Double gloving in reducing the interoperative risk of blood borne pathogens]

The potential for blood contact with skin puts operating room personnel at increased risk of exposure to hepatitis or HIV virus. One of the most common areas of contamination with infectious biological material is the hands and fingers due to failure of glove protection. There are varying opinions regarding the frequency of glove failure during orthopaedic procedures and the necessity of wearing two gloves for added protection. The authors performed a trial of 94 procedures involving 10 surgeons from Orthopaedic Department of Pomeranian Medical University from Szczecin, Poland to answer these questions. Outer-glove perforations occurred in 15% of the cases while inner-glove--in only 3.1% (p < 0.0001). In 5 cases there was an inner-glove defect without a corresponding outer-glove perforation. Both the duration of the operation longer than 2 hours and the type of the procedure (minor versus major) were associated with increased rates of perforation (p < 0.002 and p < 0.0007 respectively). From total amount of perforated outer-gloves, only 13 (28%) were changed by the surgeon during the operation. There was no statistically significant difference between latex and neoprene used as inner-gloves (p > 0.17) in failure rates. The authors conclude double gloving during orthopaedic procedures and changing the gloves every 2 hours may significantly reduce the operating room personnel's risk of exposure to blood borne pathogens.     

Monoblock or modular tapered stems: Making the right choice

Tapered fluted titanium stems (TFTS) allow stable fixation in diaphyseal bone, helping the revision arthroplasty surgeon obtain a satisfactory clinical outcome. Monoblock and modular TFTS have shown similar benefits with regards to survivorship and hip-specific outcome measures. Monoblock stems have a propensity for asymptomatic subsidence, whereas modular stems carry a modest risk of implant failure at the stem–body modular junction. An experienced revision surgeon can use a monoblock TFTS can be used for most cases. The infrequent revision arthroplasty surgeon, on the other hand, is best suited to use a modular TFTS, especially when a trans-femoral osteotomy is planned.     

Double chambered right ventricle in a 62-year-old female: a surgical case report]

A 62-year-old female was admitted with a chief complaint of transient syncope on exertion. Angiography in right ventricle revealed a defect caused by an anomalous muscle bundle and a pressure gradient of 151 mmHg was observed between the two chambers by cardiac catheterization. Resection of the anomalouse muscle bundle was undertaken using a lower median sternotomy starting at the 2nd intercostal space level and through the outflow tract right ventriculotomy. Patch plasty was also undertaken in the outflow tract. Post-operative course was uneventful and pressure gradient had disappeared at the post-operative catheterization. A rare case of DCRV in a 62-year-old patient with a pressure gradient of 151 mmHg in the right ventricle was reported.     

Reduction of discomfort during mammography utilizing a radiolucent cushioning pad

The purpose of this study was to evaluate the use of a radiolucent cushioning pad during routine screening mammography to determine the degree of reduction in discomfort, any correlation of that reduction with various clinical factors, and the pad's impact on image quality, compression force, and radiation dose. A total of 512 patients presenting for routine screening mammography were evaluated. The radiolucent cushioning pads (MammoPad, Biolucent Inc., Aliso Viejo, CA) were placed on the bucky and compression paddle of the mammographic equipment (M-IV, Lorad Corp., Danbury, CT). For each patient, the radiolucent pads were used for imaging one breast while the opposite breast, which served as a control, was imaged without the pads. In all patients, the breast was positioned and compressed in standard fashion, using routine craniocaudal (CC) and mediolateral oblique (MLO) views. Patients completed a questionnaire before and after the mammogram. A visual analog scale (VAS) was used to record anticipated discomfort as well as the discomfort experienced during compression with and without the pads. Age, hormone replacement status, prior experience with mammography, compression force, and breast composition were recorded, as were dose parameters (mAs and kVp), from which midglandular dose values were calculated. On the side where the pads were used to cushion the breast, 73.5% (371/505) of women experienced a significant decrease in discomfort. Of those who benefited, there was a 47% decrease in discomfort. On the pad side, compression force was increased an average of 14%, and there was a 4% decrease in dose for the CC view and no increase in dose for the MLO view. When comparing benefit versus nonbenefit groups, a significant reduction in discomfort did not correlate with any of the clinical factors evaluated, with the exception of experienced discomfort reported after the mammogram. Use of the MammoPad radiolucent cushion on the bucky and compression paddle was an effective means of reducing discomfort during compression for a majority (73.5%) of our patients undergoing screening mammography. Image quality and the ability to detect all pertinent anatomy were maintained.     

Double dissociation between serotonergic and dopaminergic modulation of medial prefrontal and orbitofrontal cortex during a test of impulsive choice

Dysregulation of the prefrontal cortex (PFC) has been implicated in impulse control disorders, including attention deficit hyperactivity disorder. A growing body of evidence suggests that impulsivity is non-unitary in nature, and recent data indicate that the ventral and dorsal regions of the PFC are differentially involved in distinct aspects of impulsive behaviour, findings which may reflect differences in the monoaminergic regulation of these regions. In the current experiment, levels of dopamine, serotonin and their metabolites were measured in the medial PFC (n = 12) and orbitofrontal cortex (OFC) (n = 19) of rats using in vivo microdialysis during the delay-discounting model of impulsive choice, where impulsivity is defined as selection of small immediate over larger delayed rewards. Yoked groups were also dialysed to control for instrumental responding and reward delivery. Significant increases in 5-hydroxytryptamine efflux were observed in the mPFC, but not in the OFC, during task performance but not under yoked control conditions. In the OFC, 3,4-di-hydroxy-phenylocetic acid (DOPAC) levels increased in animals performing the task but not in yoked animals, whereas mPFC DOPAC levels increased in all subjects. These data suggest a double dissociation between serotonergic and dopaminergic modulation of impulsive decision-making within distinct areas of frontal cortex.     

