Lateral pillar is the key in supporting pre-collapse osteonecrosis of the femoral head: a finite element model analysis of propensity-score matched cohorts

Background

This study was designed as a cohort study using propensity-score matching to age, gender, and body mass index (BMI) for finite element model (FEM) analysis from pre-collapse CT images of collapsed and non-collapsed hips. Through FEM analysis, a global graphical output around the hip joint can provide simple impression of stress distribution: concentration or dispersion.

Methods

A total of 32 hips with ARCO stage 2 or 3 ONFH who were on follow up for over a one-year period were retrospectively reviewed. 16 hips with no interval progression of collapse were set as the study group, then 16 hips with progression of collapse which required arthroplasty were set as the control group using propensity-score matching. FEM was generated through Mechanical Finder for each patient, then 4500 N of load was applied to 1000 mm² area at the top of iliac crest to analyze the models in terms of equivalents for yield stress.

Results

Age, sex, and BMI had no significant differences between the two groups, while location (p = 0.015) was lateral, and size (p = 0.015) was significantly greater in the collapsed group. Non-collapsed hips mostly exhibited stress dispersion allocated to medial and lateral pillars, while collapsed hips exhibited stress concentration focused on the lateral pillar and the primary compression trabecula. (p = 0.001).

Conclusion

Through FEM analysis, stress concentration to the lateral pillar and the primary compression trabeculae can be used to predict future collapse in ONFH with high probability. Results provide a simple and intuitive, yet valuable information to aid surgeons. Therefore, especially for young patients, holding out the lateral pillar through joint preserving procedures might be the key in preventing further collapse.

Comparative analysis of titanium coating on cobalt-chrome alloy in vitro and in vivo direct metal fabrication vs. plasma spraying

Background

Titanium surface coating on cobalt-chromium (CoCr) alloy has characteristics desirable for an orthopedic implant as follows: strength, osteointegrative capability, and biocompatibility. Creating such a coated surface takes a challenging process and two dissimilar metals are not easily welded. In our study, we utilized additive manufacturing with a 3D printing called direct metal fabrication (DMF) and compared it to the plasma spraying method (TPS), to coat titanium onto CoCr alloy. We hypothesized that this would yield a coated surface quality as acceptable or better than the already established method of plasma spraying. For this, we compared characteristics of titanium-coated surfaces created by direct metal fabrication method (DMF) and titanium plasma spraying (TPS), both in vitro and in vivo, for (1) cell morphology, (2) confocal microscopy images of immunofluorescent assay of RUNX2 and fibronectin, (3) quantification of cell proliferation rate, (4) push-out biomechanical test, and (5) bone histomorphometry.

Method

For in vitro study, human osteoblast cells were seeded onto the coated surfaces. Cellular morphology was observed with a scanning electron microscope. Cellular proliferation was validated with ELISA, immunofluorescent assay. For in vivo study, coated rods were inserted into the distal femur of the rabbit and then harvested. The rods were biomechanically tested with a push-out test and observed for histomorphometry to evaluate the microscopic bone to implant ratio.

Result

For cell morphology observation, lamellipodia and filopodia, a cytoplasmic projection extending into porous structure, formed on both surfaces created by DMF and TPS. The proliferation of the osteoblasts, the DMF group showed a better result at different optic density levels (p = 0.035, 0.005, 0.001). Expression and distribution of fibronectin and Runx-2 genes showed similar degrees of expressions. The biomechanical push-out test yielded a similar result (p = 0.714). Histomorphometry analysis also showed a similar result (p = 0.657).

Conclusion

In conclusion, DMF is a method which can reliably create a proper titanium surface on CoCr alloy. The resulting product of the surface shows a similar quality to that of the plasma spraying method, both in vivo and in vitro, in terms of biological and mechanical property.

Patients with more comorbidities have better detection but poorer management of chronic diseases

Background

The burden of non-communicable diseases (NCDs) is rising rapidly in middle-income countries (MICs), where NCDs are often undiagnosed, untreated and uncontrolled. How comorbidity impacts diagnosis, treatment, and control of NCDs is an emerging area of research inquiry and have significant clinical implications as highlighted in the recent National Institute for Care Excellence (NICE) guidelines for treating patients suffering from multiple NCDs. This is the first study to examine the association between increasing numbers of comorbidities with being undiagnosed, intreated, and uncontrolled for NCDs, in six large MICs.

Methods

Cross-sectional analysis of WHO SAGE Wave 1 (2007-10), which consisted of adults aged ≥18 years from six populous MICs including, China, Ghana, India, Mexico, Russia and South Africa (overall n = 41, 557).

Results

Higher number of comorbidities was associated with better detection of hypertension, angina and arthritis, and better odds of having treatment for hypertension and angina. However, increasing comorbidity had the opposite effect on being uncontrolled, and was associated with increased odds of uncontrolled hypertension, angina, arthritis, and asthma. Comorbidity with concordant conditions was associated with improved diagnosis and treatment of hypertension and angina. Comorbidity with concordant conditions was not associated with decreased nor increased odds of being uncontrolled for all NCDs.

Conclusions

Patients with more comorbidities have better diagnosis of chronic conditions, but this does not translate into better management and control of these conditions. Improving continuity of care and monitoring treatment are priorities for health systems with ageing populations.

Key messages

Patients with more comorbidities have better diagnosis of chronic conditions. but this does not translate into better management and control of these conditions.

What influences use of dental services by the Korean disabled people? The role of perceived barriers in dental care system

OBJECTIVE

To identify the perceived barriers to dental care for disabled people in South Korea using the revised Andersen's model of access to health care.

