Controversies in the management of congenital pseudarthrosis of the tibia and fibula

Congenital pseudarthrosis of the tibia (CPT) is a rare but well recognised condition. Obtaining union of the pseudarthrosis in these children is often difficult and may require several surgical procedures. The treatment has changed significantly since the review by Hardinge in 1972, but controversies continue as to the best form of surgical treatment. This paper reviews these controversies.

Cite this article: Bone Joint J 2013;95-B:1027–34.

Do South African general practitioners believe that ‘Exercise is Medicine’?

Background. Physical activity (PA) has been described as medicine, owing to the clear evidence for its role in the prevention and management of various diseases.Objectives. To determine the knowledge, perceptions and attitudes of South African general practitioners (GPs) towards the promotionof PA.Methods. A total of 255 private-sector GPs from various provinces in SA participated in our cross-sectional study, by completing a selfreportquestionnaire surveying their knowledge, perceptions and attitudes towards the promotion of PA.Results. The findings indicated that South African GPs in general do promote PA to their patients for treatment and health promotion. Themajority of GPs in our study strongly believed that promoting PA is an important part of primary healthcare. The GPs frequently promotedexercise in the treatment of obesity, type 2 diabetes and hyperlipidaemia.Conclusion. South African GPs appear to be recommending PA to their patients at a primary-care level. Clear practice guidelines are needed to promote PA in a way that will have a population-level impact. To aid this, GPs are encouraged to provide written information to promote PA in a way that will have an effect.

Do South African general practitioners believe that ‘Exercise is Medicine’?

Background. Physical activity (PA) has been described as medicine, owing to the clear evidence for its role in the prevention and management of various diseases.Objectives. To determine the knowledge, perceptions and attitudes of South African general practitioners (GPs) towards the promotionof PA.Methods. A total of 255 private-sector GPs from various provinces in SA participated in our cross-sectional study, by completing a selfreportquestionnaire surveying their knowledge, perceptions and attitudes towards the promotion of PA.Results. The findings indicated that South African GPs in general do promote PA to their patients for treatment and health promotion. Themajority of GPs in our study strongly believed that promoting PA is an important part of primary healthcare. The GPs frequently promotedexercise in the treatment of obesity, type 2 diabetes and hyperlipidaemia.Conclusion. South African GPs appear to be recommending PA to their patients at a primary-care level. Clear practice guidelines are needed to promote PA in a way that will have a population-level impact. To aid this, GPs are encouraged to provide written information to promote PA in a way that will have an effect.

Cymbopogon citratus Protects against the Renal Injury Induced by Toxic Doses of Aminoglycosides in Rabbits

Renal injury is the most common side-effect of aminoglycosides. These antimicrobial drugs are particularly effective against Gram-negative microorganisms. The present study was conducted to investigate the renal protective activity of Cymbopogon citratus in gentamicin-induced nephrotoxicity. Male rabbits were divided into four groups (n=6) including group 1 (0.9% saline treated), group 2 (80 mg/kg/day gentamicin-treated), group 3 (200 mg/kg/day Cymbopogon citratus treated) and group 4 (80 mg/kg/day gentamicin and 200 mg/kg/day Cymbopogon citratus treated). Biochemical kidney functioning parameters, urinary enzymes and histopathological examination were performed. The results of the present study showed that simultaneous administration of Cymbopogon citrates and gentamicin significantly protected alteration in body weight, blood urea nitrogen, serum creatinine, creatinine clearance, serum uric acid, serum electrolytes, urinary volume, urinary protein, urinary lactate dehydrogenase and urinary alkaline phosphatase induced by gentamicin. Histological examination of the kidney also suggested the same. It is concluded from the current study that co-administration of Cymbopogon citratus with gentamicin for 3 weeks successfully prevented renal damage associated with aminoglycosides.

Assessing the potential effectiveness of food and beverage taxes and subsidies for improving public health: a systematic review of prices, demand and body weight outcomes

Taxes and subsidies are increasingly being considered as potential policy instruments to incentivize consumers to improve their food and beverage consumption patterns and related health outcomes. This study provided a systematic review of recent U.S. studies on the price elasticity of demand for sugar-sweetened beverages (SSBs), fast food, and fruits and vegetables, as well as the direct associations of prices/taxes with body weight outcomes. Based on the recent literature, the price elasticity of demand for SSBs, fast food, fruits and vegetables was estimated to be -1.21, -0.52, -0.49 and -0.48, respectively. The studies that linked soda taxes to weight outcomes showed minimal impacts on weight; however, they were based on existing state-level sales taxes that were relatively low. Higher fast-food prices were associated with lower weight outcomes particularly among adolescents, suggesting that raising prices would potentially impact weight outcomes. Lower fruit and vegetable prices were generally found to be associated with lower body weight outcomes among both low-income children and adults, suggesting that subsidies that would reduce the cost of fruits and vegetables for lower-socioeconomic populations may be effective in reducing obesity. Pricing instruments should continue to be considered and evaluated as potential policy instruments to address public health risks.

