The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. Americans Associations for Neurologic Surgeons

BACKGROUND

Traumatic brain injury poses a serious public health challenge. Treatment paradigms have dramatically shifted with the introduction of the American Association of Neurologic Surgeons (AANS) Guidelines for the Management of Severe Head Injury. Implementation of the AANS guidelines positively affects patient outcomes and can be successfully introduced in a community hospital setting.

METHODS

Data were collected both retrospectively and prospectively from the records of all trauma patients between 1994 and 1999. A cohort of 93 patients was selected. Thirty-seven patients were treated before the implementation of the AANS guidelines, and these were statistically compared with 56 patients treated after the implementation of the guidelines.

RESULTS

Implementation of the recommendations in the AANS guidelines in a standardized protocol resulted in a 9.13 times higher odds ratio of a good outcome relative to the odds of a poor outcome or death compared with a group managed before the practice change. A Glasgow Coma Scale (GCS) admission score > 8 was associated with a 6.58 times higher odds ratio of a good outcome compared with a GCS admission score < or = 8. Odds ratio of a good outcome decreased by a factor of 0.92 for each year increase in age of patients starting at age 9. A dedicated neurotrauma team and comprehensive treatment algorithms are critical elements to this success. Hospital charges increased by more than $97,000 per patient, but are justifiable in the face of significantly improved outcomes.

CONCLUSION

Implementation of a traumatic brain injury protocol in a community hospital setting is practical and efficacious. Appropriate invasive monitoring of systemic and cerebral parameters guides care decisions. The protocol results in an increase in resource usage, but it also results in statistically improved outcomes justifying the increase in expenditures.

Inhibition of DMBA-induced mammary cancer by the monoterpene d-limonene

We investigated whether the addition of d-limonene to the diets of rats would modify the process of mammary tumor induction by 7,12-dimethylbenz[a]anthracene (DMBA). When diets containing 1000 or 10 000 p.p.m. d-limonene were fed to rats from one week before DMBA administration to the end of the experiment (27 weeks post DMBA treatment), a significant reduction in mammary carcinogenesis was observed at each level. The inhibition of carcinogenesis was mainly due to an increase in latency; however, major differences in incidence could be seen during the follow-up period. For example, rats fed 10 000 p.p.m. of d-limonene had a 72% reduction in mammary tumors when compared to controls at 18 weeks post DMBA treatment. In addition to inhibiting the appearance of mammary tumors, d-limonene was also found to cause the regression of frank mammary tumors. No toxicity was evident in these rats even at the highest d-limonene dose. Control and all treated rats gained weight at the same rate throughout the experiment. In addition, no differences were found in their peripheral blood counts (Hct, total white cell and differential count).

Expression of an extracellular calcium-sensing receptor in rat stomach

BACKGROUND & AIMS

Circulating levels of Ca2+ can influence secretory functions and myoelectrical properties of the stomach. A Ca2+-sensing receptor (CaR) has recently been identified in tissues that regulate systemic Ca2+ homeostasis. The aim of this study was to evaluate expression of CaR in the stomach of the rat.

METHODS

In forestomach and glandular stomach, reverse-transcription polymerase chain reaction was used to amplify a 380-base pair product, which is 99% homologous with transcripts obtained in parathyroid and kidney.

RESULTS

Northern analysis of gastric mucosal polyA+ RNA revealed 7. 5- and 4.1-kilobase transcripts, similar to those obtained in rat parathyroid and kidney. Immunohistochemistry revealed CaR expression in regions of the submucosal plexus and myenteric neurons. In sections of intact tissue, preparations of primary culture surface cells and surgically dissected gastric glands, staining was observed consistently in epithelial cells of the gastric glands and in gastric surface cells. In parietal cells in isolated gastric glands, intracellular levels of Ca2+ responded to conditions that are known to activate CaR.

