Another fractured neck of femur: do we need a lateral X-ray?

OBJECTIVE

This study aimed to define the role of the lateral X-ray in the assessment and treatment planning of proximal femoral fractures. Occult fractures were not included.

METHODS

Radiographs from 359 consecutive patients with proximal femoral fractures admitted to our emergency department over a 12 month period were divided into anteroposterior (AP) views and lateral views. Three blinded reviewers independently assessed the radiographs, first AP views alone then AP plus lateral views, noting the fracture classification for each radiograph. These assessments were then compared with the intra-operative diagnosis, which was used as the gold standard. A 2 × 2 contingency square table was created and Pearson's χ(2) test was used for statistical analysis.

RESULTS

The rate of correct classification by the reviewers was improved by the assessment of the lateral X-ray in addition to the AP view for intracapsular fractures (p<0.013) but not for extracapsular fractures (p=0.27). However, the only advantage obtained by assessing the lateral view in intracapsular fractures was the detection of displacement where the fracture appeared undisplaced on the initial AP view.

CONCLUSION

This study provides statistical evidence that one view is adequate and safe for the majority of hip fractures. The lateral radiograph should not be performed routinely in order to make considerable savings in money and time and to avoid unnecessary patient discomfort.

Clinical trial: gastric acid suppression in Hispanic adults with symptomatic gastro-oesophageal reflux disease - comparator study of esomeprazole, lansoprazole and pantoprazole

BACKGROUND

Hispanic-Americans are a rapidly growing population in the United States, yet gastro-oesophageal reflux disease (GERD) is not well studied in this population.

AIM

To compare the efficacy of esomeprazole, lansoprazole and pantoprazole in suppressing gastric acid, including the area of the 'acid pocket,' in Hispanics with GERD.

METHODS

In this open-label, 3-way crossover study, 83 Hispanics with symptomatic GERD were randomized to 1 of 6 possible treatment sequences of three 5-7-day dosing periods with esomeprazole 40 mg, lansoprazole 30 mg and pantoprazole 40 mg daily separated by 10-17-day washout periods. Intragastric pH was measured for 24 h using dual probes with a distal and proximal (area of the 'acid pocket') electrode.

RESULTS

Esomeprazole suppressed intragastric acid (pH >4.0) significantly longer over 24 h (primary end point) compared with lansoprazole and pantoprazole (P < 0.0001), and proximal gastric acid (pH >4.0) significantly longer over 24 h compared with lansoprazole (P < 0.05) and pantoprazole (P < 0.0001).

CONCLUSIONS

Esomeprazole was more effective than lansoprazole and pantoprazole in suppressing gastric acidity at both intragastric distal and proximal (area of the acid pocket) sites in Hispanics with GERD. Future studies are warranted to understand better the role of the acid pocket in GERD (Clinical trial numbers: D9612L00106; ClinicalTrials.gov: NCT00410592).

Competitive fixed-interval performance in humans

Two persons responded in the same session in separate cubicles, but under a single schedule of reinforcement. Each time reinforcement was programmed, only the first response to occur, that is, the response of only one of the subjects, was reinforced. "Competitive" behavior that developed under these conditions was examined in three experiments. In Experiment 1 subjects responded under fixed-interval (FI) 30-s, 60-s, and 90-s schedules of reinforcement. Under the competition condition, relative to baseline conditions, the response rates were higher and the pattern was "break-and-run." In Experiment 2, subjects were exposed first to a conventional FI schedule and then to an FI competition schedule. Next, they were trained to respond under either a differential-reinforcement-of-low-rate (DRL) or fixed-ratio (FR) schedule, and finally, the initial FI competition condition was reinstated. In this second exposure to the FI competition procedure, DRL subjects responded at lower rates than were emitted during the initial exposure to that condition and FR subjects responded at higher rates. For all subjects, however, responding gradually returned to the break-and-run pattern that had occurred during the first FI competition condition. Experiment 3 assessed potential variables contributing to the effects of the competitive FI contingencies during Experiments 1 and 2. Subjects were exposed to FI schedules where (a) probability of reinforcement at completion of each fixed interval was varied, or (b) a limited hold was in effect for reinforcement. Only under the limited hold was responding similar to that observed in previous experiments.

