Inadvertent advancement of guide wire across the knee caused by incarcerated bone fragment at the nail tip during femoral nailing

Fracture of femoral shaft in adults is common and mostly managed with intramedullary interlocking nails. Complications during closed intramedullary femoral nailing are uncommon, and mostly of them are caused by technical reasons. We describe a case of closed nailing for a femoral shaft fracture in which a jammed intramedullary guide wire, due to an incarcerated bone fragment at the nail tip, was inadvertently advanced across the knee. Forceful attempt of nail insertion caused this complication, which was probably attributed to nail design.     

Impact of the introduction of fee for service payments on types of minor surgical procedures undertaken by general practitioners: observational study

The 1990 general practitioners (GPs) contract introduced item of service payment for minor surgery, payable for six categories of procedure. Early review showed no substitution of cheaper procedures for more expensive treatments. Detailed payment data from six Health Authorities for the period 1993-2000 show an 11 per cent increase in claims, largely accounted for by the rise in cautery, incorporating cryotherapy. Cryotherapy is no more effective at treating warts than cheap commercially available products, but is quite profitable for GPs. This is yet another example of item of service payment distorting treatment priorities. The new GP contract, and the initiative to develop GPs with special interests in dermatology and minor surgery, will allow primary care trusts to develop minor surgery undertaken by appropriately skilled and experienced GPs, and which reflects the needs of the population.     

Hetisine-type diterpenoid alkaloids from the Bhutanese medicinal plant Aconitum orochryseum

Investigation of Aconitum orochryseum, a Bhutanese traditional medicine ("gSo-ba Rig-pa") plant locally known as "Bong-kar", resulted in the isolation of three new hetisine-type diterpenoid alkaloids, named orochrine (1), 2-O-acetylorochrine (2), and 2-O-acetyl-7alpha-hydroxyorochrine (3), together with the previously reported alkaloids atisinium chloride (4) and virescenine (5). The structures of the new alkaloids were elucidated by spectroscopic data analysis.     

Human and animal rabies prevention and control cost in Bhutan, 2001–2008: The cost–benefit of dog rabies elimination

The objective of this study was to estimate the cost of various interventions and to quantify the economic impacts of rabies in Bhutan. Cost–benefit of dog rabies elimination versus human post exposure treatment cost was also assessed. The average direct medical cost of human post-exposure treatment (using rabies vaccine only) was estimated to be Nu. 1615 (US$ 35.65) per 5-dose Essen regimen per patient. The cost would increase to Nu. 2497 (US$ 55.13) and Nu. 19,633 (US$ 433.41) per patient when one dose of either equine rabies immunoglobulin (ERIG) or human rabies immunoglobulin (HRIG) is administered, respectively. The societal cost (direct medical and indirect patient expenses) per patient was estimated to be Nu. 2019 (US$ 45), Nu. 2901 (US$ 64) and Nu. 20,037 (US$ 442) using vaccine only, vaccine with ERIG and vaccine with HRIG, respectively. The average cost per dog vaccination and sterilization were estimated to be Nu. 75 (US$ 1.66) and Nu. 288 (US$ 6.36), respectively. The total direct cost of rabies and various interventions between 2001 and 2008 was estimated to be Nu. 46.95 million (US$ 1.03 million). The direct cost for intensified human PET was estimated to be Nu. 5.85 million (US$ 0.11 million) per year with a cumulated estimated costs of Nu. 35.10 million (US$ 0.70 million) while the cost of mass dog vaccination with at least 70% coverage is estimated to be approximately Nu. 10.31 million (US$ 0.21 million) at the end of 6 years. The combined cost of mass dog vaccination and human PET was estimated to be greater than the cost of human PET alone during the first 2 years of the campaign, and then would be lower than human PET cost alone after the 5th year of the campaign. The total cumulated cost of the combined strategy was estimated to be Nu. 34.14 million (US$ 0.73 million) and would be lower than the cumulated cost of human PET alone (Nu. 35.10 million, US$ 0.77 million) at the end of 6 years. Rabies represents a substantial economic impact to the Bhutanese society. Well-planned and implemented mass dog vaccination would result in elimination of rabies reservoirs in the domestic dog population and would eliminate human rabies cases. It would also reduce the recurrent expenditure on human post-exposure treatment.     

Multiple shift patient classification: is it necessary?

Efficient, cost-effective patient classification systems are an essential component of information needed for staffing projections, budgeting, productivity monitoring, and determining the cost of nursing services. Data collection on every shift is typical of GRASP-based patient classification systems. In this study, comparisons among multiple shift measurements showed that no relevant information was being gained by multiple daily assessments of patient care requirements.     

Does Pulsatile Flow Influence the Incidence of Postoperative Hypertension?

Twenty patients undergoing primary elective aorta--coronary artery bypass were divided into two equal groups, both receiving identical premedication, anesthetic, and pump primes. The control patients received hypothermic nonpulsatile flow and the study patients received hypothermic pulsatile flow. Hypertension, defined as a pressure of 160/100 mm Hg or higher, was observed in 80% of the control patients and 20% of the patients receiving pulsatile flow (p less than 0.05). Serial renin measurements demonstrated maximum values in the intensive care unit and coincided with the onset of postoperative hypertension in the control patients. Those patients who had received pulsatile flow did not demonstrate notable renin stimulation. Catecholamines were markedly elevated during bypass and in the intensive care unit, but there was no significant difference between the two groups. Peripheral vascular resistance was not significantly lower with pulsatile flow, except in the first study performed in the intensive care unit. We conclude that catecholamines and the renin-angiotensin system contribute to the production of postoperative hypertension and that pulsatile flow diminishes renin stimulation. Pulsatile flow results in a decreased incidence of postoperative hypertension.