Two‐Stage Revision Hip Arthroplasty with or without the Use of an Interim Spacer for Managing Late Prosthetic Infection: A Systematic Review of the Literature

The aim of the present paper was to identify, appraise, and synthesize the available evidence on two‐stage revision hip arthroplasty with or without the use of an interim spacer for managing late prosthetic infection. The review methodology was designed by referencing the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) checklist and flow diagram, and a Population, Intervention, Comparator, Outcomes and Study (PICOS) design framework was used to search for studies to incorporate within the review. Two independent investigators were involved in searching for relevant articles that fulfilled the inclusion criteria for the study. Critical appraisal of the selected articles was carried out using the relevant Critical Appraisal Skills Programme checklists. From an initial pool of 125 articles, four studies satisfied the inclusion criteria and quality assessment and were included for final review. Two patient groups were identified from within the selected studies: spacer and non‐spacer. Both groups were assessed in terms of functional outcome, infection cure rates, and technical difficulties encountered during treatment. Better functional outcome was reported in the spacer group, both in the interim period between the two stages and after completion of treatment. The use of spacers reduced operative difficulty during the second stage and accelerated patient discharge. Reinfection and infection persistence rates were higher in the non‐spacer group. Within the spacer group, articulated spacers performed better in all parameters. The results of this review reinforce the available evidence supporting the use of interim hip spacers in revision hip arthroplasty for managing prosthetic infection and also indicate that articulated hip spacers could be an attractive option going forward.     

Parameters and standardization in obstetric Doppler

Obstetric Doppler is still largely empirically based, although possible clinical applications are already under examination. This article examines some of the basic instrumentation and hemodynamic issues — which physiological parameters would we ideally like to assess, and what can we do in practice with current Doppler instrumentation? It is shown that the rate of blood flow and the flow resistance are two of the most basic hemodynamic parameters. It is possible to estimate the flow rate with (specialized) Doppler equipment, but there is no method available at present to measure the flow resistance. Analysis of the blood velocity waveform provides some information concerning flow resistance, as long as it can be assumed that other factors that might affect the waveform have not deviated significantly from the norm. Practical considerations in choosing the instrumentation and designing the examination protocol are discussed, and issues of quality control are emphasized.     

Repair of cartilaginous fractures during chick limb development.

The embryonic chick wing has been used extensively in experimental analyses of the mechanisms involved in limb development. This study employs the embryonic wing in an examination of the possible origin of congenital pseudoarthrosis, a poorly understood limb disorder. To this end, chick radii were fractured in the middiaphysis prior to the onset of osteogenesis (6.5-7 days of incubation). The subsequent development of the fractured elements was examined using both whole mount preparations and histology. Callus cartilage did not form around any of the fractures. Nonetheless, the majority (29 of 33 specimens) of fractures united during primary osteogenesis (within 24-36 h of the operation), with bone formation occurring both across the fracture site and also over the cut ends of the cartilage. In addition, bones that exhibited a configuration similar to that described as giving rise to a type II congenital pseudoarthrotic condition were obtained. Typically, these bones showed an "hourglass" constriction midshaft and anterior bowing. These results suggest that the embryonic chick limb may serve as a useful experimental model system for the investigation of this congenital limb disorder.     

Methadone: old problems for new programmes

The present paper is concerned with factors which compromise the effective delivery of programmes incorporating methadone. Current clinical practices and programme characteristics are reviewed and policy issues regarding the role of methadone are considered, especially within the context of containing the spread of HIV infection. These issues are discussed in relation to empirical outcome studies, local prescribing trends and clinical case material. The authors conclude that there is an urgent need for: (1) an evaluation of the outcome of private practitioner methadone dispensation versus comprehensive agency-based therapy; (2) the accreditation of staff in all programmes incorporating methadone; and (3) the development of monitoring mechanisms, including on-site clinical audits of programmes.     

Frequent consulters in general practice: a systematic review of studies of prevalence, associations and outcome

We conducted a systematic review of the observational literature on frequent consulters in general practice. Electronic searching identified 34 studies which met our inclusion criteria. Frequent consulters were identified in a wide range of primary health care settings, confirming that a small proportion of patients is responsible for a disproportionate number of consultations. A cutoff of 9-14 consultations per annum was used to define a frequent consulter in most studies. Studies have examined a variety of associated characteristics, and indicate that frequent consulters are highly heterogeneous, and have high rates of physical disease, psychiatric illness and social difficulties. Few are likely to conform to the "heartsink" stereotype. These patients are likely to have multiple, complex problems, often including chronic physical disease, with or without psychological and social problems. The natural history of frequent consulting behavior seems to be to persist in many cases. Implications for management are discussed.