Culture, diversity and inclusion: a survey of British Hip Society members

AIM

To explore the perceptions and experiences of members of the British Hip Society (BHS) as they relate to culture, diversity and inclusion in the professional sphere.

METHOD

BHS members participated in an anonymised online survey in 2021. Quantitative and qualitative data were collected on demographics, professional experiences and perceptions of workplace culture. Members provided suggestions for improving working culture and supporting inclusivity.

RESULTS

A 45% response rate (n=217) was achieved. Most respondents were male consultant surgeons, of white ethnicity. Almost a quarter of respondents reported experiencing barriers to career progression within the hip subspecialty. Experience of barriers was more common among women and those of non-white ethnicity. Several members experienced an elitist, exclusive culture in the BHS which is closed to outsiders. Thematic analysis of textual data revealed narratives which portray the perception of the society as a closed-door society, and described a clique culture in orthopaedics, and the pervasiveness of discrimination and banter.

CONCLUSION

We found that barriers to inclusion and diversity exist within the professional society. Exploring the narratives around these has informed strategies to overcome them and has shaped future BHS initiatives. To ensure our patients receive the best possible surgical care, it is vital that those with the skills and expertise to deliver it, are supported by the Society and feel a sense of belonging and representation.

The provision of a time-critical elective surgical service during the COVID-19 Crisis: a UK experience

INTRODUCTION

With the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic.

MATERIALS AND METHODS

A protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 'clean' site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff.

RESULTS

A total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive.

CONCLUSION

This study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.

The Exeter V40 cemented femoral component at a minimum 10-year follow-up: the first 540 cases

Aims

The aim of this study was to report the initial results of the Exeter V40 stem, which became available in 2000.

Patients and Methods

A total of 540 total hip arthroplasties (THAs) were performed in our unit using this stem between December 2000 and May 2002. Our routine protocol is to review patients postoperatively and at one, five, and ten years following surgery.

Results

A total of 145 patients (26.9%) died before ten years and of the remaining 395 stems, 374 (94.7%) remain in situ. A total of 21 well-fixed stems (5.3%) were revised. Ten were exchanged using a cement-in-cement technique to facilitate acetabular revision. Three were revised for infection, one for instability, one for fracture of the stem, and six following a periprosthetic fracture. An additional 16 acetabular components (4.1%) were revised; five for aseptic loosening and 11 for instability. There were no revisions for aseptic loosening of the stem, and no evidence of aseptic loosening in any hip. The fate of every stem is known and all patients remain under review. Survivorship, with revision of the stem for aseptic loosening as the endpoint, was 100%. At 13.5 years, the Kaplan-Meier survival rate for all-cause revision of the stem was 96.8% (95% confidence interval (CI) 94.8 to 98.8) and all-cause revision (including acetabular revision, infection, and instability) was 91.2% (95% CI 88.3 to 94.1).

Conclusion

Conclusion No stem was revised for aseptic loosening in this series. The contemporary Exeter V40 stem continues to perform well, and survival has remained comparable with that of the Exeter Universal stem. Cite this article: Bone Joint J 2018;100-B:1002-9.

The Rim Cutter does not show an advantage over modern cementing techniques: a five-year radiological and clinical follow-up of the Rim Cutter used with flanged acetabular components

AIMS

We report the incidence of radiolucent lines (RLLs) using two flanged acetabular components at total hip arthroplasty (THA) and the effect of the Rim Cutter.

PATIENTS AND METHODS

We performed a retrospective review of 300 hips in 292 patients who underwent primary cemented THA. A contemporary flanged acetabular component was used with (group 1) and without (group 2) the use of the Rim Cutter and the Rimfit acetabular component was used with the Rim Cutter (group 3). RLLs and clinical outcomes were evaluated immediately post-operatively and at five years post-operatively.