BASIC RESEARCH DESIGN

Cross-sectional analytic interview study.

PARTICIPANTS

Korean people with a disability residing in residential facilities, or those at home who attend vocational rehabilitation facilities, special schools, or welfare facilities, were sampled from Seoul and non-Seoul areas in 2016 and were interviewed face-to-face. In total, 456 disabled Koreans, or their primary caregivers participated.

RESULTS

Household income, disability duration and perceived barriers in the dental care system were perceived to impact on dental care utilisation, while the need for dental care services did not significantly explain the use of dental care by disabled people in South Korea. Those with low household incomes were less likely to use dental care services, compared to people with moderate and high household incomes. As disability duration increased, disabled people were more likely to use dental services. Those who perceived the barriers to dental care as higher were less likely to use dental services.

CONCLUSION

These data suggest that policies are needed to support disabled people with low household incomes. Lowering barriers in the dental care system may encourage people with disabilities to access timely and adequate dental services.

Titanium Powder Coating Using Metal 3D Printing: A Novel Coating Technology for Cobalt-Chromium Alloy Implants

Background

Three-dimensional (3D) printing with a direct metal fabrication (DMF) technology has been innovatively introduced in the field of surface treatment of prostheses. The purpose of this study was to determine whether such modifications on the surface of cobalt-chromium (CoCr) alloy by titanium powder coating using DMF improves the osseointegration ability of CoCr alloy.

Methods

We compared the in vitro and in vivo ability of cells to adhere to DMF-coated CoCr alloy with machining. Biological and morphological responses to human osteoblast cell lines were examined by measuring cell proliferation rate and observing expression of actin filament. For in vivo study, we inserted different specimens in each medulla of the distal femurs of rabbit. After 3 months, the distal femurs were harvested, and a push-out test and histomorphometric analyses were performed.

Results

The cell proliferation rate and cell adhesion in the DMF group were higher compared with those in the machined group. Human osteoblast cells on the DMF-coated surface were more strongly adhered and well-proliferated compared with those on the other surface. In the in vivo test, there was a significant difference in the ultimate shear strength between the DMF and machined groups (2.49 MPa vs. 0.87 MPa, respectively, p = 0.001). In the histomorphometric analysis, there was a significant difference in the mean bone-to-implant contact percentages between the DMF and machined groups (72.3 ± 6.2% vs. 47.6 ± 6.9%, respectively, p < 0.001).

Conclusion

Titanium coating of CoCr alloy with 3D metal printing provides optimal surface characteristics and a good biological surface both in vitro and in vivo.

Proximal Femoral Shape Changes the Risk of a Leg Length Discrepancy After Primary Total Hip Arthroplasty

BACKGROUND

To evaluate how canal morphology affects the technical aspects of total hip arthroplasty, we investigated the effects of femoral cortical index (FCI) on the re-establishment of leg length at the conclusion of surgery.

METHODS

We retrospectively reviewed age, gender, body mass index, and radiographs of 516 patients with osteoarthritis or osteonecrosis who underwent unilateral cementless primary total hip arthroplasty between 2008 and 2015. Patients were divided into level of FCI and leg length discrepancy (LLD). Each cohort was compared in terms of demographics and LLD. One-way analysis of variance and Kruskal-Wallis test were used.

RESULTS

The mean FCI and LLD were 0.6 ± 0.1 and 3.5 ± 6.3 mm, respectively. Utilization of an extended offset stem was highest with Dorr type A and B hips (P = .001). High FCI increased the risk of lengthening (P = .017) and low FCI increased the risk of shortening (P = .005).

CONCLUSION

A high FCI increases the probability of a leg length increase and a low FCI increases the probability of a leg length decrease. Surgeons might consider informing patients in advance of possible variation in leg length depending on the patients' proximal femoral shape and bony quality.

The biological response to laser-aided direct metal-coated Titanium alloy (Ti6Al4V)

Objectives

Laser-engineered net shaping (LENS) of coated surfaces can overcome the limitations of conventional coating technologies. We compared the in vitro biological response with a titanium plasma spray (TPS)-coated titanium alloy (Ti6Al4V) surface with that of a Ti6Al4V surface coated with titanium using direct metal fabrication (DMF) with 3D printing technologies.

Methods

The in vitro ability of human osteoblasts to adhere to TPS-coated Ti6Al4V was compared with DMF-coating. Scanning electron microscopy (SEM) was used to assess the structure and morphology of the surfaces. Biological and morphological responses to human osteoblast cell lines were then examined by measuring cell proliferation, alkaline phosphatase activity, actin filaments, and RUNX2 gene expression.

Results

Morphological assessment of the cells after six hours of incubation using SEM showed that the TPS- and DMF-coated surfaces were largely covered with lamellipodia from the osteoblasts. Cell adhesion appeared similar in both groups. The differences in the rates of cell proliferation and alkaline phosphatase activities were not statistically significant.

Conclusions

The DMF coating applied using metal 3D printing is similar to the TPS coating, which is the most common coating process used for bone ingrowth. The DMF method provided an acceptable surface structure and a viable biological surface. Moreover, this method is automatable and less complex than plasma spraying.

Cite this article: T. Shin, D. Lim, Y. S. Kim, S. C. Kim, W. L. Jo, Y. W. Lim. The biological response to laser-aided direct metal-coated Titanium alloy (Ti6Al4V). Bone Joint Res 2018;7:357–361. DOI: 10.1302/2046-3758.75.BJR-2017-0222.R1.

