Elevated prostate specific antigen (PSA) levels a risk factor for pathological hip fracture in metastatic prostatic carcinoma

Metastatic carcinoma of the prostate is increasing in incidence and commonly affects the proximal femur, but fracture risk is difficult to predict. Prophylactic fixation may avert the technical problems and reduce post-operative complications associated with acute pathological fracture treatment. This is a retrospective study of 14 patients who sustained a pathological fracture in the proximal femur from prostatic metastases. Risk factors for fracture were assessed, peri-operative complications highlighted and patient survival noted. At time of the initial diagnosis of prostate carcinoma, 12/14 patients (86%) had uptake in the proximal femur on isotope bone scan and 11/14 (79%) had an initial prostate specific antigen (PSA) level above 100 ng/ml. A higher initial PSA level correlated with a shorter time to fracture. The subtrochanteric region was the most common fracture location and was technically the most demanding to fix. Blood loss and transfusion requirements were high. Post-operative survival was 71%, 50% and 36% at 6, 12 and 18 months, respectively. From our findings, we suggest that patients with a greatly elevated PSA (>100 ng/ml), a positive isotope bone scan and plain X-ray changes in the proximal femur are at high risk of fracture and should be referred early for prophylactic stabilisation.

Antegrade locked intramedullary nailing in humeral shaft fractures

Thirty-three humeral nailings were carried out using the Russell-Taylor nail. Twenty-two acute fractures and one non-union united, gave an overall union rate of 70%. Eighteen patients (56%) experienced pain in the shoulder or at the fracture site. Thirteen patients (41%) had poor shoulder function. Only 17 (51%) of the patients were satisfied with the outcome. Fourteen patients (42%) needed further surgery. We conclude that antegrade intamedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. There was no significant correlation between fracture comminution and fracture healing in our study.

Is vaginal birth after cesarean safe? Experience at a community hospital

OBJECTIVE

We sought to evaluate the effectiveness and safety of promoting a trial of labor after prior cesarean birth in a community hospital.

STUDY DESIGN

A 4-year prospective cohort study was conducted of all patients who had prior cesarean births (N = 1481). A comparison of outcomes was performed between those who elected repeat cesarean delivery (n = 727) and those who attempted a trial of labor after previous cesarean(s) (n = 754).

RESULTS

We found that the vaginal birth after cesarean attempt rate was 50.9% and declined significantly during the last 2 years of the study. The elective repeat cesarean rate was 49.1% and increased significantly during the last 2 years of the study. In addition, we found that neonatal outcomes were similar, with the exception of 2 neonatal deaths caused by uterine rupture. Twelve uterine ruptures occurred (1.6%), and 11 of the 12 ruptures involved either induction or augmentation of labor, or both.

CONCLUSIONS

A trial of vaginal birth after cesarean is safe provided that induction of labor is not used. The uterine rupture rate of 1.6% is higher than reported in the literature; this may reflect underreporting by community hospitals.

RANK is the intrinsic hematopoietic cell surface receptor that controls osteoclastogenesis and regulation of bone mass and calcium metabolism

We have generated RANK (receptor activator of NF-kappaB) nullizygous mice to determine the molecular genetic interactions between osteoprotegerin, osteoprotegerin ligand, and RANK during bone resorption and remodeling processes. RANK(-/-) mice lack osteoclasts and have a profound defect in bone resorption and remodeling and in the development of the cartilaginous growth plates of endochondral bone. The osteopetrosis observed in these mice can be reversed by transplantation of bone marrow from rag1(-/-) (recombinase activating gene 1) mice, indicating that RANK(-/-) mice have an intrinsic defect in osteoclast function. Calciotropic hormones and proresorptive cytokines that are known to induce bone resorption in mice and human were administered to RANK(-/-) mice without inducing hypercalcemia, although tumor necrosis factor alpha treatment leads to the rare appearance of osteoclast-like cells near the site of injection. Osteoclastogenesis can be initiated in RANK(-/-) mice by transfer of the RANK cDNA back into hematopoietic precursors, suggesting a means to critically evaluate RANK structural features required for bone resorption. Together these data indicate that RANK is the intrinsic cell surface determinant that mediates osteoprotegerin ligand effects on bone resorption and remodeling as well as the physiological and pathological effects of calciotropic hormones and proresorptive cytokines.