RESULTS

There was no significant difference in the incidence of RLLs on the immediate post-operative radiographs (p = 0.241) or at five years post-operatively (p = 0.463). RLLs were seen on the immediate post-operative radiograph in 2% of hips in group 1, in 5% in group 2 and in 7% in group 3. Five years post-operatively, there were RLLs in 42% of hips in group 1, 41% in group 2 and in 49% in group 3. In the vast majority of hips, in each group, the RLL was present in DeLee and Charnley zone 1 only (86%, 83%, 67% respectively). Oxford and Harris Hip scores improved significantly in all groups. There was no significant difference in these scores or in the change in scores between the groups, with follow-up.

CONCLUSION

Despite the Rim Cutter showing promising results in early laboratory and clinical studies, this analysis of the radiological and clinical outcome five years post-operatively does not show any advantage over and above modern cementing techniques in combination with a well performing cemented acetabular component. For this reason, we no longer use the Rim Cutter in routine primary THA. Cite this article: Bone Joint J 2017;99-B:1450-7.

Cement-in-cement femoral component revision in the multiply revised total hip arthroplasty: results with a minimum follow-up of five years

AIMS

We present the clinical and radiological results at a minimum follow-up of five years for patients who have undergone multiple cement-in-cement revisions of their femoral component at revision total hip arthroplasty (THA).

PATIENTS AND METHODS

We reviewed the outcome on a consecutive series of 24 patients (10 men, 14 women) (51 procedures) who underwent more than one cement-in-cement revision of the same femoral component. The mean age of the patients was 67.5 years (36 to 92) at final follow-up. Function was assessed using the original Harris hip score (HHS), Oxford Hip Score (OHS) and the Merle D'Aubigné Postel score (MDP).

RESULTS

The mean length of follow-up was 81.7 months (64 to 240). A total of 41 isolated acetabular revisions were performed in which stem removal facilitated access to the acetabulum, six revisions were conducted for loosening of both components and two were isolated stem revisions (each of these patients had undergone at least two revisions). There was significant improvement in the OHS (p = 0.041), HHS (p = 0.019) and MDP (p = 0.042) scores at final follow-up There were no stem revisions for aseptic loosening. Survival of the femoral component was 91.9% (95% confidence intervals (CI) 71.5 to 97.9) at five years and 91.7% (95% CI 70 to 97) at ten years (number at risk 13), with stem revision for all causes as the endpoint.

CONCLUSION

Cement-in-cement revision is a viable technique for performing multiple revisions of the well cemented femoral component during revision total hip arthroplasty at a minimum of five years follow-up. Cite this article: Bone Joint J 2017;99-B:199-203.

The Exeter Universal cemented femoral stem at 20 to 25 years: A report of 382 hips

AIMS

We present a minimum 20-year follow-up study of 382 cemented Exeter Universal total hip arthroplasties (350 patients) operated on at a mean age of 66.3 years (17 to 94).

PATIENTS AND METHODS

All patients received the same design of femoral component, regardless of the original diagnosis. Previous surgery had been undertaken for 33 hips (8.6%). During the study period 218 patients with 236 hips (62%) died, 42 hips (11%) were revised and 110 hips (29%) in 96 patients were available for review. The acetabular components were varied and some designs are now obsolete, however they were all cemented.

RESULTS

With an endpoint of revision for aseptic loosening or lysis, survivorship of the stem at 22.8 years was 99.0% (95% confidence interval (CI) 97.0 to 100). One stem was revised 21 years post-operatively in a patient with Gaucher's disease and proximal femoral osteolysis. Survivorship with aseptic loosening or lysis of the acetabular component or stem as the endpoint at 22.8 years was 89.3% (95% CI 84.8 to 93.8). With an endpoint of revision for any reason, overall survivorship was 82.9% (95% CI 77.4 to 88.4) at 22.8 years. Radiological review showed excellent preservation of bone stock at 20 to 25 years, and no impending failures of the stem.

CONCLUSION

The Exeter femoral stem continues to perform well beyond 20 years. Cite this article: Bone Joint J 2016;98-B:1441-9.

Revision of hemiarthroplasty to total hip arthroplasty using the cement-in-cement technique

Revision of a cemented hemiarthroplasty of the hip may be a hazardous procedure with high rates of intra-operative complications. Removing well-fixed cement is time consuming and risks damaging already weak bone or perforating the femoral shaft. The cement-in-cement method avoids removal of intact cement and has shown good results when used for revision total hip arthroplasty (THA). The use of this technique for the revision of a hemiarthroplasty to THA has not been previously reported.

