Pelvic fractures: value of plain radiography in early assessment and management

Assessment of pelvic fractures in severely traumatized, clinically unstable patients presents a diagnostic problem. Traditional plain-radiographic classifications of the fracture are of limited preoperative value to the surgeon who must apply corrective force in opposition to the original force vector causing the fracture. Computed tomographic scanning is an effective method of examining the pelvis but is time consuming and may be impractical in cases of severe injury. In a retrospective analysis of the plain radiographs of 142 cases of pelvic fracture, four patterns of force were identified, presenting distinctive, recognizable radiographic appearances. These patterns are anteroposterior compression, lateral compression, vertical shear, and a complex pattern. The resulting classification of pelvic fracture, based on radiographic and clinical findings, correlates with associated injury to soft-tissue structures and enables the surgeon to begin corrective procedures rapidly.     

The perceptual priming phenomenon in amnesia

Alcoholic Korsakoff patients and controls were given three variants of a priming task. In the first task, a study list of words was followed by a recognition test phase and then a perceptual identification test phase. In the second task, the order of the two test phases was reversed. The amnesics performed like normals on the priming for identification task and the delay did not affect their performance. However, recognition by amnesics was significantly impaired when the delay was introduced; although it too was normal with no delay. In a third task, pseudowords were used as stimuli. Under these conditions the amnesics could not be primed nor could they recognize the material. The implications of these findings for current theories of amnesia were discussed.     

Spinal fractures during fluoride therapy for osteoporosis: Relationship to spinal bone density

Recent studies report that fluoride therapy for osteoporosis increases spinal bone density without improving vertebral fracture rate, challenging the notion that restoration of bone mass improves bone fragility. To further evaluate this issue, the relationship between spinal bone density and vertebral fracture rate was examined in a large number of fluoride-treated, osteoporotic patients. A retrospective assessment was made of clinical data collected from our observations of 389 osteoporotics treated with fluoride 30±8 mg/day (mean±SD) (equivalent to 66±17 mg NaF/day) and calcium 1500 mg/day for 28±18 months. Fracture rate and bone density were assessed in the same region of the spine (i.e., T12 through L4) using quantitative computed tomography (QCT).Spinal bone density increased with time on fluoride, but the relationship was hyperbolic (r=0.99,p<0.0001; asymptote=167 mg/cc on double-reciprocal plot), suggesting a plateau in the response. The spinal fracture rate decreased as a function of time on therapy (r=–0.83,p<0.01), and was inversely related to spinal bone density during fluoride therapy (r=0.70,p<0.001 on arithmetic plot;r=–0.79,p<0.001 on semi-log plot). The subgroup of patients who responded to treatment with a significant increase in spinal bone density had a 48% reduction in spinal fracture rate compared with non-responders (p<0.001). The subgroup of patients who sustained a fracture during fluoride therapy not only had a slower rate of increase in spinal bone density in response to fluoride therapy, but were also significantly older, had more fractures prior to fluoride therapy, and had a lower pretreatment spinal bone density; consequently, spinal bone density after treatment with fluoride was also lower in this subgroup of patients compared with those who did not sustain a fracture (p<0.001). These findings are consistent with both the general hypothesis that bone density is an important determinant of fracture risk in osteoporosis, and the specific hypothesis that an increase in spinal bone density in response to fluoride treatment is associated with a decrease in the risk for vertebral fractures.     

Asthma self-management skills and the use of asthma education during pregnancy.

During pregnancy, patients with asthma are at risk of poor outcomes, particularly when asthma is poorly controlled. The aim of this study was to determine the level of asthma self-management skills and knowledge among pregnant subjects and describe the implementation of an asthma education programme delivered in an antenatal clinic setting. Pregnant subjects with asthma were assessed by an asthma educator at 20 (n = 211) and 33 weeks gestation (n = 149). Lung function, symptoms, medication use, adherence, knowledge and inhaler technique were assessed. They were asked whether they had a written asthma action plan, or performed peak flow monitoring. Asthma was classified as mild, moderate or severe. At the first visit with the asthma educator, 40% of females reported nonadherence to inhaled corticosteroids, inhaler technique was assessed as inadequate in 16% and 42% had inadequate medication knowledge. Peak flow monitoring was performed by 3% and 15% had a written action plan. There were significant improvements in all aspects of asthma self-management following education. In females with severe asthma, night symptoms and reliever medication use significantly decreased after education. In conclusion, during pregnancy, patients with asthma have poor asthma knowledge and skills, and may benefit from self-management education as part of their obstetric care.     

