68%. From 2012 to 2013 there were 24 cyclist trauma referrals. The most common level injured was cervical spine (71%). Five patients (20.8%) had neurological deficit with 12.5% complete paralysis ASIA A disability score. The spinal fixation rate was 29.1%, 16.6% were managed with a HALO device. In total, 25% of patients were injured whilst training on a racer style bicycle, including all of the patients with complete spinal cord injury. CONCLUSION: There has been a significant increase in spinal trauma due to cycling accidents over this four year period. Competitive cycling has been a factor in the most severely injured patients. Increased public awareness campaigns for those participating in cycling for sport may be warranted.

The Selfie Wrist - Selfie induced trauma.

The selfie phenomenon has exploded worldwide over the past two years. Selfies have been linked to a large number of mortalities and significant morbidity worldwide. However, trauma associated with selfies including fractures, is rarely publicised. Here we present a case series of upper extremity trauma secondary to selfies across all age groups during the summer period. Four cases of distal radius and ulna trauma in all age groups were reported. This case series highlights the dangers associated with taking selfies and the trauma that can result.

Assessment of the 2D:4D ratio in aggression-related injuries in children attending a paediatric emergency department.

BACKGROUND: The 2D:4D ratio is a sexually dimorphic trait. A lower ratio is correlated with sporting prowess, successful financial trading, risk taking behaviour, aggression, and aggression-related injuries, such as the fifth metacarpal fractures. AIMS: We aimed to assess if the ratio correlates to skeletally immature patient aggression. METHODS: Radiology reports were searched for the terms "5th metacarpal" or "boxer". Of 537 X-rays, 142 had fractures. The mechanism of injury was recorded in 102 patients, differentiating aggressive and non-aggressive injury groups. Bone age and chronological age were recorded. RESULTS: A clear male preponderance for aggression was identified with only 60% of non-aggressive injuries occurring in males compared to 95% in the aggression group (p < 0.001). Patients with aggression injuries were older chronologically (14.6 vs 12.7, p < 0.001) and by bone age (14.5 vs 13.0, p < 0.001). For male patients, there was no difference in the 2D:4D ratio (p = 0.94); however, for females, the difference was significant (p = 0.04). CONCLUSIONS: Aggression injuries occur at an older age and are more common in males. In the female cohort, there was a distinct difference in digit ratio.

'A band of brothers'-an exploration of the range of medical ethical issues faced by British senior military clinicians on deployment to Afghanistan: a qualitative study.

AIMS: To identify and explore features of ethical issues that senior clinicians faced as deployed medical directors (DMDs) to the British Field Hospital in Afghanistan as well as to determine the ethical training requirements for future deployments. METHOD: A qualitative study in two phases conducted from November 2014 to June 2015. Phase 1 analysed 60 vignettes of cases that had generated ethical dilemmas for DMDs. Phase 2 included focus groups and an interview with 13 DMDs. FINDINGS: Phase 1 identified working with limited resources, dual conflict of meeting both clinical and military obligations and consent of children as the most prevalent ethical challenges. Themes found in Phase 2 included sharing clinical responsibilities with clinicians from other countries and not knowing team members' ways of working, in addition to the themes from Phase 1. DISCUSSION: This study has drawn together examples of scenarios to form a repository that will aid future training. Recommendations included undertaking ethics training together as a team before, during and after deployment which must include all nationalities who are assigned to the same operational tour, so that different ethical views can be explored beforehand.

Factors associated with fertility of nulliparous dairy heifers following a 10-day fixed-time artificial insemination program with sex-sorted and conventional semen.