Learning and retaining simulated arthroscopic meniscal repair skills

BACKGROUND

Previous studies of task-specific skills have suggested that a loss of technical performance occurs if the skill is not practiced for a six-month period. The aims of this study were to objectively demonstrate the learning curve for a complex arthroscopic task (meniscal repair) by means of motion analysis and to determine the impact of task repetition on the retention of this skill.

METHODS

Nineteen orthopaedic residents with experience in routine knee arthroscopy but not in arthroscopic meniscal repair were recruited into a randomized study. During the initial learning phase, all subjects performed twelve meniscal repairs on a knee simulator over a three-week period. A validated motion analysis tracking system was used to objectively record the performance and learning of each subject; the outcomes were the time taken, distance traveled, and number of hand movements. The subjects were then randomized into three groups. Group A performed one meniscal repair each month, Group B performed one meniscal repair at three months, and Group C performed no repairs during this interim phase. All three groups then returned at the six-month point for the final assessment phase, during which they carried out an additional twelve meniscal repairs over three weeks.

RESULTS

All subjects demonstrated a clear learning curve during the initial learning phase, with significant objective improvement in all motion analysis parameters over the initial twelve episodes (p < 0.0001). Although some residents had reached a learning plateau by twelve episodes, others continued to make further improvements for up to another nine episodes. Importantly, Group C did not display any loss of skill between the initial learning phase and final evaluation phase despite a six-month break in task repetition (p > 0.05).

CONCLUSIONS

In contrast to previous studies, residents did not lose any skill over a six-month interruption in task performance, and other residents took longer to produce a more consistent performance.

The use of standard operating procedures in day case anterior cruciate ligament reconstruction

The current rate of day-case anterior cruciate ligament reconstruction (ACLR) in the UK remains low. Although specialised care pathways with standard operating procedures (SOPs) have been effective in reducing length of stay following some surgical procedures, this has not been previously reported for ACLR. We evaluate the effectiveness of SOPs for establishing day-case ACLR in a specialist unit. Fifty patients undergoing ACLR between May and September 2010 were studied prospectively ("study group"). SOPs were designed for pre-operative assessment, anaesthesia, surgical procedure, mobilisation and discharge. We evaluated length of stay, readmission rates, patient satisfaction and compliance to SOPs. A retrospective analysis of 50 patients who underwent ACLR prior to implementation of the day-case pathway was performed ("standard practice group"). Eighty percent of patients in the study group were discharged on the day of surgery (mean length of stay=5.3h) compared to 16% in the standard practice group (mean length of stay=21.6h). This difference was statistically significant (p<0.05, Mann-Whitney U test). All patients were satisfied with the day case pathway. Ninety-two percent of the study group were discharged on the day of surgery when all SOPs were followed and 46% where they were not. High rates of day-case ACLR with excellent patient satisfaction can be achieved with the use of a specialised patient pathway with SOPs.

Simple visual parameters for objective assessment of arthroscopic skill

BACKGROUND

Restrictions placed on the working hours of doctors over the past decade have resulted in substantial changes to the training and assessment of orthopaedic surgical residents. Many who are responsible for training the surgeons of the future have become concerned that this reduced clinical exposure is having a detrimental impact on technical skill acquisition. Consequently, there is a need for surgical educators to develop more objective methods for assessing surgical skill. The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity, and gaze control could objectively discriminate among various levels of arthroscopic experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods.

METHODS

Twenty-seven subjects were divided into a novice group (n = 7), a resident group (n = 15), and an expert group (n = 5) on the basis of arthroscopic experience. All subjects performed a diagnostic knee arthroscopy task on a simulator. Their performance was assessed with use of novel simple visual parameters that included the prevalence of instrument loss, triangulation time, and prevalence of lookdowns. Performance was also evaluated with use of previously validated technical skill assessment methods (a global rating scale and motion analysis).

RESULTS

A significant difference in performance among the groups was demonstrated with use of all three novel visual parameters, the global rating scale, and motion analysis (p < 0.05). There were strong and highly significant correlations (p < 0.0001) between each of the novel parameters and the previously validated skill assessment methods.

CONCLUSIONS

This study demonstrates the construct validity of three novel visual parameters for objectively assessing arthroscopic performance. These parameters are simple, can be used easily in the operating room, and are strongly correlated with current validated methods of technical skill assessment.

