Genicular corticoperiosteal flap salvage of resistant atrophic non-union of the distal radius metaphysis

Non-union at the metaphyseal level is rare following a fracture of the distal radius. When a non-union does occur, it is usually easily treated with cancellous bone graft from the iliac crest. Resistant and multiply operated atrophic non-unions more frequently occur at the diaphyseal level of long bones. A corticoperiosteal free flap based on the articular branch of the descending genicular artery has previously been described to treat such difficult non-union cases in various sites, but not at the distal radius. At the distal radius metaphysis, the close relationship with the extensor tendons raises concern regarding the ability to fit this free flap to the non-union site without significant interference with tendon function. By careful technique of crumbling the cortex of the flap without tearing the periosteal continuity, the flap can be contoured and snugly fit to this particular site while preserving tendon function. A unique case is presented of a multiply operated resistant atrophic non-union of the distal radius metaphysis in a heavy smoker that was rapidly healed using the genicular corticoperiosteal free flap.     

Significance of diffuse cardiac activity on In-111 labeled leucocyte scans

To assess the significance of diffuse cardiac activity (DCA) seen on In-111 labeled leukocyte scans, we reviewed 87 studies performed over the last 4 years. Inflammatory cardiac conditions were seen as frequently in patients with DCA (15%) as those without (7%, P=0.3). There was a higher ratio of RBC:WBC in the final WBC preparation in the false-positive DCA group than the true positive DCA and no DCA groups. False-positive studies showing DCA are most likely due to residual blood pool activity.Presented in part, 70th annual meeting, Radiological Society of North America, Washington D.C., 25 November 1984     

Postoperative radiotherapy for locally advanced colon cancer

Background: The role of adjuvant postoperative radiotherapy for locally advanced colon cancer is not well documented. Methods: Seventy-eight patients who underwent a complete resection of B2-C colon cancer received postoperative radiotherapy. Twenty-eight patients received ⩽45 Gy; 50 patients received 50–55 Gy. Twenty-seven patients received adjuvant fluorouracil-based chemotherapy. All patients were followed for a minimum of 3 years; no patients were lost to follow-up. Results: The overall local control rate was 88%. The 5-year actuarial rate of local control was 96% after 50–55 Gy postoperative radiotherapy compared with 76% after <50 Gy (p=0.0095). Multivariate analysis of local control showed that only radiotherapy dose significantly influenced this end point. Cause-specific survival rates at 5 years were B2, 67%; B3, 90%; C1, 100%; C2, 61%; C3, 36%; and overall, 63%. Multivariate analysis of cause-specific survival showed that only stage significantly influenced this end point. Bowel obstruction caused by adhesions developed in three patients and required a laparotomy; radiation-induced sarcoma developed in one additional patient. Conclusions: Postoperative radiotherapy appears to reduce the risk of local recurrence in patients with locally advanced colon cancer. The optimal dose is probably 50–55 Gy at 1.8 Gy per fraction. Postoperative radiotherapy may improve cause-specific survival for patients with stages B3 and C2 cancers.     

Role of endothelin in the exercise intolerance of chronic heart failure

In conclusion, plasma levels of the endothelialderived vasoconstrictor endothelin-1 (but not those of other neurohormonal vasoconstrictor factors), measured during exercise correlated closely with objective variables of exercise capacity in patients with heart failure. These findings suggest that endothelin-1 may contribute to exercise intolerance in patients with heart failure, perhaps by limiting the ability of the peripheral vasculature to dilate during exercise.     

Presenile dementia: Sufferers,carers and services

An extensive search was made for people with presenile dementia (PSD) still under 65 years living in the Southampton Health District. Twenty-seven sufferers were identified. People with PSD had a high degree of cognitive, behavioural and self-care disabilities and carers showed considerable stress. Services were received from the old age psychiatry team, and to a lesser extent from social services and the Community Rehabilitation Unit. Community psychiatric nurses were the commonest form of support. The four sufferers in receipt of no services were less impaired. Identified needs included more counselling and advice and specific provision for the more physically active sufferer.     

The evolution of today's hospital emergency departments —Current problems and challenges

The announcement of the National Heart Attack Alert Program by the National Heart, Lung and Blood Institute in June of 1991 prompted leaders of the Florida Chapter of the American College of Cardiology to develop a statewide program to reduce the morbidity and mortality from acute myocardial infarctions within Florida. It became apparent that the success of such a program would require the prompt institution of thrombolytic agents or other revascular-ization procedures in appropriate patients. No longer could the decision regarding institution of therapy await discussion by telephone and/or the arrival at the emergency department (ED) of the patient's primary care physician or cardiologist. Efforts to establish appropriate protocols for therapy revealed that many of the 25,000 or more physicians currently staffing the 5,600 or so EDs in this country were moonlighting residents or practitioners from a variety of specialties or subspe-cialties with limited or no formal EM training. Furthermore, it was learned that there were in the entire country only about 800 postgraduate, year-one Council for Graduate Medical Education accredited training positions. There were only 21 such training positions in the entire state of Florida. The reasons for these deficiencies are discussed and a challenge to correct this person power crisis is issued, not principally to the leadership of EM, but to the entire medical profession.     