Tumor molecular profiling of responders and non-responders following pembrolizumab monotherapy in chemotherapy resistant advanced cervical cancer

Optimal treatment for advanced cervical cancer after first line chemotherapy remains undefined. Immune checkpoint inhibition with pembrolizumab, a programmed cell death protein 1(PD-1) inhibitor, is under investigation. We analyzed the micro-environmental and molecular genetic profile of tumors from 4 patients with metastatic cervical cancer treated with off-label second-line pembrolizumab in an effort to identify predictive biomarkers. All patients received 2 mg/kg of pembrolizumab, 3-weekly until disease progression. Immunohistochemistry(IHC) for PD-1, PD-L1, CD3 and CD8, as well as next generation sequencing (NGS) for 50 cancer-related genes were performed on tumor samples. All patients tolerated treatment well with no discontinuation of treatment due to toxicity. One patient experienced dramatic and prolonged partial response, and remains stable on pembrolizumab with a progression free survival (PFS) of 21 months at the time of reporting of this series. Three patients experienced disease progression as best response. In the exceptional responder, there was no tumoral expression of PD-L1, however, combined positive score (CPS) for PD-L1 was 1 and we identified somatic mutations in ERBB4(R612W), PIK3CA(E542K) and RB1(E365K). In 2 patients, despite progressive disease defined by RECIST v1.1, symptom stabilization on pembrolizumab was observed. The tumors of both patients had PD-1 expression in ≥1% of stromal lymphocytes. All patients with response or clinical benefit had CPS for PD-L1 ≥ 1. NGS revealed PIK3CA mutations in 3 tumors. Pembrolizumab is a promising therapeutic option in advanced cervical cancer. Further evaluation of biomarkers may guide optimal patient selection.

A systematic review of methods to measure family co-participation in physical activity

The family environment is key in influencing children's health behaviours. Encouraging family co-participation in physical activity may therefore be an effective approach to increasing children's physical activity levels. Yet, little is known about how to best assess family co-participation in physical activity. This review summarizes methods to measure family co-participation in physical activity, which was defined as joint physical activities including at least one healthy child (0-18 years) and one other family member. Methods were identified through a systematic literature search, cross-referencing pre-selected reviews and contacting research groups. Thirty-seven measurement methods were included. Questionnaires were the most common method used, with the majority assessing frequency of co-participation and few also assessing duration and type. Reliability and internal consistency of scales were often reported, but rarely specified for the item(s) relevant to co-participation. Other methods of measuring co-participation included diaries, event history calendars, direct observations and accelerometry combined with diary, ecological momentary assessment or global positioning systems (GPS). Whilst a large number of measurement methods of family co-participation in physical activity exist, few are comprehensive and/or report acceptable psychometric properties. Future work should focus on reaching consensus in defining family co-participation in physical activity, and subsequently developing reliable and valid measures.

Preventing childhood obesity in Asia: an overview of intervention programmes

The rapid economic growth in Asia in the past few decades has contributed to the global increase in childhood obesity prevalence. Yet, little is known about obesity prevention efforts in this region. This systematic review provides an overview of child obesity prevention programmes in Asia. Searches were performed in six electronic databases. Out of 4,234 studies, 17 were included, among them 11 controlled trials (of which five were randomized). Only one study was published before 2007. Identified studies were predominantly conducted in China and Thailand and targeted primary school children in a school setting. Most studies implemented different programmes, frequently targeting behavioural modification through nutrition/health education lectures and/or physical activity sessions. Programme effects related to obesity outcome measures were mixed. Most substantial effects were found for outcomes such as improved health knowledge and/or favourable lifestyle practices. The relatively small number of relevant publications in Asia highlights the need for scientific evaluations of existing and future programmes. This will help ensure the implementation and dissemination of evidence-based approaches that have been proven to be effective in the Asian context. Targeting preschool settings and applying a comprehensive multisectoral approach may increase the effectiveness and sustainability of childhood obesity prevention programmes.

Total Hip Arthroplasty in Patient with Aplastic Anemia

Purpose

Patients with aplastic anemia (AA) are now living longer and therefore are at increased risk for the development of osteonecrosis of the hip. However, studies on the results of total hip arthroplasty (THA) are lacking. The purpose of this study is to present the result of THA in patients with AA.

Materials and Methods

We retrospectively reviewed the data for a group of 29 patients (45 hips) with AA who presented to our institution for THA between May 2008 and May 2012. All hips were replaced because of osteonecrosis of the femoral head. A specific prospective protocol was followed for the perioperative transfusion of platelets and blood. The clinical and radiographic evaluations were done, and the minimum follow-up period was 3 years (mean, 49.2 months; range, 36 to 84 months).

Results

Three hips had excessive perioperative bleeding and hematoma formation, and then hematoma evacuations were done; one hip was finally revised because of infection of acetabular component. One patient with poorly controlled AA died due to delayed infection on the hip joint. All hips showed stable fixation, and the mean Harris hip score was improved from 54.2 points (range, 42 to 69 points) preoperatively to 90.8 points (range, 73 to 97 points) at the time of the latest follow-up.

Conclusion

In the present study, the durability of implant fixation was maintained and the clinical results demonstrated a sustained increase in function of the hip. Postoperatively, paying attention to bleeding and infection should be needed.

Near-Road Exposure and Impact of Air Pollution on Allergic Diseases in Elementary School Children: A Cross-Sectional Study

PURPOSE

The study aims to classify schools based on traffic pollutants and their complex sources, to assess the environment, to determine the state of allergic diseases among students using the International Study of Asthma and Allergies in children (ISAAC) questionnaire, and to assess their connection to air pollutants.

MATERIALS AND METHODS

A total of seven schools were divided into three categories according to the characteristics of their surrounding environments: three schools in traffic-related zones, two schools in complex source zones I (urban), and two schools in complex source zones II (industrial complex). ISAAC questionnaires were administered and the 4404 completed questionnaires were analyzed.

