Thromboprophylaxis in pelvic and acetabular trauma surgery. The role of early treatment with low-molecular-weight heparin.

We prospectively studied the outcome of a protocol of prophylaxis for deep vein thrombosis (DVT) in 103 consecutive patients undergoing surgical stabilisation of pelvic and acetabular fractures. Low-molecular-weight heparin (LMWH) was administered within 24 hours of injury or on achieving haemodynamic stability. Patients were screened for proximal DVT by duplex ultrasonography performed ten to 14 days after surgery. The incidence of proximal DVT was 10% and of pulmonary embolus 5%. Proximal DVT developed in two of 64 patients (3%) who had received LMWH within 24 hours of injury, but in eight of 36 patients (22%) who received LMWH more than 24 hours after the injury (p < 0.01). We conclude that LMWH, when begun without delay, is a safe and effective method of thromboprophylaxis in high-risk patients with major pelvic or acetabular fractures.

Protein requirement of elderly women: nitrogen balance responses to three levels of protein intake.

BACKGROUND: For elderly women, insufficient data exist to assess the accuracy of the assumed mean protein requirement of 0.6 g of protein x kg(-1) x day(-1), and the adequacy of the current Recommended Dietary Allowance (RDA) of 0.8 g of protein x kg(-1) x day(-1). The aims of this study were to assess the mean protein requirement and suggested safe and adequate protein intake (protein allowance) of elderly women using a shorter-term nitrogen balance protocol. METHODS: During three separate 18-day trials, 11 elderly women (age range, 70-81 years) were randomly fed eucaloric diets designed to provide either 0.50, 0.75, or 1.00 g of protein x kg(-1) x day(-1). Nitrogen balance was determined at Weeks 2 and 3 (Days 7-10 and 14-17, respectively) of each trial using data from total nitrogen analyses of duplicate food composites, 24-hour urine collections, and stool collections. The mean protein requirement was calculated using linear regression of individual women's data from all three trials and inverse prediction. RESULTS: At protein intakes of 0.53 +/- 0.02, 0.76 +/- 0.02, or 1.06 +/- 0.05 g of protein x kg(-1) x day(-1), net nitrogen balances during Week 2 were -14.5 +/- 3.1, 3.8 +/- 2.5 and 23.4 +/- 3.3 mg of nitrogen x kg(-1) x day(-1), respectively, for these body weight- and body composition-stable women. At Week 3, the net nitrogen balances were -0.1 +/- 2.7, 8.5 +/- 3.6 and 42.0 +/- 3.0 mg of nitrogen x kg(-1) x day(-1). From Week 2 to Week 3, shifts to more positive nitrogen balances occurred due to decreases in urinary nitrogen excretion. The mean protein requirement at Week 2 was calculated to be 0.70 +/- 0.09 g of protein. kg(-1) x day(-1) (coefficient of variation [CV] = 13%) and at Week 3 was calculated to be 0.56 +/- 0.09 g of protein x kg(-1) x day(-1) (CV = 17%). From these data, an adequate protein allowance was estimated to be greater than the RDA at Week 2 (0.90 g of protein x kg(-1) x day [d](-1)), and not different than the RDA at Week 3 (0.76 g of protein x kg(-1) x d(-1)). CONCLUSIONS: The decrease over time in urinary nitrogen excretion from Week 2 to Week 3 suggests that these elderly women did not achieve a metabolic steady state during this shorter-term nitrogen balance study. Collectively, these data suggest that the total protein needs of elderly women are at or above the current RDA for protein. However, the results of this study indicate that shorter-term nitrogen balance protocols are insufficient to firmly establish the RDA for protein of elderly women, and further research is required using alternative criteria measures.

Is the acquisition of a separate view of the sacroiliac joints in the prone position justified in patients with back pain?

One hundred consecutive patients in whom radiographs of the sacroiliac joints had been requested concurrently with radiographs of the lumbar spine and/or pelvis were reviewed to ascertain the diagnostic value of the sacroiliac radiograph. In 92 patients, radiographs of the lumbar spine or pelvis provided complete visualization of the sacroiliac joints, 81 of which were judged normal, six abnormal, and five equivocal. Review of the specific sacroiliac radiographs confirmed the six abnormal cases, and resulted in one equivocal case being judged abnormal. In no case did the sacroiliac joint radiograph result in a normal diagnosis being changed to abnormal. Where the sacroiliac joints appear normal on a lumbar spine or pelvic radiograph, there is no diagnostic benefit, and a considerable radiation penalty, from the performance of additional radiographs specific to those joints.

Complications in percutaneous transluminal angioplasty: relationships with patient age.

Five hundred consecutive attempted lower limb angioplasties for ischaemic disease (370 patients, mean age 65.6 years, range 33-91 years) were reviewed. Significant complications occurred in 44 cases (8.8%). Nine patients (1.8%) underwent emergency surgery related to a complication. A further 12 patients (2.4%) underwent elective surgery related to a complication. In addition, four patients died within 30 days of the procedure; one following surgery performed because of a complication of angioplasty, one following a myocardial infarction, one following severe bleeding associated with subsequent thrombolytic therapy and one during emergency surgery related to a complication of angioplasty. A correlation was found between complication rate and age. This relationship was independent of the approach to, the position of, and the severity of the treated lesion. Elderly patients are at increased risk of complication in lower limb angioplasty.

Ultrasonic diagnosis of masseteric hypertrophy.

Masseteric hypertrophy may present a diagnostic dilemma, its confirmation frequently being by exclusion of other conditions. The literature relating to this syndrome is reviewed. A study to confirm the suitability of ultrasound in diagnosis, and to establish a normal range, is described. Sixty-two masseter muscles were measured using a standardized technique and the derived normal range for transverse dimension was 8.5-13.5 mm. Three instances of clinically diagnosed masseteric hypertrophy were examined; in each case measured transverse masseteric dimension was significantly greater than the normal range. Direct ultrasonic measurement of masseteric bulk should replace computed tomography as the definitive investigation in suspected cases.