CONCLUSIONS

These are the first reported observations that CaR is expressed in different epithelial cells of mammalian gastric mucosa and its enteric nerve regions. The effects of extracellular Ca2+ on gastric function may be attributable to activation of CaR.

An uncoupling protein 2 gene variant is associated with a raised body mass index but not Type II diabetes

AIMS/HYPOTHESIS

Linkage between markers close to the uncoupling protein 2 and 3 genes (11q13) and resting metabolic rate and a pre-diabetic phenotype have been found. The syntenic region in mouse has been found to be linked to quantitative traits associated with obesity and diabetes. UCP2 and UCP3 could therefore have an important role in body weight regulation and susceptibility to diabetes. We investigated a recently identified variant of the UCP2 gene in exon 8 as a marker for glucose and weight homeostasis.

METHODS

Length variation of the UCP2 exon 8 variant was studied by the polymerase chain reaction and agarose gel electrophoresis. Sequence variants of the UCP3 gene were sought by semi-automated DNA sequencing.

RESULTS

In 453 South Indian subjects, we found an association in women between the UCP2 exon variant and body mass index (p = 0.018). These findings were replicated in a separate group of South Indian subjects (n = 143, p < 0.001) irrespective of sex. Although no association was found between the UCP2 exon 8 variant and overt obesity in British subjects, the UCP2 genotype of obese women (n = 83) correlated with fasting serum leptin concentration (p = 0.006) in the presence of extreme obesity. These observations could not be explained by tight linkage disequilibrium with a coding region variant in the region of the UCP3 gene of biological significance. Lastly, no association was found between UCP2 and Type II (non-insulin-dependent) diabetes using either a family based design (85 families) or case control study (normal glucose tolerance n = 335, impaired glucose tolerance n = 42, Type II diabetes n = 76).

CONCLUSION/INTERPRETATION

We have described a UCP2 gene exon 8 variant that may affect susceptibility to weight gain by influencing regulation of leptin.

Multicentre prospective cohort study of body mass index and postoperative complications following gastrointestinal surgery

BACKGROUND

There is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.

METHODS

This was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4-month interval (October-December 2014) were eligible for inclusion. The primary outcome was the 30-day major complication rate (Clavien-Dindo grade III-V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital-level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).

RESULTS

Of 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30-day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).

CONCLUSION

Overweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.

Loading of Cefixime to pH sensitive chitosan based hydrogel and investigation of controlled release kinetics

Chitosan (biopolymer) and polyvinyl pyrolidone (PVP) with aminopropyletriethoxy silane (cross linker) based hydrogels were prepared and tested for controlled drug release. The drug release and kinetics were studied as a function of pH. Formulations were characterized by Fourier Transform Infrared (FTIR) and Thermogravimetric (TGA) analysis and TAP 32 hydrogel formulation was the most stable and hydrogel samples showed promising antibacterial activity against E. coli strain. The maximum swelling (4386%) was observed for TAP 32 formulation in distilled water, which was decreased with the concentration of ions. The diffusion exponent (n) values of all hydrogel formulations were recorded to be <0.5, which is an indication of Quasi-Fickian diffusion. The maximum swelling was observed at pH 2 and decreased at higher pH. The pH sensitivity of hydrogels found to be promising for their use in drug delivery, which was tested for cefixime drug. Drug release of 81.6% was observed for the period of 12 h in a simulated gastric fluid (SGF). The values of R² for zero order, first order, Higuchi, Hixson, Korsmeyer-Peppas and Baker-Lonsdale were 0.97, 0.9818, 0.99, 0.99, 0.88 and 0.80, respectively. The hydrogels based on chitosan and PVP revealed potential for controlled cefixime drug release in gastric pH medium.