A total of 28 consecutive hemiarthroplasties (in 28 patients) were revised to a THA using an Exeter stem and the cement-in-cement technique. There were four men and 24 women; their mean age was 80 years (35 to 93). Clinical and radiographic data, as well as operative notes, were collected prospectively and no patient was lost to follow-up.

Four patients died within two years of surgery. The mean follow up of the remainder was 70 months (25 to 124). Intra-operatively there was one proximal perforation, one crack of the femoral calcar and one acetabular fracture. No femoral components have required subsequent revision for aseptic loosening or are radiologically loose.

Four patients with late complications (14%) have since undergone surgery (two for a peri-prosthetic fracture, and one each for deep infection and recurrent dislocation) resulting in an overall major rate of complication of 35.7%.

The cement-in-cement technique provides reliable femoral fixation in this elderly population and may reduce operating time and rates of complication.

Cite this article: Bone Joint J 2015;97-B:1623–7.

Clinical and radiographic outcomes of acetabular impaction grafting without cage reinforcement for revision hip replacement: a minimum ten-year follow-up study

Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan-Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.

Revision total hip replacement using the cement-in-cement technique for the acetabular component

The technique of femoral cement-in-cement revision is well established, but there are no previous series reporting its use on the acetabular side at the time of revision total hip replacement. We describe the technique and report the outcome of 60 consecutive acetabular cement-in-cement revisions in 59 patients at a mean follow-up of 8.5 years (5 to 12). All had a radiologically and clinically well-fixed acetabular cement mantle at the time of revision. During the follow-up 29 patients died, but no hips were lost to follow-up. The two most common indications for acetabular revision were recurrent dislocation (46, 77%) and to complement femoral revision (12, 20%).

Of the 60 hips, there were two cases of aseptic loosening of the acetabular component (3.3%) requiring re-revision. No other hip was clinically or radiologically loose (96.7%) at the latest follow-up. One hip was re-revised for infection, four for recurrent dislocation and one for disarticulation of a constrained component. At five years the Kaplan-Meier survival rate was 100% for aseptic loosening and 92.2% (95% CI 84.8 to 99.6), with revision for any cause as the endpoint.

These results support the use of cement-in-cement revision on the acetabular side in appropriate cases. Theoretical advantages include preservation of bone stock, reduced operating time, reduced risk of complications and durable fixation.

Preservation of the original femoral cement mantle during the management of infected cemented total hip replacement by two-stage revision

The removal of all prosthetic material and a two-stage revision procedure is the established standard management of an infected total hip replacement (THR). However, the removal of well-fixed femoral cement is time-consuming and can result in significant loss of bone stock and femoral shaft perforation or fracture. We report our results of two-stage revision THR for treating infection, with retention of the original well-fixed femoral cement mantle in 15 patients, who were treated between 1989 and 2002. Following partial excision arthroplasty, patients received local and systemic antibiotics and underwent reconstruction and re-implantation at a second-stage procedure, when the infection had resolved. The mean follow-up of these 15 patients was 82 months (60 to 192). Two patients had positive microbiology at the second stage and were treated with six weeks of appropriate antibiotics; one of these developed recurrent infection requiring further revision. Successful eradication of infection was achieved in the remaining 14 patients. We conclude that when two-stage revision is used for the treatment of peri-prosthetic infection involving a THR, a well-fixed femoral cement mantle can be safely left in situ, without compromising the treatment of infection. Advantages of this technique include a shorter operating time, reduced loss of bone stock and a technically more straightforward second-stage procedure.