OBJECTIVE: To examine factors associated with fertility on dairy farms that used a common fixed-time artificial insemination (FTAI) program in yearling heifers. METHODS: Records were analysed from 954 yearling heifers on 10 south-west Victorian dairy farms that used a common FTAI program, involving the insertion of a 1.9-g progesterone-releasing device for 10 days; 2 mg oestradiol benzoate at insertion; 500 µg cloprostenol on day 7; and FTAI 48 h after device removal. Weight, age, expression of oestrus, sire, semen type (frozen sex-sorted or frozen conventional) and timing of insemination were examined for their relationship with first-service conception rates. RESULTS: Heifers over 300 kg body weight were 1.18-fold more likely to express oestrus during the FTAI program. For every extra 1 kg, there was a 1.5% increase in the likelihood of expressing oestrus. First-service conception rates were 40.3% and 56.0% for sex-sorted and conventional semen, respectively, and were significantly higher when oestrus was expressed. The difference was greater for sex-sorted semen (3.4-fold) compared with conventional semen (1.5-fold). The interval from device removal to insemination varied between 47 and 51.4 h and had no significant effect on conception rates. However, there was a trend towards a higher conception rate for sex-sorted semen when inseminations were performed >50 h after device removal. CONCLUSIONS: Increased fertility was associated with larger heifers and heifers that expressed oestrus, particularly when sexed-sorted semen was used. Variation in the timing of AI with respect to device removal between 47 and 51.4 h did not adversely affect conception rates.

The 100 most cited publications in cardiac surgery: a bibliometric analysis.

INTRODUCTION: This study is a citation analysis of the top 100 most cited papers in adult cardiac surgery. Bibliometric analyses are viewed as a proxy marker of a paper's influence and, therefore, an analysis of the most influential papers published in recent decades. METHODS: Impact factor ranking as of 2012 was used to decide which journals to include in our searches. The Thompson Reuters Web of Knowledge was used to search for citations of all papers relevant to cardiac surgery within selected journals. Journals in the areas of surgery, cardiothoracic surgery, general medicine, anaesthesia, perfusion and pathology were included. RESULTS: The most frequently cited paper was found to be that of Nashef et al. (Eur J Cardiothorac Surg 16(1):9-13, 1999) introducing the EuroSCORE operative risk evaluation system. A number of authors including Alderman, Carpentier and Cox had more than one paper in the top 100. CONCLUSION: Despite the potential flaws with bibliometric analysis, and its application to cardiac surgery, there is inherent merit in an analysis of this type.

The forgotten foot - An assessment of foot and ankle radiograph pathology in final year medical students.

INTRODUCTION: It has been shown that doctors in Emergency Departments (EDs) have inconsistent knowledge of musculoskeletal anatomy. This is most likely due to a deficiency in focused musculoskeletal modules at undergraduate level in medical school. The aims of this study were to evaluate the knowledge of final year medical students on foot anatomy and common foot and ankle pathology as seen on radiographs. METHODS: Final year medical students were asked to complete our short examination on a handout. The handout was anonymous and non-mandatory. There were four images. The first image is the anatomical section and the remaining images are the pathological section. RESULTS: All 235 students responded. 57% were females. For the identification of the normal bones of the foot as shown on an X-ray, the average score for the group was 2.69 (out of a maximum of 6) {SD 1.67}7. Only 8.3% achieved a 6/6 or 100% grade i.e. recognising all six bones correctly. A further 8.3% achieved 5/6 (83%). 8.3% failed to correctly identify any bone seen on the X-ray, a corresponding score of 0. DISCUSSION: This quick test showed normal anatomy of the foot and common pathology. One would expect final year medical students to be familiar with, especially two weeks before their finals in surgery. The curriculum should address the paucity of time spent in educating students in foot and ankle pathology.

A bibliometric analysis of the 100 most influential papers in burns.

The importance of a published paper to a particular area is reflected in the quantity of citations obtained from peers. In burns, it is unknown which papers have been the most influential on this specialty. The purpose of our study was to identify the 100 most cited papers in burns and to analyze their characteristics. Twenty-seven journals were chosen for analysis. These included high impact factor scientific journals and journals dedicated to burns and trauma. Only twelve of these journals contributed to the 100 most cited papers in burns and we analyzed each paper individually looking at its subject matter, authorship, article type, institution, country and year of publication. Our citation analysis revealed an interesting mix of clinical and scientific papers that documents the key landmarks in burn care over the past 66 years.

The 100 top-cited classic papers in hand surgery.