RESULTS

The frequency of asthma treatment during the past 12 months showed a significant increase (p<0.05) with exposure to NO₂ [1.67, 95% confidence intervals (CIs) 1.03-2.71] in the complex source zones. The frequency of allergic rhinitis treatment during the past 12 months increased significantly with exposure to Black Carbon (1.60, 95% CIs 1.36-1.90) (p<0.001), SO₂ (1.09, 95% CIs 1.01-1.17) (p<0.05), NO₂ (1.18, 95% CIs 1.07-1.30) (p<0.01) for all subjects.

CONCLUSION

In terms of supporting children's health, care, and prevention related to major spaces for children, such as school zones, spaces used in coming to and leaving school, playgrounds, and classrooms are essential to ensuring not only the safety of children from traffic accidents but also their protection from local traffic pollutants and various hazardous environmental factors.

Total Hip Arthroplasty in Patient with the Sequelae of Legg-Calvé-Perthes Disease

Purpose

Patients who have secondary hip osteoarthritis as sequelae of Legg-Calvé-Perthes disease (LCPD) are severe deformities of femoral head and acetabulum. A few studies have presented that the clinical results and risks associated with total hip arthroplasty (THA) for patients with a history of LCPD were not satisfactory. In this study, we reported the radiographic and clinical outcomes of THA in patients with sequelae of LCPD.

Materials and Methods

Between March 2007 and May 2012, 23 hips (23 patients) underwent cementless THA and were followed up at least 2 years after surgery. There were 11 male patients and 12 female patients with an average age of 49.2 years old (range, 25 to 69 years old), and the average follow up period was 40.8 months (range, 24 to 84 months). The clinical and radiological evaluations were performed.

Results

The Harris hip score improved from 48.3 points preoperatively to 92.4 points at the time of the last follow-up. The shortening of affected limb was improved from -1.6 cm to 0.2 cm. The complications included one case of sciatic nerve palsy that developed after extensive lengthening of lower extremity, three cases of intraoperative femur fractures. There was no component loosening.

Conclusion

Fractures and motor nerve palsies may be more frequent in this population. Careful preoperative planning should be performed to overcome the technical pitfalls. If overcoming this early complication, the clinical and radiological evaluations showed excellent outcomes at average 40-month follow-ups.

A simple method using a PACS to minimize leg length discrepancy in primary THA: a method to minimize leg length discrepancy

We determined whether a PACS-based method (head-lesser trochanter distance [HLD]) better equalized leg length discrepancy (LLD) after primary THA than a conventional method. We retrospectively reviewed 312 patients (379 hips) with osteonecrosis or primary osteoarthritis who underwent primary cementless THA: 198 patients (240 hips) underwent THA using the HLD method, while the conventional group consisted of 114 patients (139 hips) in whom we measured with the method of McGee and Scott. We then compared the LLDs in the two groups. We observed no difference in the mean postoperative LLD. A higher percentage of patients in the HLD group had an LLD less than 6 mm: 81% vs 68% hips, respectively. HLD method decreases the possibility of an LLD over 6mm after THA.

Exposure to heavy metals in blood and risk perception of the population living in the vicinity of municipal waste incinerators in Korea

BACKGROUND, AIM, AND SCOPE

The purpose of this study was to monitor and present the heavy metal concentrations in the blood of residents of areas near municipal waste incinerators (MWIs), who are more prone to environmental pollution. We also sought to compare and analyze the residents' perception of environmental pollution as one of the factors affecting heavy metal concentrations in the blood using a survey about the perceived damage caused by the facilities. Since heavy metal levels in the blood can be affected not only by local environmental pollution but also by personal and occupational factors, heavy metal levels in the blood need to be verified and consistently monitored.

METHODS

Residents who live within 300 m of MWIs in Seoul are acknowledged to be under indirect influence according to the Waste Disposal Act. A survey was given to 841 residents living within 300 m of a MWI from 2006 to 2009. The concentrations of heavy metals (lead, cadmium, and mercury) in the blood were measured in the 841 surveyed residents and in 105 residents in reference areas. Additionally, the perception of the damage caused by municipal waste incinerators was investigated using scores from 1 to 5 on a Likert scale.

RESULTS

The measurements of the heavy metal concentrations in the blood showed that the mean concentrations of lead, cadmium, and mercury were 43.1, 1.7, and 1.3 ug/L, respectively. The blood levels of lead and cadmium were slightly higher in the group of the subjects who had resided the longest near the municipal waste incinerators. When compared with the domestic investigation by the Ministry of Environment, the concentrations of lead and cadmium were a little higher, while that of mercury was a little lower. Overall, there was no significant difference in the distribution of heavy metal levels in the blood among age groups. Additionally, the investigation of the perceived damage from municipal waste incinerators showed that the subjects.

Evaluating the PM damage cost due to urban air pollution and vehicle emissions in Seoul, Korea

This study evaluated the prospective damage costs of PM(2.5) inhalation. We performed a health risk assessment based on an exposure-response function to estimate the annual population risk in the Seoul metropolitan city, Korea. Also, we estimated a willingness-to-pay (WTP) amount for reducing the mortality rate in order to evaluate a statistical life value. We combined the annual population risk and the value-of-statistical-life to calculate the damage cost estimate. In the health risk assessment, we applied the PM(2.5) relative risk to evaluate the annual population risk. We targeted an exposure population of 5,401,369 persons who were over the age of 30. Using a Monte-Carlo simulation for uncertainty analysis, we estimated that the population risk of PM(2.5) inhalation during a year in Seoul is 2181 premature deaths for acute exposure and 18,510 premature deaths for chronic exposure. The monthly average WTP for 5/1000 mortality reduction over ten years is $20.20 USD (95% C.I: $16.60-24.50) and the implied value-of-statistical-life (VSL) is $485,000 USD (95% C.I: $398,000-588,000). The damage cost estimate due to risk from PM(2.5) inhalation in Seoul is about $1057 million USD per year for acute exposure, and $8972 million USD per year for chronic exposure. It is important to note that this cost estimate does not reflect all health damage cost estimates in this urban area. This recommendation is a model for evaluating a mortality risk reduction and as such we must re-evaluate an integrated application of morbidity risk.

