Frailty and Aging in HIV- Status Post 13 Years of National Awareness

The People aged 50 years and above comprise over 50% of people living with HIV (PLWH) in the US. Despite the advances made with anti-retroviral therapy in increasing their life span, PLWH are plagued with non-AIDS associated conditions which increase their risk for morbidity and mortality. Frailty, a decline in physical and functional reserve, is one of the manifestations of aging, has a prevalence of 5-30%, and occurs up to 2 decades earlier in people aging with HIV (PAWH). The majority of providers for PAWH have minimal experience with the concept of gerontology, frailty, and aging. Hence, there is a gap in clinicians' knowledge on how to address frailty and aging in PAWH. This review will focus on the clinical interventions that mitigate frailty and aging in PAWH as well as highlight areas of investigation towards achieving these mediations. Beyond the identification of the roles of exercise and nutrition, more studies are needed on the pragmatic approach to apply these resources to routine care. There should be continued reinforcement of the proven strategy of combination antiretroviral therapy as well as treatment of co-infections and age-appropriate health and cancer screening in PAWH.

Vascular occlusion following application of subcutaneous anterior pelvic fixation (INFIX) technique

We report a case of bilateral external iliac artery compression after application of subcutaneous anterior pelvic fixation (INFIX) technique in a 51-year-old male with an unstable pelvic fracture sustained following a motor vehicle accident. This has not been previously reported in the literature. The management of this complication is discussed in detail, along with key precautions and technical steps to consider while utilizing the 'INFIX' technique for pelvic fractures.

A rare case of primary bone lymphoma mimicking a pelvic abscess

Primary bone lymphoma (PBL) is a rare, malignant, neoplastic disorder of the skeleton that accounts for less than 5% of all primary bone tumours. We present an extremely rare case of PBL mimicking a pelvic abscess around the sacroiliac joint, which has never been reported in the medical literature, and discuss learning points highlighted from this case.

Malreduction of syndesmosis--are we considering the anatomical variation?

Previous studies have demonstrated the need for accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. A computed tomography (CT) scan allows better visualisation of the transverse relationship between the fibula and incisura fibularis. The difference ('G' a term we coined for ease of description) between the fibula and the anterior and posterior facets of the incisura fibularis was compared between normal and injured ankles following syndesmotic fixation in 19 patients. The mean diastasis (MD) was also calculated, representing the average measurement between the fibula and the anterior and posterior incisura. When compared with the normal side, eight out of 19 (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis. However, if a standard value of G (2mm) was used for the injured leg only, all of the 19 cases would have abnormal values of 'G' following reduction. Our study has clearly demonstrated the need for individualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of 'G' of 2mm as the normal limit cannot be applied universally, as apparent from the data presented in this study.

Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures

OBJECTIVE

To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique.

DESIGN

Prospective Cohort.

SETTING

Level I Trauma Centre.

PATIENTS/PARTICIPANTS

A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures.

INTERVENTION

All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken.

MAIN OUTCOME MEASURE(S)

Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >108.

RESULTS

A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.08 with a mean difference of 16.28(p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >108 from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.38 with a mean difference of 11.58 (p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >108 from the uninjured limb.

CONCLUSIONS

Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation.The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.

The first case of criminalization of transmission of hepatitis B in the UK: defendant sentenced to two years’ imprisonment on the grounds of hepatitis B deoxyribonucleic acid sequencing

A 29-year-old Turkish man Ercan Yasar, who worked as a restaurant worker in Cheltenham, infected a Cheltenham woman 27 years of age with hepatitis B and chlamydia between 14 and 17 September 2007. He was charged with biological grievous bodily harm, which carries a maximum of five years’ imprisonment if found guilty following a trial. The defendant, Ercan Yasar, pleaded guilty to the charge and was given appropriate credit for entering an early guilty plea and was sentenced to two years’ imprisonment before the Gloucester Crown Court on 14 November 2008.

Breakage of arm of Multiload intrauterine device during removal

We report a case of intrauterine device (IUD) removal five years after its insertion which was broken during the removal procedure. One of the arms of the IUD remained inside the uterus. We allowed three months for spontaneous expulsion. When this did not happen, we proceeded with a hysteroscopic removal. Because of its embebbed position in the myometrium this could not be removed during hysteroscopy and finally it was left in situ. The patient was monitored every three months for a period of 12 months. There was no problem. We report this case because doctors may find it necessary to remove the IUD in certain situations and be aware of such a breakage and various precautions to prevent this.

Percutaneous fusion of the sacroiliac joint with hollow modular anchorage screws: clinical and radiological outcome

We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix. Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control. The short form-36 questionnaire and Majeed's scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs. Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed's score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology. We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion.