Effects of age on thermal sensitivity in the rat

Age-dependent changes in thermal sensitivity were evaluated with reflex- and operant-based assessment strategies in animals ranging in age from 8 to 32 months. The impact of inflammatory injury on thermal sensitivity was also determined in animals of different ages. The results showed that operant measures of escape behavior are needed to demonstrate significant changes in thermal sensitivity across the life span of female Long-Evans rats. Increased escape from both heat (44.5 degrees C) and cold (1.5 degrees C-15 degrees C) was observed for older animals, with a greater relative increase in sensitivity to cold. Physical performance deficits were demonstrated with aging but were not associated with changes in escape responding. Reflex responding to cold stimulation was impaired in older animals but was also influenced by physical disabilities. Reflex responding to heat was not affected by increasing age. Inflammation induced by formalin injections in the dorsal hindpaw increased thermal sensitivity significantly more in older animals than in their younger counterparts.

Insights into the critical role of NADPH oxidase(s) in the normal and dysregulated pancreatic beta cell

It is now widely accepted that reactive oxygen species (ROS) contribute to cell and tissue dysfunction and damage in diabetes. The source of ROS in the insulin secreting pancreatic beta cells has traditionally been considered to be the mitochondrial electron transport chain. While this source is undoubtedly important, we fully describe in this article recent information and evidence of NADPH oxidase-dependent generation of ROS in pancreatic beta cells and identify the various isoforms that contribute to O(2)(*-) and H(2)O(2) production in various conditions. While glucose-stimulated ROS generation may be important for acute regulation of insulin secretion, at higher levels ROS may disrupt mitochondrial energy metabolism. However, ROS may alter other cellular processes such as signal transduction, ion fluxes and/or cell proliferation/death. The various beta cell isoforms of NADPH oxidase (described in this review) may, via differences in the kinetics and species of ROS generated, positively and negatively regulate insulin secretion and cell survival.

Self-reported water and drowning risk exposure at surf beaches

OBJECTIVE

To document patterns of water exposure at surf beaches by gender and identify factors that predict bather confidence to return to shore if caught in a rip current.

METHOD

Recreational surf beach bathers (N=406) provided self-completed data on water exposure patterns, surf activity behaviours and potential drowning risk and protective factors.

RESULTS

Relative to females, males visited surf beaches more frequently, expected to spend longer in the water and in deeper water, and more often bathed after using alcohol (p<0.05). Confidence to return to shore if caught in a rip current was predicted by confidence to identify a rip current, self-rated swimming ability, gender, times visited any beach, and age in a standard linear regression model (adjusted R(2)=0.68).

CONCLUSION

The study supports explanations that high male drowning rates result from more frequent exposure to water than females at high situational risk levels.

IMPLICATIONS

Controlled studies are required to determine the role in drowning of overconfidence, swimming ability, surf experience, floatation devices and response to sea conditions.

Phase II study of intrabuccally-administered amplitude-modulated electromagnetic fields in patients with advanced hepatocellular carcinoma

e15573

Background: Over the past few years we have identified tumor-specific frequencies for several common forms of cancer. The goal of this study was to assess the tolerability and effectiveness of electromagnetic fields amplitude-modulated at tumor-specific frequencies and administered by means of an intrabuccal spoon-shaped probe in patients with advanced hepatocellular carcinoma (HCC). Methods: From October 2005 to July 2007, patients with advanced HCC and Child-Pugh A or B were recruited in a phase II study. Three daily 60 min outpatient treatments were administered until disease progression or death. Imaging studies were performed every eight weeks. The primary efficacy end point was progression-free survival ≥ 6 months. Secondary efficacy end points were progression-free survival and overall survival. Results: A total of 41 patients were enrolled, 17 had Child-Pugh A, 20 Child-Pugh B disease. The median age was 64.0 years. Seventeen patients (34.1%) were progression-free for more than 6 months. Median progression-free and overall survivals were 4.8 months (95% CI 2.3–6.0) and 6.9 months (95 CI 4.8–11.1). As of December 2008, four patients are alive and two patients, who are still undergoing therapy, remain progression-free for 30.4 and 30.7 months, respectively. Four patients had partial response (9.8%) and sixteen had stable disease for at least 12 weeks (39.0%) according to the RECIST criteria resulting in 48.8% disease control. All responses were confirmed by independent review. There were no NCI grade 2, 3 or 4 toxicities. One patient developed grade 1 mucositis and one patient grade 1 fatigue. Conclusions: In patients with advanced HCC and impaired hepatic function, treatment with amplitude-modulated electromagnetic fields is safe, well tolerated, and shows evidence of anti-tumor effects, which are long-lasting in some patients.