Cyclosporine-induced graft-versus-host disease following autologous bone marrow transplantation in acute myeloid leukaemia

Cyclosporine was used to induce graft-versus-host disease (GVHD) in patients with acute myeloid leukaemia (AML) receiving autologous bone marrow transplantation (ABMT). Nine consecutive patients with AML in remission were conditioned with either busulphan and cyclophosphamide or melphalan and total body irradiation (TBI) followed by ABMT. Cyclosporine, 1 mg/kg daily from days 1-28 was administered intravenously in four patients and orally in five. Acute GVHD of the skin, confirmed by histological and immunological criteria occurred in three patients, 4-28 days after ABMT and lasted 8-18 days. Incidence and severity of GVHD were independent of cyclosporine levels. Three patients subsequently relapsed, of whom two had had evidence of GVHD. All of these patients were in second remission at time of graft, and therefore poor risk. The potential of cyclosporine to induce GVHD in the AML autograft setting is demonstrated, although the significance of this observation in terms of an antileukaemia effect needs clarification.     

Controlled-tension suture-tying forceps.

Suture-tying forceps have been designed to enable surgeons to tie consecutive sutures to the same tension to create an evenly compressed wound. The tensioning effect of the forceps was tested by tying a suture to the end of a cantilever beam strain-gauge device. Three sutures were used: 10/0 nylon, 8/0 polyglactin (Vicryl) and 8/0 virgin silk. The tests were repeated, coating the tips with citrated blood, sodium hyaluronate and saline. Adjustment of the forceps altered the suture tension in 0.015-N steps. Sterilization of the forceps by ethylene oxide or by an autoclave caused no obvious regression in the forceps performance. When the suture and surface lubricant remain constant, there is a linear relationship between forceps setting and the tension induced in the suture.     

Ultrastructural immunocytochemistry of the intact tissue cyst of Toxoplasma in the brains of mice with congenital toxoplasmosis

Electron immunocytochemistry, using rabbit polyclonal anti-Toxoplasma IgG as the primary layer in immunogold staining, was used to assess the distribution of Toxoplasma antigen within, and in relation to, intact tissue cysts in brain tissue from mice with congenital toxoplasmosis. Toxoplasma antigen was widely distributed in the matrix of the cyst, being most concentrated in the proximity of the inner surface of the parasitophorous vacuole membrane (PVM). Relatively little Toxoplasma antigen was detected directly associated with cystozoites. Small amounts of antigen were detected within the host cell components exterior to the PVM and in the host neuropil immediately adjacent to the tissue cyst.     

Symptomatic improvement with one-year cisapride treatment in neuropathic chronic intestinal dysmotility.

AIM: To assess the efficacy of a prokinetic agent in the long-term treatment of chronic intestinal dysmotility and the influence of extrinsic denervation. METHODS: We assessed symptoms, compliance and untoward effects in an open, 1-year trial of cisapride, 20 mg t.d.s., in 37 patients with neuropathic forms of chronic intestinal dysmotility. Patients' autonomic function had previously been characterized; effects of cisapride at 12 weeks in a placebo-controlled trial were previously reported. RESULTS: Seventeen patients had idiopathic dysmotility, 11 had diabetes mellitus with autonomic dysfunction, five had had previous gastric surgery and four had neurological syndromes. Median medication compliance was 98.9% for the study period completed by each individual. Median duration of follow-up was 9.5 months; 20 patients completed 1 year of treatment, and 27 of 37 at least 6 months of treatment; seven dropped out because of lack of benefit. Mean total symptom score was significantly reduced at the last observation relative to the entry into the trial; this was particularly the case in those patients without abdominal vagal dysfunction. One patient withdrew because of aggravation of abdominal pain. CONCLUSIONS: During an open, long-term trial, cisapride, 20 mg t.d.s., provided continued symptomatic relief to patients with chronic intestinal dysmotility, particularly those without vagal neuropathy.