Production of formaldehyde and acetone by hydroxyl-radical generating systems during the metabolism of tertiary butyl alcohol

t-Butyl alcohol is not a substrate for alcohol dehydrogenase or for the peroxidatic activity of catalase and, therefore, it is used frequently as an example of a non-metabolizable alcohol. t-Butyl alcohol is, however, a scavenger of the hydroxyl radical. The current report demonstrates that t-butyl alcohol can be oxidized to formaldehyde plus acetone by hydroxyl radicals generated from four different systems. The systems studied were: (a) two chemical systems, namely, the iron catalyzed oxidation of ascorbic acid and the Fenton reaction between H2O2 and iron; (b) an enzymatic system, the coupled oxidation of xanthine by xanthine oxidase; and (c) a membrane-bound system, NADPH-dependent microsomal electron transfer. The oxidation of t-butyl alcohol appeared to be mediated by hydroxyl radicals, or by a species with the oxidizing power of the hydroxyl radical, because the production of formaldehyde plus acetone was (a) inhibited by competing scavengers of the hydroxyl radical; (b) stimulated by the addition of iron-EDTA; and (c) inhibited by catalase. The last observation suggests that H2O2 served as the precursor of the hydroxyl radical in all three systems. A possible mechanism is hydrogen abstraction to form the alkoxyl radical [CH3)3-C-O.), spontaneous fission of the alkoxyl radical to produce acetone and the methyl radical (CH3.), interaction of the methyl radical with O2 to form the methyl peroxy radical (CH300.), and decomposition of the later to formaldehyde. These results extend the alcohol oxidizing capacity of the microsomal alcohol oxidizing system to a tertiary alcohol. Since t-butyl alcohol is not a substrate for alcohol dehydrogenase or catalase, the ability of microsomes to oxidize t-butyl alcohol lends further support for a role for hydroxyl radicals in the microsomal alcohol oxidation system. In view of the production of formaldehyde, and the reactivity as well as further metabolism of this aldehyde, caution should be used in interpreting experiments in which t-butyl alcohol is used as a presumed "non-metabolizable" alcohol. t-Butyl alcohol may be a valuable probe for the detection of hydroxyl radicals in intact cells and in vivo.

Chromosome 9 related aberrations and deletions of the CDKN2 and MTS2 putative tumor suppressor genes in human chondrosarcomas

Deletions on the short arm of chromosome 9 (9p21 region) have been reported in a number of hematopoietic and solid tumors. These aberrations on 9p have been previously associated with the loss of the interferon gene cluster and the gene for methylthioadenosine phosphorylase (MTAP), localized to the 9p21-22 region. Recently, two putative tumor suppressor gene(s) CDKN2 and MTS2 have been mapped to the 9p21 region, and shown to be deleted in a large number of tumors including leukemias, melanomas, bladder cancers and brain tumors. We have previously reported a similar 9p21 abnormality and deletions of the CDKN2 and MTS2 genes in a myxoid chondrosarcoma cell line and its subclones. In this study we report consistent abnormalities of chromosome 9 in additional chondrosarcomas examined by a detailed cytogenetic and molecular analysis. Seven chondrosarcoma cell lines, one primary chondrosarcoma, and a benign chondroma were examined. Four of the seven tumor cell lines examined showed grossly visible aberrations of chromosome 9. Molecular analysis of these chondrosarcoma cell lines revealed hemizygous deletions of the interferon genes, and the absence of the MTAP gene, protein or activity. In addition, four of the seven chondrosarcoma cell lines also showed deletions of the CDKN2 and/or MTS2 putative tumor suppressor genes, or the absence of the CDKN2 protein product. No such chromosome 9 related aberrations were detected in the benign chondroma. These data suggest that chromosome 9p21 abnormality, and deletions of the CDKN2 and MTS2 tumor suppressor genes may be a significant event in the development of chondrosarcomas.