Treatment of Crowe IV high hip dysplasia with total hip replacement using the Exeter stem and shortening derotational subtrochanteric osteotomy

We evaluated all cases involving the combined use of a subtrochanteric derotational femoral shortening osteotomy with a cemented Exeter stem performed at our institution. With severe developmental dysplasia of the hip an osteotomy is often necessary to achieve shortening and derotation of the proximal femur. Reduction can be maintained with a 3.5 mm compression plate while the implant is cemented into place. Such a plate was used to stabilise the osteotomy in all cases. Intramedullary autograft helps to prevent cement interposition at the osteotomy site and promotes healing. There were 15 female patients (18 hips) with a mean age of 51 years (33 to 75) who had a Crowe IV dysplasia of the hip and were followed up for a mean of 114 months (52 to 168). None was lost to follow-up. All clinical scores were collected prospectively. The Charnley modification of the Merle D’Aubigné-Postel scores for pain, function and range of movement showed a statistically significant improvement from a mean of 2.4 (1 to 4), 2.3 (1 to 4), 3.4 (1 to 6) to 5.2 (3 to 6), 4.4 (3 to 6), 5.2 (4 to 6), respectively. Three acetabular revisions were required for aseptic loosening; one required femoral revision for access. One osteotomy failed to unite at 14 months and was revised successfully. No other case required a femoral revision. No postoperative sciatic nerve palsy was observed.

Cemented Exeter femoral components perform well in the treatment of Crowe IV dysplasia with this procedure.

The concentric all-polyethylene Exeter acetabular component in primary total hip replacement

We report the outcome of the flangeless, cemented all-polyethylene Exeter acetabular component at a mean of 14.6 years (10 to 17) after operation. Of the 263 hips in 243 patients, 122 prostheses are still in situ; 112 patients (119 hips) have died, 18 hips have been revised, and three patients (four hips) were lost to follow-up. Radiographs at the final review were available for 110 of the 122 surviving hips. There were acetabular radiolucent lines in 54 hips (49%). Two acetabular components had migrated but neither patient required revision. The Kaplan-Meier survivorship at 15 years with 61 hips at risk with revision for any cause as the endpoint was 89.9% (95% confidence interval (CI) 84.6 to 95.2) and for aseptic loosening of the acetabular component or lysis 91.7% (95% CI 86.6 to 96.8). In 210 hips with a diagnosis of primary osteoarthritis, survivorship with revision for any cause as the endpoint was 93.2% (95% CI 88.1 to 98.3), and for aseptic loosening of the acetabular component 95.0% (95% CI 90.3 to 99.7). The cemented all-polyethylene Exeter acetabular component has an excellent long-term survivorship.

The Exeter Universal cemented femoral component at 15 to 17 years

The first 325 Exeter Universal stems (309 patients) implanted at the originating centre were inserted between March 1988 and February 1990 by a group of surgeons with differing experience. In this report we describe the clinical and radiological results at a mean of 15.7 years (14.7 to 17.3) after operation with no loss to follow-up. There were 97 patients (108 hips) with replacements still in situ and 31 (31 hips) who had undergone a further procedure. With an endpoint of revision for aseptic loosening, the survivorship at 17 years was 100% and 90.4% for the femoral and acetabular component, respectively. The mean Merle D’Aubigné and Postel scores at review were 5.4 (sd 0.97) for pain and 4.5 (sd 1.72) for function. The mean Oxford score was 38.4 (sd 9.8) (0 to 48 worst-to-best scale) and the mean combined Harris pain and function score was 73.2 (sd 16.9). Radiological review showed excellent preservation of bone stock in the proximal femur and no failures of the femoral component.

Revision of the cemented femoral stem using a cement-in-cement technique

The removal of well-fixed bone cement from the femoral canal during revision of a total hip replacement (THR) can be difficult and risks the loss of excessive bone stock and perforation or fracture of the femoral shaft. Retaining the cement mantle is attractive, yet the technique of cement-in-cement revision is not widely practised. We have used this procedure at our hospital since 1989. The stems were removed to gain a better exposure for acetabular revision, to alter version or leg length, or for component incompatibility.

We studied 136 hips in 134 patients and followed them up for a mean of eight years (5 to 15). A further revision was required in 35 hips (25.7%), for acetabular loosening in 26 (19.1%), sepsis in four, instability in three, femoral fracture in one and stem fracture in one. No femoral stem needed to be re-revised for aseptic loosening.

A cement-in-cement revision of the femoral stem is a reliable technique in the medium term. It also reduces the risk of perforation or fracture of the femoral shaft.