Fibre based cellular transfection

Optically assisted transfection is emerging as a powerful and versatile method for the delivery of foreign therapeutic agents to cells at will. In particular the use of ultrashort pulse lasers has proved an important route to transiently permeating the cell membrane through a multiphoton process. Though optical transfection has been gaining wider usage to date, all incarnations of this technique have employed free space light beams. In this paper we demonstrate the first system to use fibre delivery for the optical transfection of cells. We engineer a standard optical fibre to generate an axicon tip with an enhanced intensity of the remote output field that delivers ultrashort (~ 800 fs) pulses without requiring the fibre to be placed in very close proximity to the cell sample. A theoretical model is also developed in order to predict the light propagation from axicon tipped and bare fibres, in both air and water environments. The model proves to be in good agreement with the experimental findings and can be used to establish the optimum fibre parameters for successful cellular transfection. We readily obtain efficiencies of up to 57 % which are comparable with free space transfection. This advance paves the way for optical transfection of tissue samples and endoscopic embodiments of this technique.

The effect of a venous filter on the embolic load during medullary canal pressurization: a canine study

BACKGROUND

Acute intramedullary stabilization of femoral shaft fractures in multiply injured patients is controversial. Intravasation of medullary fat during canal pressurization has been suspected to trigger adult respiratory distress syndrome. The goal of the present study was to evaluate the effect, on the lungs, of a filter placed into the ipsilateral common iliac vein during medullary canal pressurization in a canine model.

METHODS

With use of an established model of fat embolization, twelve mongrel dogs were randomized into two groups. In six dogs, a special filter was inserted percutaneously into the left common iliac vein while the dogs were under general anesthesia. In all dogs, the left femur and tibia were then pressurized by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and echocardiographic images were recorded throughout the experiment. After one hour, the animals were killed and the lungs were harvested for histomorphometric analysis.

RESULTS

Without the filter, the mean pulmonary artery pressure increased by 11.8 +/- 2.1 mm Hg (p < 0.001). With the filter, the mean pulmonary artery pressure increased by only 2.2 +/- 0.8 mm Hg (p < 0.02). Without the filter, there was a significant increase in the index of pulmonary vascular resistance as compared with the baseline value (p < 0.05). With the filter, there was no such increase. Histomorphometric analysis demonstrated that the presence of the filter reduced the absolute area of embolization and the volume percentages of lung and pulmonary vasculature embolized.

CONCLUSIONS

In this canine experiment, temporary placement of a venous filter prior to medullary canal pressurization reduced the embolic load and minimized its hemodynamic effects.

Non-union of acetabular fractures

Non-unions of acetabulum are rare. Seven cases of acetabular non-unions are reported in this retrospective study. Five out of our seven patients had either transverse or associated transverse with posterior wall fractures. All patients had surgical stabilisation of their index fractures. A diagnosis of non-union was made at an average of 5.8 months from the original injury based on clinical and radiological features. Five of the six patients who underwent re-stabilisation and bone grafting of the non-union healed where as the remaining one did not heal after two attempts at re-stabilisation and was treated with excision arthroplasty. Two of the healed five, subsequently developed osteoarthritis and had total hip arthroplasty where as one patient had already developed degeneration of his hip at the time of diagnosis and hence treated with total hip arthroplasty. Analysis of the non-unions confirmed that fixation was unstable in all with residual displacement seen in two of them. In conclusion acetabular fracture non-union appear to be associated with transverse fractures and unstable fixation.

Role of frozen section histology in diagnosis of infection during revision arthroplasty

The accurate diagnosis of deep infection in total joint arthroplasty is difficult. No single test on its own is entirely reliable. Frozen section histology has been used for the last two decades as an adjunct to diagnose infection with variable results. In this retrospective analysis, experience of the use of frozen section histology as a diagnostic tool in 45 cases of suspected infected total joint arthroplasty is reported. Taking intraoperative cultures as the "gold standard", the results showed 50% sensitivity, 95% specificity, positive predictive value of 60%, negative predictive value of 92%, and an accuracy of 89%, which is similar to other existing reports in the literature. Based on these findings, the use of frozen section histology in diagnostic work-up of all suspected cases of total joint infection is recommended.

Check radiography after fixation of hip fractures: is it necessary?

Technological advances in radiography in the form of image intensification has not only made internal fixation of femoral neck fracture much easier but these high resolution films can be saved as hard copies and can also be reversed into 'positives' at a later date. However, requesting routine post-operative check radiographs for these fractures are still a common practice. A retrospective study was carried out to compare the quality of image intensifier films with conventional post-operative radiographs. 79 sets of films were reviewed with particular reference to adequacy of fixation and possible joint penetration by the screws. No significant difference was noted between the two sets of films. We suggest that routine post-operative radiographs after femoral neck fracture fixation are unnecessary unless there is some clinical indication. This has significant implications in relation to patient discomfort, radiation exposure and cost-effectiveness.