Stenotrophomonas maltophilia contamination of nebulizers used to deliver aerosolized therapy to inpatients with cystic fibrosis

There is circumstantial evidence that nebulizer equipment may be a source of Stenotrophomonas maltophilia for patients with cystic fibrosis. Eighty-nine inpatient nebulizers were examined for evidence of S. maltophilia contamination of which nine (10%) yielded 14 strains of the bacterium. Environmental samples were obtained from 73 different sites on the ward, of which 17 (23%) yielded a further 21 strains. Positive sites included taps, sink drains, and potable water. Genotyping using ERIC-PCR and pulsed-field gel electrophoresis revealed that two pairs of patients' nebulizers were contaminated with closely related strains. None of the S. maltophilia isolates obtained from the ward environment shared genotypes with those obtained from the nebulizers. The frequency of isolation of S. maltophilia from potable water sources on the ward suggests that contamination may result from using it to clean reusable nebulizer equipment, particularly if this is followed by inadequate drying. Although the actual source of S. maltophilia contamination of hospital-use nebulizer equipment in this study remained elusive, these results have important infection control implications.

Emergencies in the air

Medical emergencies in the air are topical. This study, undertaken by the Faculty of Prehospital Care at the Royal College of Surgeons of Edinburgh, analyses retrospectively consecutive medical emergencies occurring over a 6 month period on a single major international airline. Clinical problems are related to pre-existing problems (65%), new medical problems (28%), and traumatic injury (7%). The paper highlights the need for better pre-flight health advice and screening, a reminder to carry personal medication-especially for asthma-and the need to include ankle and leg exercises prior to getting out of the seat to reduce the incidence of syncope, which was responsible for 91% of new medical problems.

Selective cholangiography in laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now the method of choice for removing the diseased gallbladder. Asymptomatic common bile duct stones occur in approximately 6 per cent of patients. Controversy exists, however, as to whether selective or routine peroperative cholangiography should be performed during laparoscopic cholecystectomy. Over a 21-month period 300 consecutive laparoscopic cholecystectomies without routine cholangiography were attempted. There were 28 conversions. In all, 229 patients did not undergo cholangiography and in this group there were two common duct injuries. These were both identified and dealt with by open operation. Five patients underwent peroperative cholangiography, none of whom was found to have common duct pathology. Endoscopic retrograde cholangiopancreatography was performed in 38 patients. Of 27 who had this investigation performed before operation, common duct stones were diagnosed in seven (26 per cent). Two common duct stones were discovered in 11 patients who underwent the investigation after operation. Thus only two of 240 patients (0.8 per cent) who did not undergo preoperative or peroperative cholangiography subsequently had symptomatic duct stones. Peroperative cholangiography may be indicated in selected patients who have had symptoms of common bile duct stones or in those in whom the biliary anatomy is unclear. However, routine preoperative or peroperative cholangiography is unnecessary during laparoscopic cholecystectomy.

Kinetics and controlled release of lidocaine from novel carrageenan and alginate-based blend hydrogels

The controlled release of drug from drug carrier has been a point of concern for the researchers to ensure the bioavailability of drug with reduced side effects. The formulation in this study is based upon biopolymers; carrageenan (CG), sodium alginate (SA) and various molecular weights of polyethylene glycol (PEG), cross-linked with (3-Aminopropyl)triethoxysilane, APTES for the sustained release of model drug (lidocaine). The physicochemical properties of the formulated hydrogel blends include bonding pattern (using Fourier Transform Infra-Red Spectroscopy (FTIR), Thermogravimetric analysis (TGA), X-ray diffraction (XRD), swelling study, antimicrobial activity and morphology of hydrogel films was analyzed by scanning electron microscopy (SEM). The as-prepared hydrogels show an improved cell compatibility against 3T3 cell line as well as cell proliferation and kinetics of drug release showed that these hydrogels are potential for controlled release of lidocaine, a numbing agent. GAP 60 exhibited maximum swelling percent (910%) and was employed to load the drug. By using in vitro model, the drug release was studied in PBS solution. Non-Fickian and other kinetic models (Zero order, Higuchi, Hixson, Korsmeyer Peppas and Baker-Lonsdale) for diffusion were followed in results. The improved properties showed that the formulated hydrogels can easily be used for the sustain drug release studies.

