A modern-day solution to a 100-year-old problem: the use of a Bespoke Off-loading Brace in the rehabilitation of 'Deck-Slap' and other high-energy lower limb injuries

'Deck-Slap' is an injury pattern first described at the Battle of Jutland; it is still relevant today, with anti-vehicle mines a significant threat to Coalition troops. The effect of a device exploding beneath a vehicle produces a wave of high energy that is rapidly transmitted through the steel floor; this causes significant axial loading of lower limbs often resulting in severe fractures (notably of the calcaneum). Recent advancements in orthopaedic surgery have allowed for limbs that were destined for immediate amputation following significant trauma to be salvaged. However, despite intense rehabilitation, many of these salvaged limbs have subsequently gone on to delayed amputation, as functional outcomes are often poor. Technologically advanced prosthetic devices are available that afford good quality of life and allow for increased activity levels; these devices are, however, expensive to procure and maintain. This report describes a United Kingdom (UK) Armed Forces soldier who suffered a typical 'deck-slap' injury in Afghanistan with subsequent limb salvage. The use of the Bespoke Off-loading Brace (BOB) is discussed. The results presented here indicate that the biomechanical function of a patient with this type of injury improves when wearing the BOB. Further studies are needed to assess long-term clinical outcomes and the functional benefit of the device as a viable and cost-effective alternative to delayed limb amputation.

Cardiac autonomic function and baroreflex changes following 4 weeks of resistance versus aerobic training in individuals with pre-hypertension

AIM

Cardiac autonomic modulation and baroreflex sensitivity (BRS) are altered in individuals with hypertension. Aerobic exercise (AE) training has been shown to improve both measures, yet little is known about the effects of resistance exercise (RE). The purpose of this study was to examine the heart rate variability (HRV) and BRS following 4 weeks of resistance or aerobic training in a population with borderline high blood pressure (BP).

METHODS

Twenty-nine mild hypertensives were recruited and randomly assigned to 4 weeks of RE or AE training. Before and after training, resting measures of HRV frequencies and BRS were obtained.

RESULTS

There was a significant decrease in resting systolic BP for both exercise training modes (RE 136 +/- 3.0 pre- to 132 +/- 3.4 post-training vs. AE 142 +/- 4.0 pre- to 137 +/- 3.6 mmHg post-training, P = 0.019). Diastolic BP decreased significantly following both exercise training modes (RE 78 +/- 1.31 pre to 74 +/- 1.1 post vs. AE 80 +/- 1.7 pre to 77 +/- 1.6 mmHg post, P = 0.002). A significant time by training mode interaction for low frequency : high frequency (HF) ratio (P = 0.017) with AE decreasing the ratio (275.21 +/- 67.28 to 161.26 +/- 61.49) and RE increasing this ratio (143.73 +/- 65.00 to 227.83 +/- 59.41). Natural log-transformed (ln) HRV values showed a time-by-training mode interaction for ln HF (P = 0.05) as ln HF increased (4.7 +/- 0.38 to 5.4 +/- 0.35 ms(2)) following AE and decreased (5.98 +/- 0.37 to 5.76 +/- 0.42 ms(2)) following RE. BRS increased following aerobic training and decreased after resistance training (6.74 +/- 1.2 to 7.94 +/- 1.3 and 10.44 +/- 1.2 to 9.1 +/- 1.2 ms mmHg(-1) respectively, P = 0.021).

CONCLUSIONS

Aerobic exercise improved the autonomic nervous system (increasing vagal tone, reducing sympathovagal balance while increasing BRS) while RE showed no improvements in cardiac autonomic tone and decreased BRS.

