Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications

Purpose  

To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children.     

Treatment of distal femoral nonunions by external fixation with simultaneous length and alignment correction

The use of external fixation for management of distal femoral nonunions may minimise some of the problems frequently encountered in these patients. Fifteen patients treated by external fixation for distal femoral nonunions between 1987 and 1997 were reviewed. There were nine males and six females. The average age was 35.4 years (17-53) with an average follow up of 4.6 years (2-8). Nine followed an open fracture, five a closed fracture and one a femoral osteotomy. Five of the cases were infected nonunions. In all cases an internal fixation device was used as the initial method of treatment. All patients had the nonunion site stabilised with an external fixator. In 12 cases the knee joint was crossed with the fixator to further stabilise the fracture site. All patients had some degree of leg length discrepancy or malalignment that required correction. Fourteen cases united. The other patient united following intramedullary nailing. The average time to union was 10.4 months (4-24). The average range of movement was 80 degrees after treatment. Up to 9 cm of lengthening was achieved using the external fixation system (mean 5.0 cm). The mean angular correction was 15 degrees. One patient had persistent pain despite union at the time of the last follow up. The advantages of preservation of soft tissue, immobilisation of the fracture site by crossing the knee joint and the facility for proximal lengthening make external fixation a definite option in the management of distal femoral nonunions.     

Encountering Meckel's diverticulum in emergency surgery for ascaridial intestinal obstruction

Background  

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. In children with intestinal ascariasis, the diverticulum remains asymptomatic or rarely the Ascaris lumbricoides may lead to its complications in the presence of massive intestinal roundworm load. Given that preoperative diagnosis is seldom carried out, when Meckel's diverticulum is found at laparotomy for obstructive intestinal complications of roundworm, the diverticulum should be removed as complications may occur at any time. The aim of this study was to describe the findings of concomitant presence of Meckel's diverticulum who had surgical intervention in symptomatic intestinal ascariasis in children.     

Who is excluded and how? An analysis of community spaces for maternal and child health in Pakistan

Background

The maternal, newborn, and child health (MNCH) indicators of Pakistan depict the deplorable state of the poor and rural women and children. Many MNCH programmes stress the need to engage the poor in community spaces. However, caste and class based hierarchies and gendered social norms exclude the lower caste poor women from accessing healthcare. To find pathways for improving the lives of the excluded, this study considers the social system as a whole and describes the mechanisms of exclusion in the externally created formal community spaces and their interaction with the indigenous informal spaces.

Methods

The study used a qualitative case study design to identify the formal and informal community spaces in three purposively selected villages of Thatta, Rajanpur, and Ghizer districts. Community perspectives were gathered by conducting 37 focus group discussions, based on participatory rural appraisal tools, with separate groups of women and men. Relevant documents of six MNCH programmes were reviewed and 25 key informant interviews were conducted with programme staff.

Results

We found that lower caste poor tenants and nomadic peasants were excluded from formal and informal spaces. The formal community spaces formed by MNCH programmes across Pakistan included fixed, small transitory, large transitory, and emerging institutional spaces. Programme guidelines mandated selection of community notables in groups/committees and used criteria that prevented registration of nomadic groups as eligible clients. The selection criteria and adverse attitude of healthcare workers, along with inadequacy of programmatic resources to sustain outreach activities also contributed to exclusion of the lower caste poor women from formal spaces. The informal community spaces were mostly gender segregated. Infrequently, MNCH information trickled down from the better-off to the lower caste poor women through transitory interactions in the informal domestic sphere.

Conclusion

A revision of the purpose and implementation mechanisms for MNCH programmes is mandated to transform formal health spaces into sites of equitable healthcare.

     

Fitness costs in chlorfenapyr-resistant populations of the chive maggot,Bradysia odoriphaga

The chive maggot, Bradysia odoriphaga (Yang and Zhang) is an economically important insect pest, affecting many key vegetables, including Chinese chive, especially in northern China. Chlorfenapyr, a halogenated pyrrole insecticide that interferes with mitochondrial oxidative phosphorylation is widely used against B. odoriphaga. In this study, we evaluated selection-induced resistance to chlorfenapyr and fitness costs in B. odoriphaga. The results showed that B. odoriphaga developed 43.32-fold resistance after continuous exposure to chlorfenapyr for over 10 consecutive generations. The life-history traits of chlorfenapyr-resistant and susceptible strains were compared using age-stage, two-sex life table approach. No significant effects were observed on the longevity and pre-adult period. However, reduction in the total pre-oviposition period (TPOP) and fecundity (eggs/female) were observed in the resistant strain. Moreover, the demographic parameters such as intrinsic rate of increase (r), net reproductive rate (R0) and finite rate of increase (λ) were also decreased significantly in the resistant strain compared to the susceptible strain. These results showed the potential of B. odoriphaga to develop resistance against chlorfenapyr under continuous selection pressure. Furthermore, there was a fitness cost linked with chlorfenapyr resistance in B. odoriphaga. We conclude that a better knowlegde on the trade-off at play between resistance degree and fitness cost could be crucial for developing further management of B. odoriphaga in China.     