Constrained total hip arthroplasty in a paediatric patient with cerebral palsy and painful dislocation of the hip. A case report

We describe a patient with cerebral palsy, of normal intelligence, who could not walk but who by the age of 16 had been successfully managed with a staged bilateral total hip arthroplasty using a constrained liner.

In vivo surface wear mechanisms of femoral components of cemented total hip arthroplasties: the influence of wear mechanism on clinical outcome

The appearance and mechanism of femoral stem wear was studied in 172 retrieved femoral components, of which 74 stems had been stable in vivo. Macroscopic, microscopic, and nano-level scales of examination were used. Loss of stem surface in response to micromotion (wear) was found to affect 93% of stems. However, changes were frequently difficult to see with the naked eye, and in 19% of cases they would have been missed completely without the use of light microscopy. The surface finish of the prosthesis determined the mechanism of stem wear. Matte surfaces showed typical abrasive processes that also damage the cement, releasing particulate debris from the cement and metal surfaces. This may destabilize the stem within the cement. Polished stems showed a typical fretting appearance with retention of debris on the stem surface and without significant damage to the cement. These differences in wear mechanism between matte and polished stems have significant effects on stem function.

Surgical treatment for meniscal injuries of the knee in adults

BACKGROUND

Injuries to the knee menisci are common and operations to treat them are among the most common procedures performed by orthopaedic surgeons.

OBJECTIVES

To evaluate the effects of common surgical interventions in the treatment of meniscal injuries of the knee. The four comparisons under test were: a) surgery versus conservative treatment, b) partial versus total meniscectomy, c) excision versus repair of meniscal tears, d) surgical access, in particular arthroscopic versus open.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE and bibliographies of published papers. Date of the most recent search: August 1998.

SELECTION CRITERIA

All randomised and quasi-randomised trials which involved the above four comparisons or which compared other surgical interventions for the treatment of meniscal injury.

DATA COLLECTION AND ANALYSIS

Trial inclusion was agreed by both reviewers who independently assessed trial quality, by use of a 12 item scale, and extracted data. Where possible and appropriate, data were presented graphically.

MAIN RESULTS

Three trials, involving 260 patients, which addressed two (partial versus total meniscectomy; surgical access) comparisons were included. Partial meniscectomy may allow a slightly enhanced recovery rate as well as a potentially improved overall functional outcome including better knee stability in the long term. It is probably associated with a shorter operating time with no apparent difference in early complications or re-operation between partial and total meniscectomy. The long term advantage of partial meniscectomy indicated by the absence of symptoms (symptoms or further operation at six years or over: 14/98 versus 22/94; Peto odds ratio 0.55, 95% confidence interval 0.27 to 1.14) or radiographical outcome was not established. The results available from the only trial comparing arthroscopic with open meniscectomy were very limited in terms of patient numbers and length of follow-up. However it is likely that partial meniscectomy via arthroscopy is associated with shorter operating times and a quicker recovery.

REVIEWER'S CONCLUSIONS

The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear repair versus excision. In randomised trials so far reported, there is no evidence of difference in radiological or long term clinical outcomes between arthroscopic and open meniscal surgery, or between total and partial meniscectomy. Partial meniscectomy seems preferable to the total removal of the meniscus in terms of recovery and overall functional outcome in the short term.

Heterocyclic Ambident Nucleophiles. V. Alkylation of Benzimidazoles

Alkylation of 5-substituted benzimidazole anions with a variety of primary alkyl halides in both protic and aprotic solvents showed only small regioselectivity , with a slight preference for reaction at N1 for 5-nitro and N3 for 5-methoxy systems. With 4-substituted benzimidazole anions, alkylation gave more divergent results with the N1 to N3 regioselectivity varying between 100:0 and 29:71. These alkylation patterns are interpreted as deriving from an interplay of electrostatic, thermodynamic, steric and associative control factors within the variable SN2 transition state structures involved. In the 4-substituted series, proximity effects, both electrostatic field and steric non-bonded, are clearly dominant.