Seasonal changes in plasma steroid levels in relation to ovarian steroidogenic ultrastructural features and progesterone receptors in the house gecko, Hemidactylus flaviviridis, in Oman

A comprehensive study of the annual ovarian cycle in the house gecko, Hemidactylus flaviviridis, was conducted in Oman. Circulating estradiol (E(2)), progesterone (P), and testosterone (T) were measured during the active and inactive phases of the cycle. The steroid levels were related to the steroidogenic ultrastructural features such as the abundance of smooth endoplasmic reticulum (SER), the presence of cisternal whorls, and close association of lipid droplets with swollen vesiculated mitochondria and SER. The steroids were measured using a sensitive detection technique HPLC-MS/MS. E(2) levels began to rise in January at the onset of vitellogenesis and continued to rise between February and May relative to ovulation, postovulation, gravidity and oviposition. Afterwards, E(2) remained low during the inactive phase (June-December). P levels increased significantly in March and peaked in April, which coincided with luteinization. P levels began to decline relative to luteolysis (May-June). Afterwards, it remained low throughout the inactive phase. T levels rose significantly in March-April coinciding with vitellogenesis, but decreased rapidly and significantly in May and remained low during the inactive phase. Progesterone receptors (PR), identified using immunohistochemistry, were strongly expressed during the breeding period, but were absent during the non-breeding period. The appearance of the steroidogenic ultrastructural features in the preovulatory and lutein granulosa cells was correlated with the significant rise in the three steroid levels and the PR. As the steroid levels declined, the granulosa cells underwent a general degeneration and disruption of the associated steroidogenic features.

Spontaneous bilateral compartment syndrome of the legs: A case report and review of the literature

INTRODUCTION

Bilateral acute compartment syndrome of the legs is a rare presentation requiring emergent surgical intervention.

PRESENTATION OF CASE

We report the case of 41-year-old woman who presented with acute bilateral compartment syndrome of the legs, complicated by rhabdomyolysis and acute renal failure.

DISCUSSION

There are very few previously reported cases of bilateral compartment syndrome of the legs. In the present case, despite any clear causative factor, we suggest that the aetiology is related to inadvertent posture during sleep.

CONCLUSION

The diagnosis of acute bilateral compartment syndrome of the legs requires a high index of suspicion, particularly in the absence of obvious aetiology. A successful outcome can be achieved with early diagnosis, prompt surgical intervention and a multidisciplinary approach.

Identifying orthopaedic surgeons of the future

The aim of this study was to investigate the effect of training on the arthroscopic performance of a group of medical students and to determine whether all students could be trained to competence. Thirty-three medical students with no previous experience of arthroscopy were randomised to a ‘Trained’ or an ‘Untrained’ cohort. They were required to carry out 30 episodes of two simulated arthroscopic tasks (one shoulder and one knee). The primary outcome variable was task success at each episode. Individuals achieved competence when their learning curve stabilised. The secondary outcome was technical dexterity, assessed objectively using a validated motion analysis system. Six subjects in the ‘Untrained’ cohort failed to achieve competence in the shoulder task, compared with one in the ‘Trained’ cohort. During the knee task, two subjects in each cohort failed to achieve competence. Based on the objective motion analysis parameters, the ‘Trained’ cohort performed better on the shoulder task (p < 0.05) but there was no significant difference for the knee task (p > 0.05).

Although specific training improved the arthroscopic performance of novices, there were individuals who could not achieve competence despite focused training.These findings may have an impact on the selection process for trainees and influence individual career choices.

Fc24-01 - Ego defense mechanisms in pakistani medical students: a cross sectional analysis

Background

Ego defense mechanisms, defined by Freud as unconscious resources used by the ego to reduce conflict between the id and superego, are a reflection of how an individual deals with conflict and stress. Vaillants’ proposed Hierarchy of Defenses states that mature defenses are associated with better adaptive functioning and health, as opposed to immature defense which are correlated negatively with measures of adaptive adult functioning.

Objectives

This study assesses the prevalence of various ego defense mechanisms employed by medical students of Karachi, which is a group with higher stress levels than the general population.

Methods

A questionnaire based cross-sectional study was conducted on 682 students from five major medical colleges of Karachi in November 2006. Ego defense mechanisms were assessed using the Defense Style Questionnaire(DSQ-40) individually and as grouped under Mature, Immature, and Neurotic factors.

Results

Neurotic defenses had a higher mean score(5.62) than Mature(5.60) and Immature(4.78) mechanisms. Immature mechanisms were more commonly employed by males whereas females employed more Neurotic mechanisms than males. Neurotic and Immature defenses were significantly more prevalent in first and second year students. Mature mechanisms were significantly higher in students enrolled in Government colleges than Private institutions (p< 0.05).

Conclusions

Neurotic mechanisms are more commonly encountered than Mature or Immature mechanisms among medical students of Karachi, and this could reflect greater stress levels than the general population. Employment of these mechanisms was associated with female gender, enrollment in a private medical college, and students enrolled in the first 2 years of medical school.