The Otto Aufranc Award: enhanced biocompatibility of stainless steel implants by titanium coating and microarc oxidation

BACKGROUND

Stainless steel is one of the most widely used biomaterials for internal fixation devices, but is not used in cementless arthroplasty implants because a stable oxide layer essential for biocompatibility cannot be formed on the surface. We applied a Ti electron beam coating, to form oxide layer on the stainless steel surface. To form a thicker oxide layer, we used a microarc oxidation process on the surface of Ti coated stainless steel. Modification of the surface using Ti electron beam coating and microarc oxidation could improve the ability of stainless steel implants to osseointegrate.

QUESTIONS/PURPOSES

The ability of cells to adhere to grit-blasted, titanium-coated, microarc-oxidated stainless steel in vitro was compared with that of two different types of surface modifications, machined and titanium-coated, and microarc-oxidated.

METHODS

We performed energy-dispersive x-ray spectroscopy and scanning electron microscopy investigations to assess the chemical composition and structure of the stainless steel surfaces and cell morphology. The biologic responses of an osteoblastlike cell line (SaOS-2) were examined by measuring proliferation (cell proliferation assay), differentiation (alkaline phosphatase activity), and attraction ability (cell migration assay).

RESULTS

Cell proliferation, alkaline phosphatase activity, migration, and adhesion were increased in the grit-blasted, titanium-coated, microarc-oxidated group compared to the two other groups. Osteoblastlike cells on the grit-blasted, titanium-coated, microarc-oxidated surface were strongly adhered, and proliferated well compared to those on the other surfaces.

CONCLUSIONS

The surface modifications we used (grit blasting, titanium coating, microarc oxidation) enhanced the biocompatibility (proliferation and migration of osteoblastlike cells) of stainless steel.

CLINICAL RELEVANCE

This process is not unique to stainless steel; it can be applied to many metals to improve their biocompatibility, thus allowing a broad range of materials to be used for cementless implants.

Degrading ability of oligocyclic aromates by Phanerochaete sordida selected via screening of white rot fungi

Seventy-nine white rot strains were screened to determine if they had the potential for use in the degradation of oligocyclic aromates (PAHs) by measuring their dye-decoloration rate. Fourteen strains that were selected based on their dye-decoloration rate were then evaluated for the ability to tolerate various levels of PAHs spiked in agar medium. The ability of white rot fungi to degrade 3- or 4-ring PAHs (anthracene, phenanthrene, fluoranthene, pyrene) was determined. Two strains of Phanerochaete sordida (KUC8369, KUC8370) were possible PAHs degraders, degrading a significantly greater amount of phenanthrene and fluoranthene than the culture collection strain P. chrysosporium (a known PAHs degrader). The production of manganese peroxidase, the only extracellular ligninolytic enzyme detected during the cultivation, was evaluated.

Postoperative mortality and factors related to mortality after bipolar hemiarthroplasty in patients with femoral neck fractures

The purpose of this study was to determine the mortality rate and factors related to mortality in elderly patients with acute and monotraumatic femoral neck fractures. This study included 241 patients with femoral neck fractures after bipolar hemiarthroplasty. We analyzed the mortality rate and the relationship between postoperative mortality and risk factors, such as age, sex, body mass index, the time to surgery, and the Society of Anesthesiologists' score. The postoperative mortality rate 1 and 3 years after surgery was 11.2% and 19.5%, respectively. There proved to be a relationship between postoperative mortality and age, the time to surgery, and the Society of Anesthesiologists score. We recommend that surgery should not be delayed, and caution should be exercised for the high-risk group patients.

Economic cost of osteoporotic hip fractures in Singapore

INTRODUCTION

The incidence of osteoporotic hip fractures in Singapore as well as in Asia will gradually increase with an ever ageing population. The objectives of this study were to understand the costs of hip fractures in our community and to analyse the various factors that lead to higher inpatient costs for hip fractures.

METHODS

We prospectively reviewed 80 elderly patients with osteoporotic hip fractures. The relevant patients' clinical data was correlated with the inpatient hospitalisation costs. We reviewed the cost and management practices of hip fractures published in the literature and compared them with our findings.

RESULTS

We found that our patients treated surgically incurred lower costs and had a shorter inpatient stay compared to those treated conservatively. The mean hospitalisation cost for patients treated surgically was S$10,515 and the mean length of stay was 16 days. We found that the length of stay, a longer delay to surgery, male gender, having ASA 3 score, and development of postoperative complications led to higher inpatient hospital costs.

CONCLUSION

With the identification of various clinical factors that are associated with high inpatient costs, we can further shorten our hip fracture patients' stay as well as reduce the hospitalisation costs.

Inadequate dietary calcium intake in elderly patients with hip fractures

INTRODUCTION

Calcium supplementation and pharmacotherapy are recommended in the preventive management of osteoporosis. Many previous studies report of underdiagnosis and undertreatment of osteoporosis among elderly patients with hip fractures. We undertook this study to determine the dietary calcium levels in our local elderly population who were admitted with hip fractures.

