Fractures of the hip in younger adults

Hip fractures are the most common fracture requiring admission with as many as 65,000 being treated each year in the UK alone. The vast majority of these are in the more aged population and are associated with bone health changes such as osteoporosis. The far smaller proportion of this group, with different centres reporting 3%–6%, are ‘young’ adults. Femoral neck fractures in younger adults are a far more infrequent occurrence and often associated with higher energy injuries. They are also accompanied by additional challenges to treatment, with higher rates of complications such as avascular necrosis and non-union increasing the risk of reoperation. Management decisions surrounding treatment of hip fractures in the older population are well supported by national guidelines; in the younger population such recommendations are lacking. This article covers some of the key principles and controversies in the management of hip fractures in the young adult population.     

肠系膜下静脉汇入角度与左半结直肠癌肝转移灶分布规律的关系

［摘要］ 目的 分析肠系膜下静脉（IMV）汇入门静脉系统角度与左半结直肠癌肝转移灶分布的关系。方法 中山大学附属第六医院2012年1月至2017年1月期间收治的113例行全腹部+盆腔CT 检查的左半结直肠癌肝转移患者的影像学资料。根据门静脉系统重建三维图像，将门静脉系统的解剖类型分为IMV汇入门静脉角、IMV汇入肠系膜上静脉（SMV）、IMV汇入脾静脉（SV）3种类型，分析IMV汇入门静脉系统分型和成角情况以及成角与肝转移灶分布关系。结果 全组男性68例，女性45例，平均年龄58.4岁；同时性肝转移93例（82.3%），异时性肝转移20例（17.7%）；其中结肠脾曲癌2例（1.8%），降结肠癌7例（6.2%），乙状结肠癌42例（37.2%），直肠上段癌62例（54.8%）；肝内单发病灶共38例（33.6%），多发病灶共75例（66.4%）。根据三维重建结果将IMV汇入门静脉系统情况分为3型：IMV汇入门静脉角（17例，15.0%），IMV汇入SMV（31例，27.4%），IMV汇入SV（65例，57.6%）。113例左半结直肠癌伴肝转移患者中，IMV汇入门静脉角共17例，IMV与SMV成角>90°患者转移灶100%位于肝左叶，IMV与SMV成角<90°患者转移灶位于肝右叶（20%）和肝左叶（80%），肝转移灶分布构成比的差异有统计学意义（P<0.05）； IMV与SV成角>90°患者转移灶位于肝右叶（25%）、肝左叶（0%）和肝左右叶（75%），IMV与SV成角<90°患者转移灶位于肝右叶（20%）、肝左叶（80%）和肝左右叶（0%），肝转移灶分布构成比的差异有统计学意义（P<0.05）。IMV汇入SMV共31例，IMV与SMV成角>90°患者转移灶位于肝右叶（66.7%）、肝左叶（8.3%）和肝左右叶（25%），IMV与SMV成角<90°患者转移灶位于肝右叶（26.3%）、肝左叶（36.8%）和肝左右叶（36.8%），肝转移灶分布构成比的差异有统计学意义（P<0.05）。IMV汇入SV共65例，IMV与SV成角>90°患者转移灶位于肝右叶（50%）、肝左叶（35.7%）和肝左右叶（14.3%），IMV与SV成角<90°患者转移灶位于肝右叶（21.6%）、肝左叶（25.5%）和肝左右叶（52.9%），肝转移灶分布构成比的差异有统计学意义（P<0.05）。结论 根据IMV汇入方式进行门静脉系统的三类分型中，IMV汇入门静脉系统的角度均与左半结直肠癌肝转移灶分布密切相关，尤其在IMV以成角>90°汇入门静脉系统时，能更好地预测左半结直肠癌肝转移灶分布区域，对于疾病的临床预判、监测和治疗具备相当参考价值。     

Fine structure of fetal rat calvarium; provisional identification of preosteoclasts

Summary This is a study of the fine structure of cells of the 20-day fetal rat calvarium. Special attention is given to identifying and characterizing preosteoclasts. These cells are relatively common and located largely, but not exclusively, at the endocranial bone surface. The preosteoclasts are characterized by abundant mitochondria, an incomplete perinuclear Golgi apparatus, and variable-shaped dense granules. The dense granules are unique in appearance in that they contain an internal dense matrix surrounded by a clear halo. Most granules are circular in shape but some are elongate or tubular in form. Granules with identical appearance are observed in osteoclasts. The preosteoclasts are mononucleate, or occasionally binucleate. It is suggested that because preosteoclasts are morphologically distinctive and relatively abundant, it should be feasible to separate these cells from a heterogeneous cell isolate.     