Nocturnal penile tumescence in healthy 20- to 59-year-olds: a revisit

This report presents data on normative nocturnal penile tumescence (NPT), based on a study of 48 healthy men aged 20-59 years, without complaints of erectile dysfunction. In general, the current measures show good concordance with those reported by Karacan and colleagues in 1976. The effect of "pathology-free" aging (from age 20 to 59) on electrographic measures of NPT is relatively modest, accounting for 8.4-14.4% of the variance. Furthermore, no age effect on visual estimates of erectile fullness or on buckling force estimates of penile rigidity were present. Maximum buckling force and maximum erectile fullness showed stability across the four decades of the Pittsburgh sample.

Diagnostic performance of nocturnal penile tumescence studies in healthy, dysfunctional (impotent), and depressed men

Nocturnal penile tumescence (NPT) studies were evaluated in 17 men with a clinical diagnosis of organic erectile dysfunction in comparison to age-matched healthy controls (n = 17) and depressed men (n = 17). The dysfunctional group had significantly fewer NPT episodes and reduced maximal penile tip changes when compared to healthy controls and depressed patients. Further, the dysfunctional group had significantly diminished erectile fullness and reduced penile rigidity. Diagnostic performance of polygraphic (night 1) and visual inspection (nights 2 or 3) components of the NPT protocol were examined in these criterion groups. A diagnostic classification based on polygraphic measures successfully discriminated 73.5% of dysfunctional and healthy control subjects, but classified 47% of depressives in the dysfunctional range. Use of visual inspection indices correctly identified 88% of the dysfunctional sample and 94% of normal controls, and reduced the "false-positive" rate in depression to only 18%. Results support the diagnostic utility of NPT studies, particularly when enhanced by visual inspection procedures. Nevertheless, the presence of major depression may confound interpretation of such studies.

Assessment of sexual function in depressed, impotent, and healthy men: factor analysis of a Brief Sexual Function Questionnaire for men

We report a study of sexual function in outpatient men with major depressive disorder (n = 42), compared with healthy control men (n = 37) and a clinic sample complaining of erectile dysfunction (n = 13). A principal-components factor analysis of the Brief Sexual Function Questionnaire confirmed differences in the clinical dimensions of sexual activity/performance, interest, satisfaction, and physiological competence. The four factors accounted for 72% of the variance in the analysis. Acceptable test-retest reliability, construct validity, and concurrent validity (with the Derogatis Sexual Function Inventory and a self-report behavioral log) were demonstrated. Parallel observations with findings from previous nocturnal penile tumescence studies in these same men are discussed.

Nocturnal penile tumescence is diminished in depressed men

Although depressed individuals commonly report decreased libido, it was not known if such changes are accompanied by neurophysiological alterations. Preliminary studies suggest that some depressed men may manifest diminished nocturnal penile tumescence (NPT), an objective measure of erectile capacity. We report NPT findings in 34 male outpatients with major depression (SADS/RDC) and an age-matched group of 28 healthy controls. A 3-night electroencephalographic (EEG) sleep/NPT protocol was utilized, with penile rigidity (buckling force) determined on night 3. Analysis of night 2 data by MAN-COVA revealed significant effects for age, the covariate (F = 2.86, p = 0.002), and diagnosis (F = 2.32, p = 0.02). Depressed men had significantly diminished NPT time (F = 16.8, p less than 0.001), even when adjusted for sleep time (F = 13.4, p less than 0.001) or rapid eye movement (REM) time (F = 7.2, p less than 0.01). NPT time was reduced by greater than or equal to 1 SD below the control mean in 40% of depressives and was comparable to the level seen in 14 nondepressed patients with a clinical diagnosis of organic impotence. An intermediate proportion of depressed patients (38%) had maximum buckling forces less than or equal to 500 g, indicating diminished penile rigidity, when compared to controls (16%) and men with presumed organic impairment (93%) (p less than 0.001). Diminished NPT time and low buckling force were associated with a history of erectile dysfunction within the index depressive episode (p less than 0.001). These findings suggest that depression in men is associated with a potentially reversible decrease in erectile capacity, which may be associated with significant sexual dysfunction.