METHODS

77 patients, between the ages of 60 and 98 years of age, and admitted to our department between January 2001 and September 2001 for hip fractures, were studied. The dietary calcium intakes of these patients were determined by a food frequency questionnaire and a detailed diet history. Bone mineral density (BMD) studies were performed on 55 of these patients to confirm the diagnosis of osteoporosis.

RESULTS

The mean daily calcium intake was found to be 650 mg. Only six of our hip fracture patients (7.8 percent) had a daily calcium intake above the recommended levels of 1,000 mg per day. For the 55 patients who had BMD performed, only one patient had a BMD within the normal range. 34 patients (64.2 percent) had hip T-scores in the osteoporotic range and 18 patients (33.9 percent) had hip T-scores in the osteopenic range. We found that the patients with BMD in the osteoporotic and osteopenic ranges had no significant difference in the dietary calcium intake.

CONCLUSION

The dietary calcium intake of our elderly patients with hip fractures is insufficient. They would benefit from dietary education and calcium supplements to prevent deterioration in bone density and subsequent osteoporotic fractures.

PXR, CAR and HNF4alpha genotypes and their association with pharmacokinetics and pharmacodynamics of docetaxel and doxorubicin in Asian patients

Previously studied candidate genes have failed to account for inter-individual variability of docetaxel and doxorubicin disposition and effects. We genotyped the transcriptional regulators of CYP3A and ABCB1 in 101 breast cancer patients from 3 Asian ethnic groups, that is, Chinese, Malays and Indians, in correlation with the pharmacokinetics and pharmacodynamics of docetaxel and doxorubicin. While there was no ethnic difference in docetaxel and doxorubicin pharmacokinetics, ethnic difference in docetaxel- (ANOVA, P=0.001) and doxorubicin-induced (ANOVA, P=0.003) leukocyte suppression was observed, with Chinese and Indians experiencing greater degree of docetaxel-induced myelosuppression than Malays (Bonferroni, P=0.002, P=0.042), and Chinese experiencing greater degree of doxorubicin-induced myelosuppression than Malays and Indians (post hoc Bonferroni, P=0.024 and 0.025). Genotyping revealed both PXR and CAR to be well conserved; only a PXR 5'-untranslated region polymorphism (-24381A>C) and a silent CAR variant (Pro180Pro) were found at allele frequencies of 26 and 53%, respectively. Two non-synonymous variants were identified in HNF4alpha (Met49Val and Thr130Ile) at allele frequencies of 55 and 1%, respectively, with the Met49Val variant associated with slower neutrophil recovery in docetaxel-treated patients (ANOVA, P=0.046). Interactions were observed between HNF4alpha Met49Val and CAR Pro180Pro, with patients who were wild type for both variants experiencing least docetaxel-induced neutropenia (ANOVA, P=0.030). No other significant genotypic associations with pharmacokinetics or pharmacodynamics of either drug were found. The PXR-24381A>C variants were significantly more common in Indians compared to Chinese or Malays (32/18/21%, P=0.035) Inter-individual and inter-ethnic variations of docetaxel and doxorubicin pharmacokinetics or pharmacodynamics exist, but genotypic variability of the transcriptional regulators PAR, CAR and HNF4alpha cannot account for this variability.

True digital artery aneurysm of the ring finger: a case report

True aneurysms of the digital artery are very rare. Only 13 cases, caused by chronic trauma from occupational or sports-related overuse, have been reported. We present the first case of a true aneurysm of the digital artery of the left ring finger caused by chronic repetitive trauma from a wedding ring. The patient was a 44-year-old teacher who presented with a 1.5-cm subcutaneous mass on the radial aspect of the proximal phalanx of the finger, just proximal to the proximal interphalangeal joint. Exploration of the mass revealed a 1-cm aneurysm continuous with the radial digital artery. The aneurysm was excised and the proximal and distal ends of the radial digital artery ligated. Microscopic examination of the excised specimen confirmed the diagnosis of a true aneurysm with the lumen filled with an organising thrombus. The patient had an uneventful recovery with good wound healing, intact sensation, and normal capillary return.

Hereditary neuropathy with liablity to pressure palsies

Hereditary neuropathy with liability to pressure palsies (HNPP) is a disease that presents with recurrent reversible episodes of neurapraxia that occur typically after trivial trauma. It is an autosomal dominant, demyelinating neuropathy. A 20-year-old man presented with left ulnar nerve palsy after a fall. He had reduced two-point discrimination over his left ulnar nerve distribution, with mild clawing of the ring and little fingers, and accompanying weakness of the first dorsal interrosseus and abductor digiti minimi of grade four power. His Froment's sign was also positive. Careful clinical examination and appropriate tests, including electromyography and genetic testing, confirmed the diagnosis of HNPP. This case report is presented to promote awareness and recognition of this disease in the local and regional context.

Diabetic muscle infarction of the peroneus brevis: a case report

Diabetic muscle infarction of the peroneus brevis is a rare complication of diabetes mellitus. It often presents with an acute leg pain without any obvious signs. Due to poor awareness of this condition, it is often misdiagnosed and results in anxiety of the patient and unnecessary investigations. It is ominous as it usually indicates vascular disease of the end organs. We report a case where the patient presented to several physicians for leg pain without any other clinical signs. The diagnosis was suspected on ultrasound and confirmed with biopsy. The symptoms improved dramatically after excision. Although most literature suggests conservative treatment by non-weight bearing and analgesia, the recovery period can last for more than 6 weeks, with a recurrence rate of 50%. We feel that there is a role for excision biopsy of the lesion for both diagnosis and treatment. In this case, symptoms improved remarkably and the patient was able to ambulate without pain 2 days after the operation without needing any analgesia.