Histamine and antihistamines

Histamine is one of the most extensively studied biological amines in medicine. It stimulates smooth muscle contraction and gastric acid secretion, increases vascular permeability, functions as a neurotransmitter, and plays various roles in immunomodulation, allergy, inflammation, haematopoiesis and cell proliferation. Histamine exerts its effects through four receptors, designated H1–H4. H1 and H2 receptors are widely distributed, H3 receptors are mainly presynaptic, and H4 receptors are mainly haematopoietic. H1 antihistamines are classified as first- and second-generation compounds. First-generation compounds lack specificity and cross the blood–brain barrier causing sedation. Second-generation compounds are less sedating and highly specific. H1 antihistamines have well-documented anti-allergic and anti-inflammatory effects and are well established in the treatment of a variety of allergic disorders. First-generation antihistamines are also used in the treatment of vestibular disorders and can be used as sedatives, sleeping aids and anti-emetics. H2 antihistamines are widely used in the treatment of gastric acid-related disorders; however, proton pump inhibitors are becoming the drugs of first choice in some of these disorders. H3 antihistamines are expected to be of potential value in the treatment of some cognitive disorder. H4 antihistamines could be of potential therapeutic benefit in the management of various immune and inflammatory disorders.     

采用华利康避免缝线异物存留的3148例手术报告

现代手术越做越细,器械越来越精,但重建组织、修复切口离不开缝线。传统的普通丝线,待做完手术,成为永久异物存留于机体中,至少异物存留是美中不足,还有可能导致伤口感染手术失败。作为医生无不追求手术能没有缝线及异物存留,进口薇乔、国产华利康等可吸收人工合成缝合线因此深受欢迎。现报告我院在选择性手术中完全使用华利康3148例,效果满意。     

Animal toxins and renal ion transport: Another dimension in tropical nephrology

Renal vascular and tubular ion channels and transporters involved in toxin injury are reviewed. Vascular ion channels modulated by animal toxins, which result in haemodynamic alterations and changes in blood pressure, include ENaC/Degenerin/ASIC, ATP sensitive K channels (K_ATP), Ca activated K channels (Kca) and voltage gated Ca channels, mostly L‐type. Renal tubular Na channels and K channels are also targeted by animal toxins. NHE3 and ENaC are two important targets. NCC and NKCC may be involved indirectly by vasoactive mediators induced by inflammation. Most renal tubular K channels including voltage gated K channels (Kv1), K_ATP, ROMK1, BK and SK are blocked by scorpion toxins. Few are inhibited by bee, wasp and spider venoms. Due to small envenoming, incomplete block and several compensatory mechanisms in renal tubules, serum electrolyte charges are not apparent. Changes in serum electrolytes are observed in injury by large amount of venom when several channels or transporters are targeted. Envenomings by scorpions and bees are examples of toxins targeting multiple ion channels and transporters.     

Ultrasound for anaesthetists

With the increasing use of ultrasound in operating theatres, critical care units and accident and emergency departments it is important that operators are aware of the fundamentals, which underpin these imaging systems. Failure to do so can result in inadequate examination and potential clinical errors. The basic physics and technology of ultrasound are outlined. The principles of Doppler ultrasound are described and the methods in which Doppler data are displayed are considered. The parameters that can be modified by the operator and the effects these have on the resultant image are discussed. Advice is given on how to set up an ultrasound system and optimize the image. Examples are given of the use of ultrasound in the clinical environment with emphasis on the type of application most likely to be encountered by the anaesthetist.     

Surgical treatment of symptomatic subependymoma of the nervous system. Report of five cases

Subependymomas are uncommon and relatively benign tumors with a distinctive histological appearance. They are generally asymptomatic and most of them are found incidentally at postmortem examination. These tumors are usually located in the fourth and lateral ventricle, and sometimes in the spinal cord. The authors present a series of 5 pure subependymomas of the central nervous system all of which were symptomatic and all of which were treated by microsurgical removal. The clinicopathological findings and the results of microsurgical treatment in this series are presented.     

Robust static and fixed‐order dynamic output feedback control of discrete‐time parametric uncertain Luré systems: Sequential SDP relaxation approaches

Design methods are proposed for static and fixed‐order dynamic output feedback controllers for discrete‐time Luré systems with sector‐bounded nonlinearities in the presence of parametric uncertainties described by polytopes. The derived design conditions are represented in terms of bilinear matrix inequalities, which are nonconvex. By using convex relaxation methods, controller design equations are derived for systems with multiple states, outputs, and nonlinearities in terms of linear matrix inequalities (LMIs) and iterative LMIs, which are associated with semidefinite programs. The proposed design methods are developed from stability conditions using parameter‐dependent Lyapunov functions, and existing iterative numerical methods are adapted to solve certain classes of nonconvex optimization problems for controller design. Several numerical examples are provided to illustrate and verify the proposed design methods. Copyright © 2016 John Wiley & Sons, Ltd.     