The number of citations that a published article has received reflects the importance that paper has on that area of practice. In hand surgery, it is unknown which journal articles are cited most frequently. The purpose of this study was to identify and analyze the characteristics of the top 100 papers in the field of hand surgery. The 100 most cited papers were identified in the following journals; the Journal of Hand Surgery (American volume), the Journal of Hand Surgery (European volume), the Journal of Hand Surgery (British and European volume), The Scandinavian Journal of Plastic and Reconstructive and Hand Surgery, Hand Clinics, and the Journal of Plastic Surgery and Hand Surgery. The articles were ranked in order of the number of citations received. These classic 100 papers were analyzed for article type, their journal distribution, as well as geographic and institutional origin.

The 100 classic papers of pediatric orthopaedic surgery: a bibliometric analysis.

BACKGROUND: Pediatric orthopaedic surgery owes its development to many pioneering individuals, and the studies that these individuals have undertaken form the basis for the clinical decisions made on the modern pediatric orthopaedic service. The aim of our study was to use citation analysis to identify the top 100 papers in pediatric orthopaedic surgery. METHODS: Using the Thomson Reuters Web of Knowledge, we searched for citations of all papers relevant to pediatric orthopaedics. The number of citations, authorship, year of publication, journal of publication, and country and institution of origin were recorded for each paper. RESULTS: The most cited paper was found to be the classic paper from 1963 by Salter and Harris that introduced the now-eponymous classification system for physeal injuries in the skeletally immature patient. The second most cited was Salter's paper describing the widely used osteotomy for the treatment of developmental dysplasia of the hip, and the third most cited was Catterall's description of the natural history of Legg-Calvé-Perthes disease. Most papers originated in the U.S., and most were published in this journal. A number of authors including Salter, Ponseti, Graf, and Loder had more than one paper in the top-100 list. DISCUSSION: This paper's identification of the classic papers of pediatric orthopaedic surgery gives us a unique insight into the development of pediatric orthopaedic surgery in the twentieth and early twenty-first centuries and identifies those individuals who have contributed the most to the body of knowledge used to guide evidence-based clinical decision-making in pediatric orthopaedics today.

Second to fourth digit ratio confirms aggressive tendencies in patients with boxers fractures.

BACKGROUND: Upper limb second to fourth digit ratio (2D:4D) has been shown to be dependent on prenatal androgen exposure. A longer relative fourth digit to second digit is indicative of increased intrauterine testosterone exposure prenatally and the converse is also true for oestrogen exposure. The 2D:4D ratio has implications in the sporting, academic, financial and sexual arenas. The purpose of this study was to examine the association between smaller finger length ratios (2D:4D) and boxers fractures, in both men and women, by comparing the 2D:4D ratios in 150 boxers fractures and comparing them to matched controls. Boxers fractures are an injury classically incurred during acts of aggression and we postulated that this cohort of patients would have a smaller 2D:4D ratio in comparison to the normal population mean ratio. METHODS: One hundred and fifty radiographs from patients with boxers fractures secondary to aggressive actions were analysed and the 2D:4D ratio was calculated. A further 150 X-rays from patients not involved in aggressive activities were used as a control group and the 2D:4D ratio was calculated in the same manner. We then performed statistical analysis to compare the 2D:4D ratios between our two groups. RESULTS: As predicted, the 2D:4D in males was smaller than females in all of the groups. However, our results showed that those presenting with a boxers fracture due to an aggression related injury had a statistically significant smaller 2D:4D ratio when compared to the normal population. CONCLUSION: Boxers fractures are injuries that typically occur from an aggressive act. It is well documented that a low 2D:4D ratio is reflective of an increased prenatal exposure to androgens, particularly testosterone. We have shown that boxers fractures are associated with a smaller 2D:4D ratio than the normal population, thus suggesting that persons exposed to high levels of prenatal androgens are more likely to exhibit aggressive tendencies in adulthood. Our results suggest that smaller digit ratios may predict a predisposition to acts of aggression, and as such result in an increased likelihood of sustaining an injury such as a boxers fracture. This relationship seems to be present independently of gender.

Suspected poisoning of cattle by scarlet pimpernel (Lysimachia arvensis L.).