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services

BACKGROUND

General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning.

AIM

To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided.

METHOD

A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received.

RESULTS

Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs.

CONCLUSION

The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.

PREPARED: Preparation for Angiography in Renal Dysfunction: a randomized trial of inpatient vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction

BACKGROUND

IV hydration before and after cardiac catheterization is effective in preventing contrast-associated renal dysfunction for patients with mild-to-moderate renal insufficiency, but necessitates overnight hospital admission. We tested an outpatient oral precatheterization hydration strategy in comparison with overnight IV hydration.

METHODS

We randomized 36 patients with renal dysfunction (serum creatinine > or = 1.4 mg/dL) undergoing elective cardiac catheterization to receive either overnight IV hydration (0.45 normal saline solution at 75 mL/h for both 12 h precatheterization and postcatheterization; n = 18) or an outpatient hydration protocol including precatheterization oral hydration (1,000 mL clear liquid over 10 h) followed by 6 h of IV hydration (0.45 normal saline solution at 300 mL/h) beginning just before contrast exposure. The predefined primary end point was the maximal change in creatinine up to 48 h after cardiac catheterization.

RESULTS

The inpatient and outpatient groups were well matched for baseline characteristics and contrast volume. By protocol design, the outpatient group received a greater volume of hydration, although the net volume changes were comparable in the two groups. The maximal changes in serum creatinine in the inpatient (0.21+/-0.38 mg/dL; 95% confidence interval [CI], 0.02 to 0.39 mg/dL) and outpatient groups (0.12+/-0.23 mg/dL; 95% CI, 0.01 to 0.24 mg/dL) were comparable (p = not significant). There were no instances of protocol intolerance.

CONCLUSIONS

A hydration strategy compatible with outpatient cardiac catheterization is comparable to precatheterization and postcatheterization IV hydration in preventing contrast-associated changes in serum creatinine. Hospital admission for IV hydration is unnecessary before elective cardiac catheterization in the setting of mild-to-moderate renal dysfunction.

Personal use of drug samples by physicians and office staff

CONTEXT

Pharmaceutical samples are commonly used in ambulatory care settings. There is limited research on their use or impact on health care providers and patients.

OBJECTIVE

To determine the extent of personal use of drug samples over a 1-year period by physicians and medical office staff.

DESIGN, SUBJECTS, AND SETTING

An anonymous cross-sectional survey of all physicians, resident physicians, nursing staff, and office staff in a family practice residency.

MAIN OUTCOME MEASURE

Quantity of drug samples taken for personal or family use.

RESULTS

Of 55 surveys issued, 53 (96%) were returned. A total of 230 separate drug samples were reported taken in amounts ranging from 1 dose to greater than 1 month's supply. Two respondents reported no use of drug samples, while 4 respondents reported taking more than 10 different samples.

CONCLUSION

Drug samples are commonly taken by physicians and office staff for personal and family use. The ethical implications of this practice warrant further discussion.

Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study

A multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial was conducted to test the efficacy of a specifically programmed, low-intensity, non-thermal, pulsed ultrasound medical device for shortening the time to radiographic healing of dorsally angulated fractures (negative volar angulation) of the distal aspect of the radius that had been treated with manipulation and a cast. Sixty patients (sixty-one fractures) were enrolled in the study within seven days after the fracture. The patients used either an active ultrasound device (thirty fractures) or a placebo device (thirty-one fractures) daily for twenty minutes at home for ten weeks. The two types of devices were identical except that the placebo devices emitted no ultrasound energy. Clinical examination was performed and radiographs were made at one, two, three, four, five, six, eight, ten, twelve, and sixteen weeks after the fracture by each site investigator. The time to union was significantly shorter for the fractures that were treated with ultrasound than it was for those that were treated with the placebo (mean [and standard error], 61 +/- 3 days compared with 98 +/- 5 days; p < 0.0001). Each radiographic stage of healing also was significantly accelerated in the group that was treated with ultrasound as compared with that treated with the placebo. Compared with treatment with the placebo, treatment with ultrasound was associated with a significantly smaller loss of reduction (20 +/- 6 per cent compared with 43 +/- 8 per cent; p < 0.01), as determined by the degree of volar angulation, as well as with a significant decrease in the mean time until the loss of reduction ceased (12 +/- 4 days compared with 25 +/- 4 days; p < 0.04). We concluded that this specific ultrasound signal accelerates the healing of fractures of the distal radial metaphysis and decreases the loss of reduction during fracture-healing.

Acceleration of tibia and distal radius fracture healing in patients who smoke

A low intensity ultrasound device was investigated as an accelerator of cortical and cancellous bone fracture healing in smokers and nonsmokers. Statistically significant reductions in healing time for smokers and nonsmokers were observed for tibial and distal radius fractures treated with an active ultrasound device compared with a placebo control device. The healing time for a tibial fracture was reduced 41% in smokers and 26% in nonsmokers with the active ultrasound device. Similarly, distal radius fracture healing time was reduced by 51% in smokers and 34% in nonsmokers with the active device. Treatment with the active ultrasound device also substantially reduced the incidence of tibial delayed unions in smokers and nonsmokers. The use of the active ultrasound device accelerates cortical and cancellous bone fracture healing, substantially mitigates the delayed healing effects of smoking, speeds the return to normal activity, and reduces the long-term complication of delayed union.

Joint regulation of cell size and cell number in the wing blade of Drosophila melanogaster

We used Drosophila melanogaster to test for compensatory control of cell area and cell number in the regulation of total wing area. In two random bred wild-type base stocks collected from different geographic locations we found a negative association between the area and the number of cells in the wing blade. Three replicate lines were selected for increased or decreased wing area, with cell area maintained at the same level as in the three controls. After eight generations of selection, despite a large and highly significant difference in wing area between the large, control and small selection lines, cell area did not differ significantly between them. Rather, the difference in wing area between selection regimes was attributable to differences in cell number. Over the course of selection, the initially significant negative correlation between cell area and cell number in the wing increased, providing evidence for compensatory regulation of cell area and cell number. As a result of the increasingly negative association between the two traits, the variance in wing area declined as selection proceeded. It will be important to discover the mechanisms underlying the compensatory regulation of cell area and cell number.

Knowledge of lymphoedema among primary health care teams: a questionnaire survey

Lymphoedema usually develops following surgery or radiotherapy for cancer, but can also occur in advanced malignant disease or be primary in origin. Lower limb lymphoedema may present particular difficulties in diagnosis, treatment and management. All types of lymphoedema can seriously impair quality of life for those affected. This study aimed to determine the level of knowledge among primary health care team members concerning the identification and management of patients at risk of developing lymphoedema, the current treatment options available for patients with established lymphoedema, and the awareness of local services available within the Cambridge Health District. A postal questionnaire survey obtained an 84.3% response rate. Many primary health care professionals were not aware of some important issues in the prevention and management of lymphoedema. This information proved useful in enabling the specialist service to develop appropriate educational initiatives.

A psychiatric day hospital program in an HMO

A model Psychiatric Day Hospital program developed in an HMO is described. The HMO and the Day Hospital program's function within the spectrum of adult psychiatric services of the organization are discussed. This program has enhanced the quality of the clinical care provided. Three measurements demonstrate the success of the program. Such a program is ideally suited to the needs of an HMO.