Broadband ultrasound attention reference database for southeast Asian males and females

INTRODUCTION

The objective of this study was to establish the broadband ultrasound attenuation (BUA) measurements of the calcaneum for Southeast Asian males and females. A database was used to draw the reference curve for the Southeast Asian male and female population.

MATERIALS AND METHODS

The database included 366 healthy females and 236 healthy males. We measured the BUA values of the left heel using the Contact Ultrasound Bone Analyser (CUBA) clinical system.

RESULTS

The mean difference between Southeast Asian males and Caucasian males was 9.3 dB MHz-1 and that for females was 5.0 dB MHz-1. The standard deviations (SDs) for Southeast Asian female and male normative values were 17.43 and 20.10, respectively. This is comparable with the SD for the McCue Caucasian female and male normative data of 16.54 and 17.45 respectively.

CONCLUSION

The study shows that the Southeast Asian population has a significantly lower normative value than the Caucasian population. This BUA reference database obtained will allow for more accurate determination of Southeast Asian patients at risk of osteoporosis.

Post-poliomyelitis syndrome: case report and review of the literature

INTRODUCTION

Postpoliomyelitis syndrome (PPS) refers to the new neuromuscular symptoms that occur in patients years after their acute poliomyelitis has stabilised. PPS cases seen now are probably related to the poliomyelitis epidemics of the 1940s and 1950s.

CLINICAL PICTURE AND INVESTIGATION

A 57-year-old Chinese man with a history of poliomyelitis affecting both lower limbs presented with left upper limb weakness. Physical examination revealed atrophy of his left upper limb muscles. There were fasciculations in the biceps and brachioradialis muscles. Electromyography revealed ongoing denervation neurogenic units in the C5 to TI myotomes comparable with PPS.

CONCLUSION

The aim of this paper is to review the present situation and to give a short summary of PPS, which can be difficult to diagnose because the symptoms of presentation are usually non-specific. We describe a case of PPS and review the current literature.

Mortality after proximal hip fracture in the Singapore population

The aims were to prospectively assess the mortality risk following proximal hip fractures, identify factors predictive of increased mortality and to investigate the time trends in mortality with comparison to previous studies. Prospectively collected data from 68 consecutive patients who had been admitted to a regional hospital from May 2001 to September 2001 were reviewed. The mean age of the patients was 79.3 years old (range, 55-98) and 72.1% females. Patients were followed prospectively to determine the mortality risk associated with hip fracture over a two-year follow-up period. The acute in-hospital mortality rate at six months, one year and two years was 5.9% (4/68), 14.7% (10/68), 20.6% (14/68) and 25% (17/68) respectively. One-year and two-year mortality for those patients who were 80 or older was significantly higher than for other patients and the number of co-morbid illnesses also had significant effect. Cox regression was performed to determine the significant predictors for survival time. It was noted that patients 80 years or older were at higher risk of death compared with those less than 80 years as well as those with higher number of co-morbid illnesses. Our mortality rates have not declined in the past 10 years when compared with previous local studies. We conclude that for this group of patients studied, their mortality at one year and two years could be predicted by their age group and their number of co-morbid illnesses. (Hip International 2005; 15: 166-70).

Treatment of benign giant cell tumours of bone in Singapore

INTRODUCTION

Giant cell tumour (GCT) is a distinct neoplasm of undifferentiated cells. The exact cell of origin is unknown. The multinucleated giant cells present are formed from the fusion of mononuclear cells. Giant cell tumour is more common in Southeast Asia than in the West. The incidence is about 20% compared to 4% to 5% in the West.

MATERIALS AND METHODS

Sixteen patients with giant cell tumour were treated in the Singapore General Hospital from 1993 to 2001. The average follow-up period was 64.4 months, with a range of 30 to 132 months. The average age of the patients was 33 years. The tumours were divided into 3 groups. The first group had meticulous curettage and high-speed burring followed by methylmethacrylate cementation. The second group had treatment similar to the first but in addition had an adjuvant treatment with liquid nitrogen, hydrogen peroxide or phenol before cementation of the cavity. The third group had wide resection done. There were 9 in the first group, 5 in the second group and 2 in the third group. The tumours were graded radiologically after the method of Campanacci et al. All patients were followed up clinically and radiologically. Of the 5 in the second treatment group, 1 had phenol irrigation, 2 had cryotherapy and 2 had hydrogen peroxide irrigation intraoperatively.

RESULTS

There was a total of 5 recurrences (31%). The 2-year recurrence-free survivorship was 75%. The mean recurrence period was 21 months. There were no complications like fracture, infection or thermal injury to the skin. There was no pulmonary metastasis or mortality. The first group, who had curettage, high-speed burr and cementation, had 44% (4 out of 9) recurrence; the second group, who had treatment like the first with additional adjuvant therapy, had no recurrence; and the third, who had wide resection, had 50% (1 out of 2) recurrence. All the recurrences had a Campanacci grade II or III tumour. There were no recurrences in the group that was treated with curettage, high-speed burr, adjuvant treatment and cementation.

CONCLUSION

Currettage, high-speed burring with added phenol/liquid nitrogen treatment and cementation is a useful and safe method in the treatment of giant cell tumours. The advantages include a low recurrence rate, as well as immediate stabilisation allowing early mobilisation. Patients who have Campanacci grade I tumours have the highest chance of being disease-free after the first operation.