46例绝经后骨质疏松症妇女骨密度及尿吡啶啉、血清Ⅰ型前胶原肽的初步分析

本文通过对60～70岁绝经后妇女20例健康对照组、28例骨质疏松组、18例骨质疏松伴骨折组骨密度及尿吡啶啉(Pyridinoline,PYD)、血清Ⅰ型前胶原肽(Carboxy\|terminalpropeptideoftypeIprocollagen,PICP)的测定,经过比较分析结果显示46例骨质疏松患者的骨密度显著低于健康对照组,18例骨质疏松伴骨折组患者的股骨颈部位的骨密度显著低于28例骨质疏松无骨折组.46例骨质疏松患者的尿PYD、血PICP均显著高于健康对照组.由此提示绝经后妇女测量骨密度尤其是股骨上端的骨密度,结合骨吸收及骨形成的生化指标尿PYD、血PICP,能更好地预测骨质疏松及提示骨折发生的危险性.     

Disaggregation of bone into crystals

Summary The sizes, shapes, and organizational states of the crystals in bone are studied by systematic disaggregation of the mineral phase. This is achieved by oxidizing the organic phase with sodium hypochlorite, dispersing the resultant particles by sonication, and separating the crystal aggregates from the crystal monomers by gravity setting in ethanol. Six different bones are compared. Bones in which crystals are intimately associated with the collagen fibrils mostly disaggregate into crystal monomers. In dense bones, where the crystals are mostly located between fibrils, they tend to persist as “fused” aggregates. All the crystals are tabular or plate-shaped. In bones in which the majority of crystals are associated with the collagen fibrils, just less than 90% of the crystals are shorter than about 450 ? in length. Their widths are on the average about 250 ?, almost an order of magnitude larger than the diameters of individual gap regions within the collagen fibril. The notion that one crystal is located in one gap region is therefore untenable and a reevaluation of the relations between collagen and mineral in bone is necessary.     

Hypertension in the elderly

Both systolic and diastolic blood pressure increase with advanced ageand more than 50% of hypertensive patients are aged above 65years. Age-related vascular and neuro-humoral changes are importantfactors leading to the development of hypertension in the elderly andthe increase in systolic and diastolic blood pressure with age in anyindividual is a consequence of the relative change in arterialresistance and stiffness. Therefore, hypertension is predominantly orpurely systolic in the elderly both in women and men. The risks ofhypertensive patients over the age of 65 years are significant andseveral trials have provided compelling evidence that treatment ofhypertension in the elderly is beneficial in terms of reduced morbidityand mortality. Goal blood pressure should be similar in older andyounger patients. Lifestyle modifications are of proven benefit and maybe the only therapy needed for stage 1 hypertension. The Sixth report ofthe JNC recommends diuretics, specifically thiazide diuretics as theinitial choice for the treatment of elderly patients without anycomorbid conditions. Beta-blockers are less effective than thiazides asfirst line treatment and may only reduce stroke events. Recently,dihydropiridine calcium antagonists have been advocated as first choiceagents for the treatment of hypertension in the elderly and are suitablealternatives when diuretics are ineffective, contraindicated or nottolerated. Newer drugs such as AT1 antagonists are also effective inlowering blood pressure in the elderly but large scale data concerningtheir protective effects are still lacking.     

The kidney in malaria: Renal and systemic haemodynamics

Summary: Renal and systemic haemodynamic alterations in malaria vary with the severity of infection. In mild malaria there is no change in renal and systemic haemodynamics. In moderate infection hypervolaemia, increased cardiac index and decreased, systemic vascular resistance are noted. the renal blood flow and glomerular filtration rate are decreased, accompanied by an increase in plasma arginine vasopressin, norepinephrine and renin activity. Yet in some patients only plasma arginine vasopressin and blood volume are increased while renal and systemic haemodynamics are normal. In severe infection blood volume is either normal or decreased; the cardiac index and systemic vascular resistance are normal, while the renal blood flow and glomerular filtration rate are markedly decreased, leading to renal failure.     