Bradycardia during hypotension following release of a tourniquet in orthopaedic surgery

Heart rate (HR) and mean arterial blood pressure (MBP) were followed in 39 consecutive patients during orthopaedic surgery with the leg exsanguinated by an inflatable tourniquet around the thigh. The circulation was stable in all patients until release of the tourniquet. Following release of the tourniquet MBP decreased from 94 +/- 5 (s.e. mean) to 45 +/- 12 mmHg (12.5 +/- 0.7 to 6.0 +/- 1.6 kPa) (P less than 0.005) in 10 patients, while it remained stable in the others. At the same time the hypotensive group showed a decrease in HR from 83 +/- 6 to 67 +/- 3 beats min-1 (P less than 0.005) while no significant change in HR was seen in the normotensive group. The hypotensive group was older (57 +/- 8 versus 50 +/- 4 years (P less than 0.05)), had a larger blood loss during surgery (2.9 +/- 1.2 versus 0.7 +/- 0.3 ml kg-1 (P less than 0.005)), and the duration of the operation was longer in this group (120 +/- 14 versus 60 +/- 27 min (P less than 0.001). It is suggested that the characteristic deviation of HR in conjunction with hypotension following release of a tourniquet is bradycardia.     

Double chambered right ventricle: surgical experience in a 60-year-old woman

The patients reported as double chambered right ventricle are mainly children. A 60-year-old woman had been pointed out for her systolic cardiac murmur without any symptom. She was admitted to our hospital for her gradual onset of fatigue, lassitude. Cardiac catheterization data revealed a 105 mmHg peak-to-peak gradient within the right ventricular cavity with normal pulmonary pressures [20/5 (12) mmHg]. Right ventricular end-diastolic pressure was 4 mmHg. Right ventriculogram demonstrated double chambered right ventricle. Electrocardiogram showed neither right ventricular hypertrophy nor upright T wave in V3R. In order to release intraventricular pressure gradient and her symptom, the anomalous muscle bundles were resected through both the right atrium and the pulmonary artery. Surgical repair without right ventriculotomy is suitable for such an elder patient with double chambered right ventricle whose ventricular function may decrease.     

Cecal and right colonic perforation on a single or multiple diverticulum. Apropos of three new cases]

There are two types of cecal diverticula: in the first type, the diverticula are often multiple, and they really are false diverticula like in sigmoiditis. The second type, the so-called single type, is a frequently single diverticulum with a complete wall, which may have a congenital origin. Cecal diverticula are often expressed between 45 and 55 years of age by symptoms mimicking appendicitis. Two signs may suggest the diagnosis: the virtual absence of nausea and vomiting, and the long delay before the onset of pain. The surgical treatment, in case of acute complications (perforation, abscess), varies according to the surgical findings. In fact, if a pseudotumoral inflammatory mass is discovered, the correct diagnosis is established in 58% to 72% of all cases only. The treatment can therefore range from simple diverticulotomy to righ hemicolectomy.     

Covid-19 and orthopaedic trauma: Quantification of orthopaedic trauma workload and staff resource allocation during a global pandemic-related lockdown

IntroductionHealthcare systems across the world have struggled as a result of the Covid-19 pandemic. Most specialties have redeployed their staff and resources to deal with the pandemic whilst ceasing their planned elective activity. However acute specialties such as Trauma and Orthopaedics still have a significant emergency caseload that must be safely managed, even in a pandemic. The aim of this study was to investigate the change in Orthopaedic Trauma caseload in a Trauma Unit and a Major Trauma Centre during a pandemic compared to pre-pandemic levels and the associated staffing requirements.MethodsThe data presented was collected from a Trauma Unit and a Major Trauma Centre in the United Kingdom. We compared the number of accident and emergency referrals, fracture clinic appointments, inpatient admissions and operations during the six weeks of the first lockdown from 23rd March to May 3, 2020, to the same time period in 2019.ResultsThe results showed that the orthopaedic trauma caseload was approximately half that of pre-pandemic levels, reducing by an average of 54.2%.ConclusionA significant orthopaedic trauma caseload still remains to be safely managed during a pandemic and appropriate resources must be allocated. Staff allocation must take into account sick cover and staff wellbeing. A proportion of staff may need to be ring fenced from redeployment to facilitate this.     

Right-sided patent ductus arteriosus with a right aortic arch and right descending aorta]

We experienced an extremely rare anomaly, i.e. right-sided persistent ductus arteriosus with a right aortic arch and right descending aorta. Reviewing the literature, we found only two cases clinically reported in Japan as far as we know. The diagnosis was established by angiography and MRI. We treated the patient successfully through right thoracotomy.