Deep vein thrombosis following hip fracture and prevalence of hyperhomocysteinaemia in the elderly

INTRODUCTION

The prevalence of deep vein thrombosis (DVT) in the West is reported to be as high as 50% after hip surgery. A study performed 14 years ago showed the incidence in Singapore to be <10%. Lately, some case-control and cross-sectional studies have suggested hyperhomocysteinaemia as an independent risk factor for DVT. This study investigates the local incidence of DVT and plasma hyperhomocysteinaemia in elderly patients presenting with proximal hip fracture.

MATERIALS AND METHODS

We recruited 104 consecutive patients from April 2001 to November 2001 who satisfy certain criteria. Firstly, patients of both genders who were >55 years old with radiological diagnosis of neck of femur fracture, intertrochanteric or subtrochanteric fracture. Secondly, these patients must not have any haemorrhagic or thrombogenic disease. Thirdly, patients were not given folate and B complex pre- or postoperation. Duplex ultrasound was then done for these patients on the 5th to 7th postoperative day.

RESULTS

The incidence of DVT above the trifurcation was 7.7%, no incidence of pulmonary embolism (PE) was detected. The incidence of hyperhomocysteinaemia was 52.3%.

CONCLUSIONS

The incidence of DVT in the local population after proximal hip fracture is much lower than in the West. The use of DVT prophylaxis in Asians should be selective to avoid incurring extra cost and its associated morbidity. Case-control studies and cross-sectional studies clearly indicate that hyperhomocysteinaemia is an independent risk factor for venous thrombosis. Given the high incidence of hyperhomocysteinaemia in our elderly with hip fracture, the prophylactic correction of hyperhomocysteinaemia with folate and vitamin B supplements is justified.

Information superhighway or billboards by the roadside? An analysis of hospital web sites

OBJECTIVES

To determine the prevalence of hospital web sites, the types of information provided within these sites, and the relationship of information to institutional characteristics.

DESIGN

Online search of hospital web sites over a 6-week period in late 1999. Web sites were abstracted for content. Bivariate comparisons were made of hospital profit status and ownership or operation by a multihospital network.

PARTICIPANTS

California acute care hospitals and their web sites.

MAIN OUTCOME MEASURES

Operation of web sites and web site content.

RESULTS

Among 390 California hospitals, 242 (62%) had easily identifiable web sites, 59 (15%) had no web sites, and 89 (23%) had sites identified only after telephone follow-up. Hospitals without sites were more likely not-for-profit, small, rural, or unaffiliated. The presentation of information was inconsistent, although most (93%) provided basic contact information. Many hospitals provided health content information (70%) or mentioned health classes (65%), but few guaranteed the quality of this information. Patient care features (online health profiles, risk identification, e-mail) were infrequent (13%) and rudimentary. Product advertising was frequent (54%) but was often nonhealth-related and unobtrusive. Of the 36% of hospitals that reported information on quality, few of the designated measures were valid and reliable measures of quality. Overall, 21% of hospitals reported accreditation (Joint Commission on Accreditation of Healthcare Organizations) status, and for-profit hospital web sites were more likely to report this accreditation.

CONCLUSION

[corrected] Consumers should be aware of current limitations in using information on hospital web sites. In the future, hospitals may better realize the potential of web sites for the delivery of health care information and patient care.

A case report of mycobacterium marinum infection of the hand

We report a case of Mycobacterium marinum infection of the hand presenting initially as triggering of the digits. We like to highlight the unusual source of the infection and difficulty of diagnosis in this case as well as the various treatment modalities.

Asthma self care efficacy and morbidity in polyclinic outpatients

The new guidelines for the management of asthma require patients to participate in the management of their condition by exercising a high level of decision-making skills in self treatment. We evaluated the self care efficacy and morbidity of 198 asthmatic patients in primary care clinics and examined the factors likely to influence these management outcomes. About 70% of the patients were considered by conventional criteria to have significant morbidity requiring medical supervision. The most significant factors determining morbidity were knowledge of medications and attack management skills. Only a minority of the patients had satisfactory levels of these skills and knowledge. A high level of stigmatization from asthma was generally present among the patients but most of them appeared to possess a high level of self-confidence in the management of their asthma. These factors were also associated with asthma morbidity, but they were as likely to have resulted from morbidity as to have influenced it. The patients' attitude towards medications were mostly negative but their confidence in their doctors and their level of family support were high; none of these factors, however, were associated with morbidity. Attack management skills as a behavioural measure of self care efficacy was not significantly predicted by any of these personal or psychosocial factors. A practical implication of these findings is that asthma self management should focus on developing specific knowledge and skills in the self treatment of asthma attacks.

An analysis of risk factors for the prediction of shoulder dystocia in 16,471 consecutive births

This paper is a univariate analysis of the demographic, antepartum and intrapartum risk factors in a series of 16,471 consecutive deliveries in a tertiary obstetric and gynaecological unit in Singapore. In total, 12,229 term vaginal cephalic deliveries with 77 cases of shoulder dystocia were entered into the study for analysis. The incidence of shoulder dystocia was found to be 0.63% of all term vaginal cephalic deliveries. There is a direct relationship between increasing infant birthweight and incidence of shoulder dystocia. The critical birthweight for the prediction of shoulder dystocia is 3600 g. In order of decreasing relative risks, the factors which appear to be predictive of shoulder dystocia are a birthweight in excess of 3600 g, diabetes in pregnancy, lower social class, of Indian origin, maternal weight in excess of 70 kg, parity more than 4, and the use of oxytocics during labour. The local birthweight distribution is very different from the West. A policy for elective caesarean section for birthweights in excess of 4000 g (97% tile) would prevent 44% of shoulder dystocias, increase the caesarean section rate by 2% and half the perinatal mortality among births with shoulder dystocia.