Assessment of sexual function, interest and activity in depressed men

Sexual function, interest, and activity were assessed in drug-free outpatient depressed men (n = 26) and in age-matched healthy control men (n = 20) by means of the Derogatis Sexual Functioning Inventory (DSFI), a retrospective sexual function questionnaire (SFQ), and a prospective daily sexual function log. Good test-retest reliability over 1 month was demonstrated for the DSFI and the SFQ in depressives and controls. Compared to healthy controls, depressed men reported significantly lower sexual interest and satisfaction, but no less sexual activity, on both retrospective questionnaires and prospective daily logs. Depressed men also showed significantly more negative body image and less 'manly' sexual role function as measured by the DSFI. Significant partial correlations (controlling for the effects of anxiety) were found between severity of depression and sexual interest, satisfaction, and role.

The effects of word orientation and imageability on visual half-field presentations with a lexical decision task

Two studies examined the effects of word orientation and word imageability in a visual half-field procedure. The studies involved a lexical decision task in which items were presented in either a horizontal or vertical orientation randomly intermixed in Experiment 1 and blocked in Experiment 2. Overall, a RVF advantage resulted with horizontal items, yet no visual-field asymmetries were found with the vertical items. These results indicate that altering the orientation can affect visual-field superiority. It is proposed that the novelty of vertical displays leads to greater involvement of the right hemisphere. Imageability was related to performance only for horizontal displays; but there were no significant differences in imageability effects between the two visual fields. It is concluded that word imageability has little effect on visual-field differences, at least not for lexical decisions.

Evaluating the impact of certificate-of-need regulation using measures of ultimate outcome: some cautions from experience in Massachusetts

Prior evaluations of certificate of need (CON) have concluded that such regulation did little to reduce the level of hospital capital investment. These studies, however, failed to examine the underlying patterns of hospital investment behavior onto which CON was imposed and further neglected to determine the lag period that separates the introduction of regulation and the appearance of outcomes actually attributable to the presence of CON. This article addresses these two issues by using rate-setting data to examine the details of hospital capital investment across the whole voluntary hospital industry in one state--Massachusetts--both before and after the introduction of certificate of need. Massachusetts voluntary hospitals were found to devote most of their capital expenditures to the construction of major new inpatient facilities built in cycles of 14 years average duration throughout the post-World War II period. The date of completion of such a facility proved to be the major determinant of a hospital's capital expenditure pattern over time, and hospitals of similar teaching status and geographic location showed considerable synchrony in the construction of such facilities. At least in Massachusetts, the introduction of certificate-of-need regulation coincided with but was not responsible for the conclusion of a major construction peak among nonteaching hospitals and the beginning of such a peak among teaching hospitals, greatly complicating the evaluation of actual CON effects. Further, capital expenditures actually approved by CON did not appear until the third year of program operation, and even five years post-CON, the majority of hospital capital expenditures reflected projects approved in the first year of regulation, a period during which the program had neither the expert staff nor extensive review capacity that characterized CON function in later years. These findings hold implications for the evaluation of CON effectiveness and, indeed, for the future existence of certificate of need.

Kinetic studies on the effects of ouabain on Na+ fluxes in frog skin

Among 48 pieces of paired frog skins of Rana pipiens in Ringer's solution, 10 pieces showed a strictly monotone decrease in the short circuit current (SCC) following ouabain treatment (10(-4) M). In 9 cases a transient attenuation, and in 27 cases a distinct wave in the ebb of the SCC, was seen. In 2 instances, two waves were seen. Associated with the not-monotone events was a transient rise in electrical skin conductance. The reasons for these mixed skin responses are unknown. One possible reason is considered here: Early during the ouabain action, some of the Na+ entering from the mucosal side is trapped in the skin by electroneutral processes, in keeping with the already known fact that ultimately cellular KCl is partly replaced by NaCl. Computer assisted model studies show how monotone, and not-monotone "transepithelial" net Na+ flux curves can be generated. Essential conditions for the generation of not-monotone Na+ flux curves are: 1. Presence of two distinct "cellular", active Na+ pools in the model. 2. Presence of a loop pathway in which a principal "transepithelial Na+ transport compartment", and a constituent "Na+/K+ maintenance compartment", are connected to each other and to the "extracellular" compartment. The model, then, predicts under which kinetic conditions monotone and not-monotone transepithelial Na+ flux curves will be seen.