The thienopyridine derivatives (platelet adenosine diphosphate receptor antagonists), pharmacology and clinical developments

The thienopyridines, ticlopidine and clopidogrel, are antiplatelet drugs. They are prodrugs and are metabolised in the liver to active metabolites that are non-competitive antagonists of the platelet adenosine diphosphate receptor, P2Y12. Inhibition of platelet aggregation by these drugs is delayed until 24-48 h after administration, with maximal inhibition achieved after 3-5 days. Recovery of platelet function after drug withdrawal is slow (7-14 days). Ticlopidine and clopidogrel are effective in preventing atherothrombotic events in cardiovascular, cerebrovascular and peripheral vascular disease. Gastrointestinal side effects and skin rashes are common. However, neutropenia and thrombotic thrombocytopenic purpura are significant and sometimes fatal adverse effects of ticlopidine. Clopidogrel appears to offer several advantages over ticlopidine: a more rapid onset of action and a lower incidence of neutropenia and thrombotic thrombocytopenic purpura.A combination of clopidogrel and aspirin has become standard for antithrombotic therapy in cardiovascular disease. The anaesthetic considerations of patients taking the thienopyridine compounds are discussed.     

Regulation of vacuolar proton pumping ATPase-dependent luminal acidification in the epididymis

Luminal acidification in the epididymis is an important process for the regulation of male fertility. Low pH and low bicarbonate concentration are among key factors that keep spermatozoa in a dormant state while they mature and are stored in this organ. Although significant bicarbonate reabsorption is achieved by principal cells in the proximal regions of the epididymis, clear and narrow cells are specialized for net proton secretion. Clear cells express very high levels of the vacuolar proton pumping ATPase （V-ATPase） in their apical membrane and are responsible for the bulk of proton secretion. In the present paper, selected aspects of V-ATPase regulation in clear cells are described and potential pathologies associated with mutations of some of the V-ATPase subunits are discussed. （Asian J Androl 2007 July; 9： 476-482）     

Checklisten im OP – ein sinnvolles Instrument zur Verbesserung der Patientensicherheit?

Checklists are working tools which are well established in high security industries e.g. in aviation. Even in healthcare they are increasingly used as mnemonic aid or to structure processes and actions in steady way. Of particular importance are applications in patient safety. The German Coalition for Patient Safety and the German Society of Surgery therefore commend the use of checklists for instance in the operating room.Since the WHO surgery safety checklist has been published debate about checklists in healthcare is again of current interest. In the focus of attention is the question if checklists are a useful instrument to reduce human error and to improve patient safety.The following article gives a definition of checklists and discusses its utilizability in health care processes. Known pros and contras of checklist use for patient safety improvement are discussed as the result of a systematic literature search in Medline and the WHO surgery safety checklist is presented. All facts presented were discussed by the German Coalition for patient safety and led to seven theses on checklists in healthcare which are presented at the end of this article.     

Testicular neoplasms in the prepubertal male

Unlike adult neoplasms, prepubertal testicular tumors are frequently benign. Yolk sac tumors, which are always malignant, constitute the majority among the histological types of neoplasm reported in the literature. Teratomas are benign in the pediatric population and are the second-most commonly reported testicular tumors. The remaining tumors are exceedingly rare and almost always benign; however, juvenile granulosa cell tumors, undifferentiated stromal tumors, and Sertoli cell tumors may rarely possess metastatic potential. Therefore, testicular neoplasms are varied, rare and often benign. However, even when they are malignant, long-term survival is excellent with prompt diagnosis and treatment. Following an English-based Medline literature search, this article reviews a concise approach towards the management of these individual tumors based on an analysis of the literature in the English language that addresses testicular neoplasms in prepubertal males.     

The empty sella

The data from 55 patients with empty sellae seen during the past five years are examined. The clinical and radiological features most helpful in defining and classifying each case are identified. The most frequent and most serious complications and the warning signs useful in diagnosis are discussed. The indications for and the results of surgical treatment are reviewed.     

歙白术木质部与韧皮部挥发油成分比较研究

目的对歙白术挥发油成分进行研究,探讨白术药材中挥发油的分布规律。方法采用组织化学和GC-MS对歙白术韧皮部、木质部所含挥发油进行研究。结果韧皮部中油室分布较木质部为多;木质部中挥发油共分离出51个峰,共鉴定出38种化合物;韧皮部共分离出47个峰,鉴定出化合物27种。结论歙白术药材的不同部位中挥发油成分差异较大,但相对含量最高的成分均为苍术酮,白术根茎中韧皮部与木质部的比例可作为评价白术药材质量优劣的参考依据之一。     

Klinefelter's syndrome in South African Indians and blacks.

Poly-X syndromes are very uncommon in Indian and Black South Africans. Two affected males of each race group are described; the Indians are probably the first to be reported in this country, and there are now 8 case histories of Klinefelter's syndrome in Blacks. The possible reasons for the rarity of the poly-X syndromes in South Africa are discussed and it is suggested that these syndromes are less common here than in other countries.