Current management of isolated sternal fractures in the UK: time for evidence based practice? A cross-sectional survey and review of literature

Routine admission of patients with isolated sternal fractures for observation is still widespread in the UK. However, the evidence appears to suggest that this is unnecessary. We undertook a cross-sectional telephone survey of management of isolated sternal fractures in the UK. We contacted 85 acute admitting units over a three-month period and were able to get a response from 67 units. Most of the hospitals were district general hospitals (52) and situated in England (49). The orthopaedic department was the most common admitting department. 51 units indicated that they regularly admit isolated sternal fractures for observation. Other indications for admission included pain control (33), abnormal cardiac enzymes (28), social circumstances (23), abnormal electrocardiogram (6), and low oxygen saturation (5). Chest X-ray was performed on admission in all hospitals. 57 hospitals performed ECG and cardiac enzyme tests prior to admission and 6 hospitals carried out echocardiogram following admission on a regular basis. Patients were not followed up on discharge. 2 hospitals with on-site cardiothoracic unit followed-up patients on discharge, and 1 hospital advised GP follow-up. A review of the literature indicated that patients with isolated sternal fractures are at low risk of significant cardiac, pulmonary or mediastinal complications and do not need extensive investigations or routine admission. The current practice of management of isolated sternal fractures in the UK does not appear to conform to available evidence. In order to decide on management plans based on more rigorous evidence, there is a need for a prospective double blind randomised study of patients with isolated sternal fractures, comparing those discharged to those admitted over a longer follow-up period.

Wilms tumor in adult

Wilms Tumor (WT) is a very rare malignancy in adults representing 1% of all renal neoplasms. It is however the most common renal tumor of children and adult patients are treated like pediatric cases. Bilateral tumors occur in 5% of adult cases. The typical presenting features are asymptomatic abdominal mass (most common), hematuria, pain, fever, and hypertension. As clinical presentation of WT is similar to that of renal cell carcinoma (RCC), it tends to be an unsuspected pathological diagnosis in most cases. The diagnosis of the tumor needs positive sonographic and computed tomography (CT) findings with histopathological confirmation. Prognosis of adult WT is relatively poor and resistant to chemotherapy. We present a case of wilms tumor in a 68 years old male patient with right sided non tender abdominal mass and occasional flank pain. The patient was normotensive but hematuric and radiological findings suggested right renal mass with enlarged lymph node and histopathological analysis revealed nephroblastoma associated with lymph node metastases.

Subclinical thyroid dysfunction does not affect one-year mortality in elderly patients after hip fracture: a prospective longitudinal study

Mortality after hip fractures in the elderly is one of the most important patient outcome measures. Subclinical thyroid dysfunction is common in the elderly population. This is a prospective study of 131 elderly patients with a mean (SD) age of 82.0 (8.9) years (range: 61-94) admitted consecutively to our trauma unit. The aim of the study was to determine the prevalence of subclinical thyroid dysfunction in an elderly cohort of patients with hip fracture and to determine if this affects the one-year mortality. There were three times more women (n=100) than men (n=31) in this cohort. All patients underwent surgical treatment for the hip fracture. The prevalence of subclinical hypothyroidism (TSH>5.5 mU/L) was 15% (n=20) and of subclinical hyperthyroidism (TSH<0.35 mU/L) was 3% (n=4). Overall 18% (n=24) of patients had a subclinical thyroid dysfunction. The twelve-month mortality was 27% (n=36). Age, gender, heart rate at admission, pre-existing coronary heart disease, ASA grade and presence of overt or subclinical thyroid dysfunction were analysed for association with twelve-month mortality using a forward stepwise logistic regression analysis. Only ASA grade was found to significantly affect mortality at twelve months (chi(2)=3.98, df=1, p=0.046). Independently the presence of subclinical hypo- or hyperthyroidism was not associated with a higher mortality (p=0.477). We conclude that subclinical thyroid dysfunction does not affect the one-year mortality in elderly patients treated surgically for hip fracture.