Effect of antacids on phenytoin bioavailability

Eight subjects were studied in a randomized crossover design to determine the effect of aluminum-magnesium hydroxide (AMH), calcium carbonate (CC), and aluminum hydroxide-magnesium trisilicate (AHMT) on the bioavailability of a single, 600-mg dose of phenytoin administered orally. Each subject received phenytoin alone on two separate occasions and phenytoin plus each of the three antacids on three other occasions. Each antacid was administered as 160 mEq at 1 and 3 hr after each meal and at bedtime on the day phenytoin was given. The mean area under the curve (AUC) was significantly decreased by AMH (p less than 0.005) and CC (p less than 0.05). AHMT had a similar trend but did not reach statistical significance (p = 0.1). Large inter- and intrasubject variability in AUC was observed when phenytoin was administered alone. In two subjects, cumulative urinary 5-(4-hydroxyphenyl)-5-phenylhydantoin at 72 hr (HPPH72) was determined. The amount of HPPH recovered had similar trends as the AUC with antacid treatments but not the same magnitude. In this study, antacids altered not only the extent of absorption but also appeared to alter the rate of absorption. Antacids administered in a peptic ulcer regimen may decrease the AUC of a single dose of phenytoin. Patients should be cautioned against concomitant use of antacids and phenytoin.

Chronic neck and back pain: a reassessment of usual surgical treatment

One hundred seventeen patients with chronic (noncancerous) back or neck pain had multidisciplinary evaluation in the Medical College of Virginia Pain Center and were followed up for one year. They ranged in age from 26 to 57 years. The 57 patients who had surgery had an average of 2.5 procedures (either laminectomies or back fusion) and only five of them returned to work. By contrast, 16 of 60 patients who had not had operation were able to secure employment after evaluation and treatment in the Pain Center.

Nonlinear regression on multiple-dose data

The examples are given to show how Metzler's nonlinear regression program can be used to estimate parameters in a model with multiple dosing. The model of one example is a set of equations involving sums of exponentials, whereas the other model is a set of differential equations reflecting first order absorption and Michaelis-Menten excretion. In both cases no data were given in one of the dosing intervals.

Treatment of chlordecone (Kepone) toxicity with cholestyramine. Results of a controlled clinical trial

Industrial workers exposed to the organochlorine pesticide, chlordecone (Kepone), had signs of toxicity in several organs. The extent of toxicity was proportional to the levels of this chemical in the tissues. In 22 patients, chlordecone was eliminated slowly from blood (half time of 165 +/- 27 days--mean +/- S.E.M.) and fat (half time of 125 days, with a range of 97 to 177), chiefly in the stool. Output of chlordecone in bile was 10 to 20 times greater than in stool, suggesting that chlordecone is reabsorbed in the "ntestine. Cholestyramine, an anion-exchange resin that binds chlordecone, increased its fecal excretion by seven times. In a five-month trial, cholestyramine significantly accelerated elimination of chlordecone from blood, with a half life of 80 +/- 4 days (S.E.M.) (P less than 0.005) and fat (half life of 64 days, with a range of 52 to 85) (P less than 0.05). Cholestyramine offers a practical means for detoxification of persons exposed to chlordecone and possibly to other lipophilic toxins.

Curing and caring -- a proposed method for self-assessment in primary care organizations

Key research in the area of quality assessment is reviewed and a method for periodic assessment in primary care organizations is proposed. The suggested approach is designed for administrative, rather than research, purposes. Therefore, it focuses on indicators that are both practical and realistic for use in periodic monitoring. The proposed method is two-staged and includes both technical performance (curing) and satisfaction (caring). At the first level of evaluation, general areas of performance are examined; these are key performance indicators in prevention, diagnosis, and management of illness, and questionnaires dealing with the accessibility and acceptability of care, coupled with objective measures of satisfaction. Those areas of performance that are not up to management standards are then examined in greater detail at the second level of evaluation. Using this approach, organizations can build a longitudinal picture of performance and chart their progress annually.