Gastric adenocarcinoma and chronic gastritis in two related Persian cats

Two 12.5-year-old castrated male Persian cats from the same household, whose dams were littermates, presented simultaneously with gastric adenocarcinoma associated with proliferative and fibrosing gastritis. Intralesional adult Ollulanus tricuspis nematodes and rare surface-associated spiral-shaped bacteria were identified in one cat. No etiologic agents were identified in tissues from the second cat; however, gastric mucosa was examined following anthelmintic treatment. Clinical signs in each cat had commenced 2 months apart and included vomiting, hematemesis, intermittent melena, and weight loss. This is the first report of gastric adenocarcinoma occurring in housemate cats or cats of common descent. Carcinogenesis may have been influenced by shared undetermined genetic and environmental factors, possibly including Ollulanus tricuspis, spiral-shaped bacteria, or other etiologies for chronic gastritis that remain unidentified.

To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects

The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.

Basis for intracellular retention of a human mutant of the retinal rod channel alpha subunit

A mutant of the a subunit of the retinal rod cyclic GMP-gated channel, [Arg654(1-bp del)], corresponding to a truncated alphaR654Dstop subunit, was previously described in patients with retinitis pigmentosa: when expressed in HEK-293 cells, this mutated a subunit was retained inside the cell, but had normal channel activity in one case where it reached the plasma membrane, indicating that the mechanism of targeting is altered by the mutation, but not the function of the channel. The corresponding mutants of the bovine rod channel (alphaR656D stop), and of the closely related olfactory neuron channel (alphaR632Dstop) alpha subunits were expressed in Xenopus oocytes and their activity was analyzed by patch-clamp. Like their human homologue, these two channels have no activity, and we show that their GFP fusion proteins are accumulated into intracellular compartments. The truncation alone or the R/D mutation alone do not prevent or modify channel activity, indicating that neither the R656 residue nor the C-terminal domain downstream of R656 is necessary for homomeric channel targeting and function. Several mutations of R656 and of the preceding residues in the R656Dstop mutant disclose that the motif responsible for the absence of channel activity is an endoplasmic reticulum retention signal (KXKXXstop) in which the nature of the residues in positions -1 and -4 is determinant.

Interaction of plant protein Ser/Thr phosphatase PP7 with calmodulin

We have recently identified PP7, a novel group of plant protein Ser/Thr phosphatases, and hypothesized that PP7 may possess a calmodulin-binding site. To test this hypothesis, we assessed the effect of calmodulin on the activity of recombinant Arabidopsis thaliana PP7 and directly tested interaction between PP7 and calmodulin using surface plasmon resonance. Calmodulin exerted a moderate inhibitory effect on the phosphatase activity of PP7 with submicromolar affinity. PP7 specifically interacted with immobilized calmodulin (but not with recoverin, another EF hand Ca(2+)-binding protein) in a strictly Ca(2+)-dependent manner with nanomolar affinity. Deletion of an insert in the catalytic domain of PP7, predicted to function as a calmodulin-binding site, greatly decreased PP7 binding to calmodulin. These findings provide the first evidence for a plant protein phosphatase directly interacting with calmodulin and indicate that PP7 might be regulated by Ca(2+) levels in vivo.

Preventing falls in older people: impact of an intervention to reduce environmental hazards in the home

OBJECTIVES

To evaluate the impact of an intervention to reduce fall hazards in the homes of older people.

DESIGN

The intervention was administered to the 570 subjects in the experimental arm of a randomized controlled trial, with follow-up of subjects for 1 year.

SETTING

Community-based seniors living in Perth, Australia.

PARTICIPANTS

People age 70 and older.

INTERVENTION

Registered nurses delivered the intervention. It consisted of a home hazard assessment, an educational strategy on general fall hazard reduction and ways to reduce identified home hazards, and the free installation of safety devices: grab rails, nonslip stripping on steps, and double-sided tape for floor rugs and mats. All intervention subjects received the home hazard assessment, and 96% received the educational strategy. Grab rails were installed in 77% of homes, rugs were stabilized in 8%, and nonslip step stripping was installed in 36%.