The ingestion of scarlet pimpernel (Lysimachia arvensis L.), also known as red chickweed, has been reported as a cause of death of cattle in Uruguay, and as the suspected cause of deaths of sheep in Australia. It has not previously been reported in association with deaths of cattle in Australia. We report the clinical and pathological findings from four cattle in western Victoria that died with a nephrosis suspected to be secondary to intoxication with scarlet pimpernel.

Imaging the spine for tumour and trauma--a national audit of practice in Irish hospitals.

BACKGROUND AND PURPOSE: The provision of appropriate spinal imaging in cases of acute injury as a consequence of trauma or tumour is becoming ever more challenging. This study assessed the use of multimodal radiological investigations in the management of spinal cord compression as a result of trauma and metastatic cancer in all major Irish hospitals. METHODS: We conducted a questionnaire of thirty four hospitals in an effort to assess the provision of these services to patients with possible spinal cord compromise. In all public hospitals the Emergency Department and/or the Orthopaedic Registrars were contacted and asked a series of questions relating to spinal clearance, spinal clearance protocols, CT and MRI scanning facilities and on site orthopaedic services. RESULTS: All centres participated in the study. 67.64% of centres routinely used a protocol in spinal clearance. In 87% of hospitals the Emergency department were responsible for clearing the spine. 85.3% of hospitals had CT availability during normal working hours (9-5) dropping to 47% availability after hours. MRI was available in 50% of hospitals, with surprisingly just two centres providing out of hours MRI imaging services. CONCLUSION: The provision of radiological services in the management of suspected spinal injuries in Irish hospitals is inadequate in comparison to international best practice. This is most marked in relation to CT and MRI.

The role of pre-operative assessment and ringfencing of services in the control of methicillin resistant Staphlococcus aureus infection in orthopaedic patients.

BACKGROUND: MRSA is a major economic and health issue internationally and as such is of particular importance in the appropriate management of orthopaedic patients. Bone, joint and implant infection can lead to unfavourable outcomes with a long protracted in hospital stay inevitable. The cost for the patient, the hospital and society are substantial. MATERIALS AND METHODS: This study was a review of a prospectively maintained database from our unit over three time points from 2005 to 2007. At each time point a new infection control measure was implemented in an effort to reduce MRSA infections. Total rates of MRSA infection and colonisation in all orthopaedic patients were recorded, before and after separation of trauma and elective services, and after the introduction of a screening pre assessment clinic. RESULTS: 12259 orthopaedic patients were reviewed over the three years. The mean age of MRSA infected patients was 71. A higher proportion of female patients were infected than male patients. The mean length of stay for infected patients was 23.4 days. The rate of infection dropped from 0.49% in 2005 to 0.24%in 2007. After the introduction of these measures there was a substantial reduction in organ space and deep tissue infections. CONCLUSION: The separation of emergency and elective orthopaedic services coupled with effective pre-operative screening has resulted in a significant reduction in MRSA infection despite an ever increasing prevalance.

Military Healthcare Battlefield Immunity.

The combatant soldier on the battlefield remains protected from any claim in negligence by the doctrine of combat immunity for any negligent act or omission they may make when fighting. In other words, the combatant soldier does not owe a fellow soldier a duty of care on the battlefield, as the duty of care is non-justiciable. However, the non-combatant Military Healthcare Professional, although sometimes operating in the same hostile circumstances as the fighting soldier, is unlikely to benefit from combat immunity for any clinical negligence on the battlefield. This is because they continue to owe their patient a duty of care, although this has not been tested in the courts. This paper considers if any military healthcare professional could ever benefit from combat immunity, which is unlikely due to their non-combatant status. Instead, this paper suggests that a modified form of immunity; namely, Military Healthcare Battlefield Immunity could be a new, unique and viable doctrine, however, this could only be granted in rare circumstances and to a much lesser degree than combat immunity.

The 100 classic papers of orthopaedic surgery: a bibliometric analysis.