Adulterant profile of illicit street heroin and reduction of its precipitated physical dependence withdrawal syndrome by extracts of St John's wort (Hypericum perforatum)

The study evaluated the adulterants in a specimen of illicit street heroin supplied under strict control by the Pakistan Anti‐Narcotic Force. It also examined the effects of Hypericum perforatum L. extracts on the naloxone‐induced heroin withdrawal syndrome. The GC‐MS analysis of the specimen showed that in addition to heroin (37.8%), the sample also contained caffeine (8.4%), phenobarbitone (12.7%), 6‐acetyl codeine (5.3%), 6‐acetyl morphine (10.9%) and noscapine (15.8%). Administration of the heroin to rats for 8 days induced physical withdrawal signs of abdominal constriction, diarrhoea and vocalization on touch after naloxone treatment. Aqueous Hypericum perforatum extracts (20 mg/kg twice daily chronically or as a single acute dose 90 min before naloxone) given orally to the heroin dependent rats attenuated abdominal constrictions both acutely and chronically while the hydroethanol and ethanol extracts were only effective in acutely treated animals. Diarrhoea was ameliorated by the hydroethanol and ethanol extracts following acute or chronic heroin treatment while the aqueous extract failed to show any effect. Vocalization on touch during withdrawal was reduced by all the extracts either chronically or acutely with the exception of chronic treatment with hydroethanol extracts. The findings suggest that Hypericum perforatum is capable of reducing the physical signs of opiate withdrawal. Copyright © 2008 John Wiley & Sons, Ltd.     

Computational Model of Device-Induced Thrombosis and Thromboembolism

A numerical model of thrombosis/thromboembolism (T/TE) is presented that predicts the progression of thrombus growth and thromboembolization in low-shear devices (hemodialyzers, oxygenators, etc.). Coupled convection–diffusion-reaction equations were solved to predict velocities, platelet agonist (ADP, thromboxane A2, and thrombin) concentrations, agonist-induced and shear-induced platelet activation, and platelet transport and adhesion to biomaterial surfaces and adherent platelets (hence, thrombus growth). Single-platelet and thrombus embolization were predicted from shear forces and surface adhesion strengths. Values for the platelet-biomaterial reaction constant and the platelet adhesion strength were measured in specific experiments, but all other parameter values were obtained from published sources. The model generated solutions for sequential time steps, while adjusting velocity patterns to accommodate growing surface thrombi.Heparinized human blood was perfused (0.75 ml/min) through 580 μm-ID polyethylene flow cells with flow contractions (280 μm-ID). Thrombus initiation, growth, and embolization were observed with videomicroscopy, while embolization was confirmed by light scattering, and platelet adhesion was determined by scanning electron microscopy.Numerical predictions and experimental observations were similar in indicating: 1) the same three thrombotic locations in the flow cell and the relative order of thrombus development in those locations, 2) equal thrombus growth rates on polyethylene and silicon rubber (in spite of differing overall T/TE), and 3) similar effects of flow rate (1.5 ml/min versus 0.75 ml/min) on platelet adhesion and thrombosis patterns.     

Successful plasma exchange combined with rituximab therapy in aggressive APS-related cutaneous necrosis

Antiphospholipid antibody syndrome (APS) is a systemic autoimmune disorder characterized by venous and/or arterial thrombosis or recurrent fetal loss associated with the presence of antiphospholipid antibodies and/or a lupus anticoagulant. The skin appears to be an important target organ and many cases of APS may present with skin manifestations. These lesions may be manifold and may take the form of livedo reticularis, livedo racemosa, ulcerations, digital gangrene, subungeal splinter hemorrhages, superficial venous thrombosis, thrombocytopenic purpura, pseudovasculitic manifestations, extensive cutaneous necrosis, or primary anetoderma. We report a case of fulminant APS-related cutaneous necrosis. A 38-year-old Caucasian male with a past history of APS, multiple deep vein thrombi/pulmonary emboli, presented with necrotic lesions on his right upper and right lower extremities. Initially, baseline anticoagulation was increased without improvement. Subsequently, plasma exchange was initiated on a daily schedule. Furthermore, rituximab 1,000 mg IV was administered on days 1 and 15. After six consecutive daily sessions of plasma exchange, there was significant regression of the necrotic lesions. After a 22-day hospital stay, the patient was discharged to home on fondaparinux. The patient presented approximately 2 months later after missing follow-up appointments. At the time, his initial lesions looked remarkably improved.