MEASUREMENTS

Hazard prevalence was assessed at baseline in all homes and 11 months later in a random sample of 51 homes. Action taken in response to the intervention was assessed by a self-completed postal questionnaire completed 11 months after the intervention.

RESULTS

All homes had at least one fall hazard. The most prevalent were floor rugs and mats (mean of 14 per home), stepovers (Stepovers are structural changes to the height of the floor that were designed to be stepped over rather than stepped upon, for example, the lip of a shower or a bath side.) (mean of seven per home), steps (mean of four per home), and trailing cords (mean of two per home). The intervention was associated with a small but significant reduction in four of the five most prevalent hazards. The mean number of unsafe rugs and mats was reduced by 1.57 per house (95% confidence interval (CI) = 0.91-2.24); the mean number of unsafe steps was reduced by 0.61 per house (95% CI = 0.28-0.94); the mean number of rooms with trailing cords was reduced by 0.43 per house (95% CI = 0.10-0.76); and the mean number of unsafe chairs was reduced by 0.10 per house (95% CI = 0.02-0.18). Safety devices were installed in 81.9% of homes. Advice on modifying specific hazards identified on the home hazard assessment resulted in over 50% of subjects removing hazards of floor rugs and mats, trailing cords, and obstacles. The general education message prompted less activity to reduce these hazards than did the advice on identified hazards.

CONCLUSIONS

Fall hazards are ubiquitous in the homes of older people. The intervention resulted in a small reduction in the mean number of hazards per house, with many study subjects taking action but removing only a few hazards. The impact of the intervention in achieving self-reported action to reduce hazards was high.

Preventing falls in older people: outcome evaluation of a randomized controlled trial

OBJECTIVES

To evaluate the outcome of an intervention to reduce hazards in the home on the rate of falls in seniors.

DESIGN

Randomized controlled trial, with follow-up of subjects for 1 year.

SETTING

Community-based study in Perth, Western Australia.

PARTICIPANTS

People age 70 and older.

INTERVENTION

One thousand eight hundred seventy-nine subjects were recruited and randomly allocated by household to the intervention and control groups in the ratio 1:2. Because of early withdrawals, 1,737 subjects commenced the study. All members of both groups received a single home visit from a research nurse. Intervention subjects (n = 570) were offered a home hazard assessment, information on hazard reduction, and the installation of safety devices, whereas control subjects (n = 1,167) received no safety devices or information on home hazard reduction.

MEASUREMENTS

Both groups recorded falls on a daily calendar. Reported falls were confirmed by a semistructured telephone interview and were assigned to one of three overlapping categories: all falls, falls inside the home, and falls involving environmental hazards in the home. Analysis was by multivariate modelling of rate ratios and odds ratios for falls, corrected for household clustering, using Poisson regression and logistic regression with robust variance estimation.

RESULTS

Overall, 86% of study subjects completed the 1 year of follow-up. The intervention was not associated with any significant reduction in falls or fall-related injuries. There was no significant reduction in the intervention group in the incidence rate of falls involving environmental hazards inside the home (adjusted rate ratio, 1.11; 95% CI = 0.82-1.50), or the proportion of the intervention group who fell because of hazards inside the home (adjusted odds ratio, 0.97; 95% CI = 0.74-1.28). No reduction was seen in the rate of all falls (adjusted rate ratio, 1.02; 95% CI = 0.83-1.27) or the rate of falls inside the home (adjusted rate ratio, 1.17; 95% CI = 0.85-1.60). There was no significant reduction in the rate of injurious falls in intervention subjects (adjusted rate ratio, 0.92; 95% CI = 0.73-1.14).

CONCLUSIONS

The intervention failed to achieve a reduction in the occurrence of falls. This was most likely because the intervention strategies had a limited effect on the number of hazards in the homes of intervention subjects. The study provides evidence that a one-time intervention program of education, hazard assessment, and home modification to reduce fall hazards in the homes of healthy older people is not an effective strategy for the prevention of falls in seniors.