Lymphocystis disease virus persists in the epidermal tissues of olive flounder, Paralichthys olivaceus (Temminch & Schlegel), at low temperatures

Olive flounder artificially infected with lymphocystis disease virus (LCDV) were reared at 10, 20 and 30 degrees C for 60 days, to compare LCD-incidence. In the fish reared at 20 degrees C, lymphocystis cells appeared on the skin and fins at 35 days post-challenge, and the cumulative LCD-incidence was 80% at 60 days. High levels of LCDV, with a mean polymerase chain reaction (PCR) titre of 10(6) PCR-U mg(-1) tissue, were detected in the fins and skin of LCD-affected fish at 20 degrees C, but were not detected in the spleen, kidney, brain and intestinal tissues of these fish. No LCD clinical signs were observed in the fish reared at 10 degrees C and 30 degrees C; however, a low level of LCDV (10(3) PCR-U mg(-1) tissue) was detected in the fins and skin of these fish. By increasing the rearing temperature from 10 to 20 degrees C, lymphocystis clusters appeared on the skin and fins of the fish with no previous LCD clinical signs within 33 days after the temperature change. It was shown that permissive cells for LCDV infection exist in the epidermis of olive flounder. At low temperatures, small amounts of LCDV were able to persist over a period extended for a further 45 days in the fish epidermis, even though the fish showed no LCD clinical signs. The optimum growth temperature of LCDV is near 20 degrees C.

Tobacco smoke: a critical etiological factor for vascular impairment at the blood-brain barrier

Active and passive tobacco smoke are associated with the dysfunction of endothelial physiology and vascular impairment. Studies correlating the effects of smoking and the brain microvasculature at the blood-brain barrier (BBB) level have been largely limited to few selective compounds that are present in the tobacco smoke (TS) yet the pathophysiology of smoking has not been unveiled. For this purpose, we characterized the physiological response of isolated human brain microvascular endothelial cells (HBMEC) and monocytes to the exposure of whole soluble TS extract. With the use of a well established humanized flow-based in vitro blood-brain barrier model (DIV-BBB) we have also investigated the BBB physiological response to TS under both normal and impaired hemodynamic conditions simulating ischemia. Our results showed that TS selectively decreased endothelial viability only at very high concentrations while not significantly affecting that of astrocytes and monocytes. At lower concentrations, despite the absence of cytotoxicity, TS induced a strong vascular pro-inflammatory response. This included the upregulation of endothelial pro-inflammatory genes, a significant increase of the levels of pro-inflammatory cytokines, activated matrix metalloproteinase, and the differentiation of monocytes into macrophages. When flow-cessation/reperfusion was paired with TS exposure, the inflammatory response and the loss of BBB viability were significantly increased in comparison to sham-smoke condition. In conclusion, TS is a strong vascular inflammatory primer that can facilitate the loss of BBB function and viability in pathological settings involving a local transient loss of cerebral blood flow such as during ischemic insults.

Results of non-operative treatment following hip fracture compared to surgical intervention

We followed all consecutive hip fracture patients admitted between 2004 and 2006, identified cases in which the intention was to treat non-operative and compared their functional outcome and mortality with a similar cohort treated surgically over the same period. We recorded length of hospital stay, place of discharge, pre and post-fracture mobility and residence, 30 days and 1 year mortality, re-admission due to same fracture and delayed surgery. The group treated surgically was recruited and matched for age, gender, pre and post-fracture mobility, mental confusion and independence. 25 patients were treated non-operative. 22 patients treated surgically over the same time period matched the patient characteristics of the non-operative arm. The mean hospital stay was 13 days in both groups. There were 4 extra-capsular fractures (3 displaced) and 21 intra-capsular fractures (5 displaced) in the non-operative arm and 11 extra-capsular fractures and 9 intra-capsular fractures in the surgically treated arm. 4 patients from the non-operative treatment group underwent late surgery because of persisting hip pain 20 days-2 months after the index event (2 cannulated screws, 1 hemiarthroplasty, 1 total hip arthroplasty). 11 patients in the surgical treatment arm underwent dynamic screw fixation, 1 had cannulated screw, 1 had total hip replacement and 7 had hemiarthroplasty. 14 of the non-operative treated patients were mobile independently or with aid before fracture but only 9 patients retained their pre-fracture mobility following treatment, compared to 16 patients pre-fracture and 11 patients post-fracture after surgery. 16 patients treated non-operative were living independently prior to injury but only 7 went back to their own residence. Of the operatively treated patients 14 patients were living independently and 10 patients went back to their previous residence. 1 month and 1 year mortality in the non-operative treated group was 4/21 and 7/21 respectively compared to 1/20 and 5/20 in the operative fixation group. There was no statistically significant difference in mobility, residence or mortality between the two groups (Fisher exact test, p>0.05). Non-operative management after hip fracture is suitable for medically unfit patients and does not result in statistically significant difference in functional outcome or mortality compared to patients treated surgically.