VESICO-URETERIC REFLUX AND SURGICALLY TREATED PELVI-URETERIC JUNCTION OBSTRUCTION IN INFANTS UNDER THE AGE OF 12 MONTHS

Background : Pelvi-ureteric junction obstruction has been increasingly diagnosed in infants, mostly as a consequence of antenatal ultrasound examinations. Methods : Of 55 infants below the age of 12 months who underwent dismembered pyeloplasty over a 7-year period, we aimed to determine the patterns and outcome of associated vesico-ureteric reflux that was present in 15 (28%) of the 53 infants in whom follow-up was available. Results : A total of eight infants had resolution of their reflux with conservative management and the median time to resolution was 15 months. Five infants proceeded to ureteroneocystotomy. Conclusions : Given the association of vesico-ureteric reflux and pelvi-ureteric junction obstruction, routine cystography is recommended when the diagnosis of pelvi-ureteric junction obstruction is made.     

Time course of changes in ETB receptor density and function in tracheal airway smooth muscle during respiratory tract viral infection in mice.

1. In the current study, the density and function of ETA and ETB receptors in mouse tracheal airway smooth muscle were determined over the time course of respiratory tract infection with influenza A/PR-8/34 virus. 2. Quantitative autoradiographic studies using [125I]-endothelin-1 revealed that the tracheal airway smooth muscle from control mice contained ETA and ETB sites in the ratio of 49%:51% (+/- 2%, n = 29 mice). Respiratory tract viral infection was associated with increases in the density of ETA sites and decreases in the density of ETB sites at days 1, 2 and 4 post-inoculation which were reversible by day 19. For example, at day 4 post-inoculation, a time when the manifestations of viral infection were at or near their peak, the ratio of ETA:ETB sites was 72%:28% (+/- 4%, n = 6 mice, P < 0.05). In contrast, at day 19 post-inoculation, by which time viral infection had essentially resolved, the ratio of ETA:ETB sites was similar to control (51%:49% (+/- 3%), n = 6 mice). 3. Endothelin-1 was a potent spasmogen in isolated tracheal airway smooth muscle preparations from control mice (ED70 = concentration producing 70% of contraction induced by 10 microM carbachol = 6.3 nM (95% confidence limits, 4.0-10; n = 6 mice)). Neither the ETA receptor-selective antagonist, BQ-123 (3 microM), nor the ETB receptor-selective antagonist, BQ-788 (1 microM) alone had any significant inhibitory effect on endothelin-1-induced contractions of mouse isolated tracheal smooth muscle. However, simultaneous treatment with BQ-123 (3 microM) and BQ-788 (1 microM) resulted in a 10 fold rightward shift in the concentration-effect curve to endothelin-1 (ED70 = 60 nM, (44-90; n = 6 mice, P < 0.05)), indicating that contraction was mediated via both ETA and ETB receptors. 4. Endothelin-1 evoked similar concentration-dependent contractions of tracheal smooth muscle isolated from control and virus-inoculated mice. In the presence of the ETB receptor-selective-antagonist, BQ-788 (1 microM), the potency and maximum response to endothelin-1 were similar in preparations from control and virus-inoculated mice at all time points investigated. However, unlike control responses, endothelin-1-induced contractions in preparations from virus-infected mice were significantly inhibited by the ETA receptor-selective antagonist, BQ-123. For example, at day 4 post-inoculation, the contractile response to 30 nM endothelin-1, in the presence of BQ-123 (3 microM), was only 20 +/- 12% (n = 6 mice, P < 0.05) of that produced in control preparations under similar conditions. However, at day 19 post-inoculation, contraction evoked by 30 nM endothelin-1 in the presence of BQ-123 (3 microM), was similar to that in preparations from control mice. 5. In summary, during the early stages (days 1-8 post-inoculation) of respiratory tract infection with influenza A/PR-8/34 virus, we observed decreases in the density of tracheal airway smooth muscle ETB receptors which were reflected in decreases in ETB receptor-mediated airway smooth muscle contraction. In addition, during the same period of viral infection we observed increases in the density of tracheal airway smooth muscle ETA receptors which were not associated with increased function of the ETA receptor-effector system linked to contraction. Virus-associated modulation of ETA and ETB receptor density and function was reversible with recovery from infection.