No significant financial relationships to disclose.

Association of NAD(P)H oxidase with glucose-induced insulin secretion by pancreatic beta-cells

We previously described the presence of nicotinamide adenine dinucleotide phosphate reduced form [NAD(P)H]oxidase components in pancreatic beta-cells and its activation by glucose, palmitic acid, and proinflammatory cytokines. In the present study, the importance of the NAD(P)H oxidase complex for pancreatic beta-cell function was examined. Rat pancreatic islets were incubated in the presence of glucose plus diphenyleneiodonium, a NAD(P)H oxidase inhibitor, for 1 h or with the antisense oligonucleotide for p47(PHOX) during 24 h. Reactive oxygen species (ROS) production was determined by a fluorescence assay using 2,7-dichlorodihydrofluorescein diacetate. Insulin secretion, intracellular calcium responses, [U-(14)C]glucose oxidation, and expression of glucose transporter-2, glucokinase and insulin genes were examined. Antisense oligonucleotide reduced p47(PHOX) expression [an important NAD(P)H oxidase cytosolic subunit] and similarly to diphenyleneiodonium also blunted the enzyme activity as indicated by reduction of ROS production. Suppression of NAD(P)H oxidase activity had an inhibitory effect on intracellular calcium responses to glucose and glucose-stimulated insulin secretion by isolated islets. NAD(P)H oxidase inhibition also reduced glucose oxidation and gene expression of glucose transporter-2 and glucokinase. These findings indicate that NAD(P)H oxidase activation plays an important role for ROS production by pancreatic beta-cells during glucose-stimulated insulin secretion. The importance of this enzyme complex for the beta-cell metabolism and the machinery involved in insulin secretion were also shown.

The first case of Lassa fever imported from Mali to the United Kingdom, February 2009

This is the first case of Lassa fever to be imported from Mali to the United Kingdom. This paper discusses the investigations, the virological analysis, the surveillance and management of contacts undertaken following a case of Lassa fever.

The first case of Lassa fever imported from Mali to the United Kingdom, February 2009

This is the first case of Lassa fever to be imported from Mali to the United Kingdom. This paper discusses the investigations, the virological analysis, the surveillance and management of contacts undertaken following a case of Lassa fever.

Exeter-Ogee total hip replacement using the Hardinge approach; the ten to twelve year results

We reviewed 131 consecutive primary total hip replacements implanted into 127 patients between 1995 and 1997. Surgery was performed through a Hardinge approach using the Exeter universal stem in combination with the Ogee Elite acetabular component.Five of 131 hips have required revision. The ten year survival analysis demonstrates: 95.3% survival with revision for any cause as the end point; 98.9% with revision for aseptic loosening of the stem as the endpoint, 98.1% revision for aseptic loosening of the acetabular component as the endpoint. There were no cases of dislocation.Our findings show that the Exeter universal stem in combination with the Ogee Elite acetabular component can be inserted through a Hardinge approach in a district general setting with results comparable to surgery performed in a specialist unit and through a posterior approach.

A fatal case of Lassa fever in London, January 2009

In January 2009, the eleventh case of Lassa fever imported to the United Kingdom was diagnosed in London. Risk assessment of 328 healthcare contacts with potential direct exposure to Lassa virus - through contact with the case or exposure to bodily fluids - was undertaken. No contacts were assessed to be at high risk of infection and no secondary clinical cases identified.