Intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament

Our objectives were to establish the envelope of passive movement and to demonstrate the kinematic behaviour of the knee during standard clinical tests before and after reconstruction of the anterior cruciate ligament (ACL). An electromagnetic device was used to measure movement of the joint during surgery. Reconstruction of the ACL significantly reduced the overall envelope of tibial rotation (10 degrees to 90 degrees flexion), moved this envelope into external rotation from 0 degrees to 20 degrees flexion, and reduced the anterior position of the tibial plateau (5 degrees to 30 degrees flexion) (p < 0.05 for all). During the pivot-shift test in early flexion there was progressive anterior tibial subluxation with internal rotation. These subluxations reversed suddenly around a mean position of 36 +/- 9 degrees of flexion of the knee and consisted of an external tibial rotation of 13 +/- 8 degrees combined with a posterior tibial translation of 12 +/- 8 mm. This abnormal movement was abolished after reconstruction of the ACL.     

Selection of outcome assessment instruments for inpatients with severe and persistent mental illness

The purpose of this article is to describe a procedure to assist in selecting outcome measures for inpatients treated at a state psychiatric hospital. The procedure combines evidence-based criteria from the literature, instruments shown to be sensitive to change in clinical trials, and the perspectives of a multidisciplinary team of researchers, administrators, providers, and patient advocates. Recent efficacy and effectiveness studies were used to identify recurrently used outcome instruments. A computerized search of more than 30 bibliographic databases, such as PsycINFO, MEDLINE, Social SciSearch, and ERIC, was conducted for articles published between 1990 and 2002. Comparisons of the most frequently used instruments were made on seven criteria proposed as best-practice indicators, including sensitivity to change and robust psychometrics. The sample produced 110 measures. Rater-completed instruments were represented more often than patient-completed ones. However, considerable variability across both methods was found on the criteria. The limited resources associated with publicly funded inpatient facilities led to a recommendation to select at least one rater-completed and one patient-completed instrument.     

Review of a routine test of cardiac function before aortic aneurysm surgery

The majority of vascular surgeons employ tests of cardiac function prior to embarking on elective abdominal aortic aneurysm (AAA) repair. This study reviewed the value of measuring preoperative ventricular ejection fraction (VEF). The records of the 207 patients considered for elective AAA repair between 1994 and 2000 were reviewed. In patients who underwent surgery, morbidity and mortality data were retrieved from the vascular department database. These outcomes were correlated with the measured VEFs. In patients turned down for surgery, the reasons were determined from patients' notes, and the role that VEF played in the decision was evaluated. Low VEF did not correlate with postoperative cardiac morbidity or mortality. The range of VEF values in patients turned down for surgery was not significantly different from those who underwent AAA repair. VEF was pivotal in the decision not to operate in only one patient over the 6-year interval. This review found no evidence that routine measurement of VEF prior to elective AAA repair was valuable either in making the decision whether to operate or in predicting outcome and complications. Little or no information was added that could not be gained on simple clinical evaluation of cardiac function.     

The London nail bombings: the St. Thomas' Hospital experience

At 18:00 h on 17 April 1999 a nail bomb exploded outside a supermarket in Brixton, London. This was the first of a series of three identical nail bombs. The injuries were due to penetrating nails, most were relatively minor, with only three patients requiring general anaesthesia for removal of nails and debridement. One 6-year-old child subsequently underwent onward referral for neurosurgical treatment.At 18:40 h on 30 April 1999, the third bomb exploded (there were no casualties at our hospital from the second bomb, that in Brick Lane on 24 April 1999) in the confined environment of the Admiral Duncan public house in Soho. The injuries were much more severe than those seen from the Brixton bomb. Two persons died on the scene and 81 were injured; 27 were transferred to our hospital. Three primary lower limb amputations were performed. Within the first 24h, four patients required ITU care and two onward referral to the regional burns unit.Injuries such as those seen in these two bombings are common in war situations. In peacetime it is rare to see this spectrum of injury and hence surgeons can be unaware of optimal management protocols. Our approach in these patients, based on thorough initial debridement and delayed closure/split skin grafting is similar to that advocated by the International Committee of the Red Cross based on their war surgery experience. We emphasise debridement without any initial reconstructive procedures. We also discuss some logistic problems of major incidents.     

The peripheral benzodiazepine receptor ligand PK11195 binds with high affinity to the acute phase reactant alpha1-acid glycoprotein: implications for the use of the ligand as a CNS inflammatory marker

The peripheral benzodiazepine receptor ligand PK11195 has been used as an in vivo marker of neuroinflammation in positron emission tomography studies in man. One of the methodological issues surrounding the use of the ligand in these studies is the highly variable kinetic behavior of [(11)C]PK11195 in plasma. We therefore undertook a study to measure the binding of [(3)H]PK11195 to whole human blood and found a low level of binding to blood cells but extensive binding to plasma proteins. Binding assays using [(3)H]PK11195 and purified human plasma proteins demonstrated a strong binding to alpha1-acid glycoprotein (AGP) and a much weaker interaction with albumin. Immunodepletion of AGP from plasma resulted in the loss of plasma [(3)H]PK11195 binding demonstrating: (i) the specificity of the interaction and (ii) that AGP is the major plasma protein to which PK11195 binds with high affinity. PK11195 was able to displace fluorescein-dexamethasone from AGP with IC(50) of <1.2 microM, consistent with a high affinity interaction. These findings are important for understanding the behavior of the ligand in positron emission tomography studies for three reasons. Firstly, AGP is an acute phase protein and its levels will vary during infection and pathological inflammatory diseases such as multiple sclerosis. This could significantly alter the free plasma concentrations of the ligand and contribute to its variable kinetic behavior. Secondly, AGP and AGP-bound ligand may contribute to the access of [(11)C]PK11195 to the brain parenchyma in diseases with blood brain barrier breakdown. Finally, local synthesis of AGP at the site of brain injury may contribute the pattern of [(11)C]PK11195 binding observed in neuroinflammatory diseases.