Cement versus noncement: Humerus

Humeral head replacement arthroplasty has been performed for more than 40 years. As the technique has been refined and advances made in joint arthroplasty of the lower extremity, the indications and success of shoulder arthroplasty have greatly improved. The humeral component in a shoulder arthroplasty can be implanted with either cement or press fit fixation. Both techniques are precise and demand attention to detail if an orthopaedic surgeon wishes to obtain the optimum result for the patient. Press fit fixation, with or without porous coating for biological fixation, can be considered for a patient with good bone stock if it is felt that a stable interface can be obtained.In patients with abnormal bone, such as those with rheumatoid arthritis who are on corticosteroids and those with osteoporosis, the use of cement can provide stable long-term fixation.A review of the literature shows a humeral component loosening rate of only 0.9%. Humeral component complications are much less frequent than those on the glenoid side.     

Leg clubs: A new approach to patient-centred leg ulcer management

Abstract Loneliness is a significant health-care issue for many elderly patients in the community. The correlation between social isolation, poor compliance to treatment, and low healing rates for patients suffering from leg ulcers is well documented. Pain, odour, bandages etc. contribute to low self-esteem, depression and social stigma. Home visits by community nurses cannot provide the social and psychological support required by these patients. Responding to the holistic needs of this client group, the author set up Debenham Leg Club in 1995 to provide leg ulcer management in an informal, non-medical setting, where the emphasis is on social interaction, participation, empathy and peer support. This social model was conceived as a unique partnership between the district nurses and the local community, in which patients are empowered, through a sense of ownership, to become stakeholders in their own treatment. The value of the 'club' concept is evident in the happy, welcoming, uninhibited atmosphere that characterizes the clinic. Non-compliance to treatment has been virtually eliminated and evidence of greater healing rates has been illustrated through many patients whose long-standing ulcers have healed or greatly improved as a direct result of this change in approach. Patients' willingness to attend for systematic 'well leg' checks and ongoing health education has dramatically reduced the incidence of recurrence.     

The Surgical Management of Spitz Nevi

BACKGROUND: The biologic behavior of Spitz nevi and atypical Spitz nevi ranges from completely benign to the rare malignant melanoma. Various recommendations for the surgical approach to these lesions have been proposed. OBJECTIVE: To determine any trend in the surgical management of Spitz nevi and atypical Spitz nevi among a community of dermatologists. METHODS: Retrospective review of the clinical features, surgical management and outcome of 89 patients with the diagnosis of Spitz nevus or atypical Spitz nevus. RESULTS: All biopsy techniques had a high incidence of involved margins: shave (67%), excision (28%), and punch (21%). Of the atypical Spitz nevi with positive margins on biopsy, there was a trend (7/9) toward reexcision with narrow margins (average 2.2 mm). CONCLUSION: The majority of atypical Spitz nevi incompletely removed by biopsy were excised with narrow uncontrolled margins. A stratified surgical approach depending on the clinical and histopathologic features of the Spitz lesion is proposed. More aggressive surgical management of Spitz lesions with atypical features may be warranted. Further studies to determine the biologic potential of these lesions are needed.     

Investigating and implementing change within the primary health care nursing team

Primary care is developing rapidly with significant impacts on the nursing team. Such changes have brought inter-professional team-working into sharper focus, particularly community care and collaborative working. This paper: examines the nursing roles within a general practice; describes the perspectives of service users; identifies areas of change; clarifies core and specialist skills; defines new roles among the primary health care nursing team; proposes a new model of working; and identifies appropriate education. The project was set in a general practice in south-west England and used an action research methodology. The objectives were to create a change in practice and to develop and refine existing theory to underpin nursing roles. Throughout the research regular team meetings allowed reflection and discussion about research findings and progress. Data were collected from multiple sources, including team workshops, patient focus group interviews, and individual interviews with GPs, practice managers and area managers. Reflective diaries and a patient survey were also used. The analysis of the quantitative and qualitative data collected from patients formed a basis for practice development and facilitated the team's reflection on the areas of change. Overall high satisfaction with services and care was expressed in the patient interviews and the questionnaire. The themes from the data highlighted areas important for patients and helped in shaping the new roles and responsibilities for team members. Regarding the team perspective, the data indicated many areas that could be considered for development. The community nursing team decided to concentrate on three key areas: child health, leg ulcer management, and cardiovascular health. The research concludes that action research presents some problems and challenges but is a useful approach to developing team-working in primary health care.     

W IRELESS AND S ATELLITE T RANSMISSION OF P REHOSPITAL F OCUSED A BDOMINAL S ONOGRAPHY FOR T RAUMA

Objective. As military operations become smaller and more remote and as humanitarian missions increase, ultrasound technology is emerging as a valuable asset for defining injuries in austere settings. This study evaluated the feasibility of focused abdominal sonography for trauma (FAST) examinations in a field environment with real-time images sent wireless to an antenna and over satellite. Methods. Using a 6-lb SonoSite portable ultrasound device with battery pack, FAST examinations were performed on a healthy volunteer, transferred wireless at distances of 1,000 and 1,500 feet from the receiving antenna using a vest-mounted microwave transmitter, and then redirected over satellite (INMARSAT) to a remote hospital for review by emergency physicians, and a radiologist. Results. Real-time wireless transmissions at 1,500 feet reliably yielded images without quality or interpretability drop compared with those recorded digitally at the examination site. A 32% reduction in image quality and interpretability was seen with still images and a 42% reduction was noted with cine loops using INMARSAT. The authors did not find the upper distance limit of the wireless transmitter used. Conclusion. This study suggests 1) that remote FAST examinations are plausible for prehospital care and triage using new-generation portable ultrasound units, 2) that line-of-sight transmission of FAST examinations when compared with on-site images results in no degradation in image quality or interpretability at distances used, 3) that ranges greater than 1,500 feet are feasible for interpretable examinations and therefore line-of-site mass casualty or field triage sites, and 4) that real-time INMARSAT transmission of FAST examinations at 64?kbps may serve a limited role for remote clinical interpretation.