A prospective study comparing SPET with MRI and CT as prognostic indicators following severe closed head injury

Ten patients were studied prospectively afer severe closed head injury to determine the relationship between long-term clinical outcome and abnormalities detected by single photon emission tomography (99Tcm-HMPAO SPET), CT and MRI obtained within 60 days of injury. The ability of SPET to detect abnormalities not visualized by CT or MRI after cerebral trauma by the results of this study. Changes detected by SPET [global cerebral blood flow (gCBF) and number of regional cerebral blood flow (rCBF) deficits] soon after trauma were shown to be more closely correlated with long-term outcome than changes detected by MRI or CT. Templates were used to classify lesions by site and a multivariate analysis was undertaken to establish the importance of defect position in predicting clinical outcome. The results suggest that lesions in the temporal lobes, frontal lobes and basal ganglia are related to poor prognosis, and that SPET yields more useful prognostic data than the other methods.

A study of frictional forces between orthodontic brackets and archwires

The differences in magnitude of static and kinetic frictional forces generated by 0.022 x 0.030-inch stainless steel (Dentaurum) and polycrystalline ceramic (Transcend) brackets in combination with archwires of different sizes (0.018 inch and 0.019 x 0.025 inch) and materials (stainless steel, nickel-titanium, and beta-titanium) at a constant ligature force were investigated. A friction-testing assembly using the Instron machine was used. In all cases, the static frictional force was greater than the kinetic frictional force. There were no significant differences in the frictional forces generated by stainless steel and polycrystalline ceramic brackets. Beta-titanium archwires produced greater frictional forces than the other two materials. Increasing the archwire diameter increased the frictional force.

The role of bone scintigraphy with pinhole collimation in the evaluation of symptomatic paediatric hips

Sixty-two children with signs and symptoms of hip pathology underwent bone scintigraphy with pinhole collimation of the hip joints. Three distinct patterns of isotope uptake were observed: a normal uptake of isotope, a focal increase or decrease of isotope uptake and a mild diffuse increase of isotope uptake. Forty-four children had normal isotope scans, an average hospital stay of 6.8 days and no significant pathology on follow-up. Ten children had a focal increase or decrease of isotope uptake, an average hospital stay of 21 days and on follow-up all had significant pathology. Eight children had a mild diffuse increase of isotope uptake, an average hospital stay of 8.75 days and no significant pathology on follow-up. We conclude: (1) Normal isotope hip scintigrams with pinhole collimation indicate an excellent prognosis in symptomatic paediatric hips; (2) Focal scintigraphic abnormalities are indicative of significant pathology; (3) A mild diffuse increase in isotope uptake on both sides of the joint is not associated with significant pathology; (4) There is a good correlation between scintigrams and the length of hospital stay; (5) Scintigraphy is at least twice as sensitive at the time of presentation as plain radiographs in the detection of pathology.

Regulation of the citrate synthase (gltA) gene of Escherichia coli in response to anaerobiosis and carbon supply: role of the arcA gene product

As an enzyme of the tricarboxylic acid cycle pathway, citrate synthase participates in the generation of a variety of cellular biosynthetic intermediates and in that of reduced purine nucleotides that are used in energy generation via electron transport-linked phosphorylation reactions. It catalyzes the condensation of oxaloacetate and acetyl coenzyme A to produce citrate plus coenzyme A. In Escherichia coli this enzyme is encoded by the gltA gene. To investigate how gltA expression is regulated, a gltA-lacZ operon fusion was constructed and analyzed following aerobic and anaerobic cell growth on various types of culture media. Under aerobic culture conditions, expression was elevated to a level twofold higher than that reached under anaerobic culture conditions. ArcA functions as a repressor of gltA expression under each set of conditions: in a delta arcA strain, gltA-lacZ expression was elevated to levels two- and eightfold higher than those seen in a wild-type strain under aerobic and anaerobic conditions, respectively. This control is independent of the fnr gene product, an alternative anaerobic gene regulator in E. coli. When the richness or type of carbon compound used for cell growth was varied, gltA-lacZ expression varied by 10- to 14-fold during aerobic and anaerobic growth. This regulation was independent of both the crp and fruR gene products, suggesting that another regulatory element in E. coli is responsible for the observed control. Finally, gltA-lacZ expression was shown to be inversely proportional to the cell growth rate. These findings indicate that the regulation of gltA gene expression is complex in meeting the differential needs of the cell for biosynthesis and energy generation under various cell culture conditions.

Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound

Sixty-seven closed or grade-I open fractures of the tibial shaft were examined in a prospective, randomized, double-blind evaluation of use of a new ultrasound stimulating device as an adjunct to conventional treatment with a cast. Thirty-three fractures were treated with the active device and thirty-four, with a placebo control device. At the end of the treatment, there was a statistically significant decrease in the time to clinical healing (86 +/- 5.8 days in the active-treatment group compared with 114 +/- 10.4 days in the control group) (p = 0.01) and also a significant decrease in the time to over-all (clinical and radiographic) healing (96 +/- 4.9 days in the active-treatment group compared with 154 +/- 13.7 days in the control group) (p = 0.0001). The patients' compliance with the use of the device was excellent, and there were no serious complications related to its use. This study confirms earlier animal and clinical studies that demonstrated the efficacy of low-intensity ultrasound stimulation in the acceleration of the normal fracture-repair process.

ED management of acute congestive heart failure in renal dialysis patients

This is a descriptive report of the management techniques used effectively in the emergency department (ED) treatment of acute congestive heart failure (CHF) in renal dialysis patients. Study design included a prospective case series of consecutive renal dialysis patients who presented to the ED of a regional dialysis center in acute CHF. Clinical presentation, ED management, and outcome were recorded. Forty-six patients (38 hemodialysis and 8 peritoneal dialysis) were included in this study. Presentation classifications for these patients were minimal distress (13 patients), moderate distress (16 patients), and severe distress (17 patients). In addition to supplemental oxygen, treatment focused on pharmacological preload and afterload reduction. Patients received sublingual nitroglycerin (NTG) (30 patients), transdermal NTG (36 patients), captopril sublingual (10 patients) nifedipine oral (nine patients), nitroprusside (four patients), morphine sulfate (one patient), NTG infusion (one patient), and clonidine (one patient). There were no deaths in the study group, and 32 of the patients were able to be dialyzed and discharged, including seven patients in the severe group. Six patients required intubation, one of whom was extubated and discharged from the ED after dialysis. Intravascular access was obtained in 29 patients but was used in only six. All patients on nitroprusside drips were weaned during the course of their dialysis. Effective ED management of acute CHF in renal dialysis patients can be accomplished through preload reduction with nitrates and afterload reduction with captopril, nifedipine, and, in severe cases, nitroprusside.

An analysis of the diagnostic accuracy of endoscopic biopsy and cytology in the detection of oesophageal malignancy

The role of combined cytohistological examination in the differentiation of benign from malignant oesophageal mucosal lesions was studied in 331 patients. Malignancy was confirmed by specimen histopathology in 58 patients. Both endoscopic biopsy and cytology were positive in 41 (71%) patients. Endoscopic biopsy alone suggested malignancy in 10 cases (17%) while cytology was positive after negative biopsy in seven (12%). Cytology yielded four false positive and 10 false negative results giving a sensitivity level of 81%, a specificity of 98% and a positive predictive value for oesophageal malignancy of 92%. Histology on the other hand yielded one false positive and seven false negative results providing a sensitivity of 87%, a specificity of 99% and a positive predictive value of 96%. No patients were left undiagnosed using both diagnostic modalities; cytology increased the diagnostic yield from 87% to 100%. Exfoliative cytology was most valuable in the diagnosis of tumours of the lower one-third of the oesophagus where seven of 31 malignancies (23%) were identified by this method alone (P less than 0.05). Neither the histological type of the tumour nor the morphological appearance was found significantly to affect the diagnostic yield (P greater than 0.05). We conclude that cytological examination should be standard practice in the investigation of oesophageal lesions.