The credibility and creativity of an author may be gauged by the number of scientific papers he or she has published, as well as the frequency of citations of a particular paper reflecting the impact of the data on the area of practice. The object of this study was to identify and analyse the qualities of the top 100 cited papers in orthopaedic surgery. The database of the Science Citation Index of the Institute for Scientific Information (1945 to 2008) was used. A total of 1490 papers were cited more than 100 times, with the top 100 being subjected to further analysis. The majority originated in the United States, followed by the United Kingdom. The top 100 papers were published in seven specific orthopaedic journals. Analysis of the most-cited orthopaedic papers allows us a unique insight into the qualities, characteristics and clinical innovations required for a paper to attain 'classic' status.

Management of traumatic head injuries in a rural Irish hospital: implications of the NICE guidelines.

BACKGROUND: The NICE guidelines were published in 2003 in an effort to standardise the management of traumatic head injuries, and advise a CT brain in certain situations. AIM: To evaluate the influence of the NICE guidelines on the management of head injuries in a county hospital. METHODS: Complete clinical data were obtained for all patients with traumatic head injuries attending the ED of a county hospital from 2001 to 2005. Symptoms, examination details and outcome data were made available. The influence of the NICE guidelines on their management was then evaluated. RESULTS: Application of the NICE guidelines to these patients would have resulted in a 56% increase in the rate of CT brains being performed. No patient who did not have a CT brain had an adverse outcome. CONCLUSION: It is possible with limited resources and normal neurological observations that patients over the age of 65 can be managed safely.

Un caso de leucemia aguda linfocítica (ALL), tipo B con un inusual rearreglo cromosómico / A case of acute lymphocytic leukemia (ALL), B with an unusual type chromosomal rearrangement

Presentamos los hallazgos cromosómicos de una mujer de cuatro años de edad con trombocitopenia. El cariotipo demostró un 1(7) q(10) como una posible deleción en 11q23 y un cuestionable rearreglo en 9p. Los estudios por FISH de ambas interfase del núcleo y metafase de la célula, usando la fase de reposo MLL y caracterización de la prueba instrumental en el gen MLL, el cual fue encriptado por análisis citogenético convencional. Específicamente, el patrón FISH fue consistente con una inserción de la región 5' del gen MLL dentro de un cromosoma 4 hacia la banda q21, mas estrechamente una variante 1(4;11) (q 21;g23). Este caso ejemplifica la importancia del FISH y su consiguiente caracterización de casos precursores B-cell all, sin algún significado pronóstico de anormalidad cromosómica.

We present the chromosome findings in a 4-year-old female with thrombocytopenia. The karyotype showed an i(7)(q10) as well as a possible deletion on 11q23 and a questionable rearrangement on 9p. FISH studies on both interphase nuclei and metaphase cells using the MLL break apart rearrangement probe were instrumental in the characterization of an MLL gene rearrangement , which was cryptic by conventional cytogenetic analysis. Specifically, the FISH pattern was consistent with an insertion of the 5' region of the MLL gene into one chromosome 4 at band q21, most likely a variant t(4;11)(q21;q23). This case exemplifies the importance of FISH in the further characterization of precursor B-cell ALL cases without any apparent prognostically significant chromosome abnormalities.

Cryptic ins(4;11)(q21;q23q23) detected by fluorescence in situ hybridization: a variant of t(4;11)(q21;q23) in an infant with a precursor B-cell acute lymphoblastic leukemia report of a second case.

We report the chromosomal findings in a 4-year-old female with precursor B-cell acute lymphoblastic leukemia (ALL). The diagnostic karyotype showed an isochromosome 7q, i(7)(q10), as well as questionable rearrangements on 9p and 11q. Fluorescence in situ hybridization (FISH) studies on both interphase and metaphase cells using the MLL "break-apart" and the centromeric chromosome 4 probes were instrumental in the characterization of an MLL gene rearrangement, which was cryptic by conventional cytogenetic analysis. Specifically, the FISH pattern was consistent with an insertion of the 5' region of the MLL gene into chromosome 4 at band q21, most likely a variant t(4;11)(q21;q23). This is the second case of FISH detection of an ins(4;11) in ALL. Our case exemplifies the importance of FISH in the further characterization of precursor B-cell ALL cases without any apparent prognostically significant chromosomal abnormalities.