Effect of rituximab on peripheral blood stem cell mobilization and engraftment kinetics in non-Hodgkin's lymphoma patients

Rituximab is used for in vivo tumor cell purging for non-Hodgkin's lymphoma (NHL) patients prior to autologous peripheral blood stem cell transplantation (PBSCT). However, its effects on PBSC mobilization and function are poorly understood. We compared the mobilization characteristics and engraftment kinetics of 13 NHL patients receiving and 34 NHL patients not receiving rituximab 6 months before PBSC mobilization. In the rituximab group, there was a significantly longer time to neutrophil engraftment (P=0.0466), a trend toward the need for BM harvest to supplement low-yield PBSC collections (31 vs 9%, P=0.08) and a significantly increased rate of bacteremia episodes (62 vs 26%, P=0.025). Median progression-free survival (PFS) and overall survival (OS) were significantly longer in the rituximab compared to the nonrituximab patients (P=0.049 and 0.042, respectively). However, patients in the nonrituximab group were at high risk for recurrence and expected to have shorter survival. Rituximab used within 6 months prior to collection may have a detrimental effect on PBSC mobilization and engraftment. However, rituximab is a major therapeutic breakthrough for NHL treatment and this negative effect may be offset by improved survival. Further studies are warranted in larger populations to determine the impact of rituximab on engraftment, PFS and OS.

Alcohol intake and risk of nonmelanoma skin cancer: a systematic review and dose-response meta-analysis

Nonmelanoma skin cancer (NMSC) comprises mainly basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). The association between alcohol intake and NMSC has been inconclusive; therefore the objective of this study is to quantify the relationship between alcohol intake and NMSC using meta-analyses. A systematic literature search of PubMed and Embase was performed on 30 October 2016. Eligible articles were case-control or cohort studies that examined alcohol intake and risk of BCC or cSCC and reported relative risks (RRs) with 95% confidence intervals (CIs). Of the 307 articles identified, 13 case-control and cohort studies were included in the systematic review, including 95 241 NMSC cases (91 942 BCC and 3299 cSCC cases). A random-effects model was used to obtain summary RRs and 95% CIs for dose-response meta-analyses. For every 10-gram increase in ethanol intake per day, a positive association was found for both BCC (summary RR of 1·07; 95% CI 1·04-1·09) and cSCC (summary RR of 1·11; 95% CI 1·06-1·16). While there was evidence suggesting a nonlinear association for BCC, it may be due to the sparse data at higher alcohol intake levels. This meta-analysis found evidence that alcohol drinking is positively associated with both BCC and cSCC risk in a dose-dependent manner. These results should be interpreted with caution due to potential residual confounding. Nonetheless, because alcohol drinking is a prevalent and modifiable behaviour, it could serve as an important public health target to reduce the global health burden of NMSC.

Comparative audit of intravenous lorazepam and diazepam in the emergency treatment of convulsive status epilepticus in children

There is little evidence on which to judge the optimal treatment for convulsive status epilepticus (CSE) in children. This study compares the effect of intravenous (iv) lorazepam with iv diazepam as the first line of treatment of CSE. We studied all children with prolonged seizures arriving in the Accident and Emergency (A&E) Department in two separate periods. In the first 6-month period iv diazepam was used as standard treatment, in the second 1-year period iv lorazepam was used. We measured latency to stopping of seizure and any adverse events. A successful treatment was defined as one in which the seizure clinically ceased within 15 minutes after siting the iv cannula, requiring no further treatment.Intravenous diazepam (0.32 mg kg (-1)) was used in 17 of 26 patients, whilst iv lorazepam (0.13 mg kg (-1)) was used in 31 of 59. There were no differences between the two groups regarding age, sex and seizure type.The seizure was successfully controlled 15 minutes after siting the iv cannula in 11 (65%) patients treated with diazepam (median time of 3 minutes) and in 20 (65%) patients treated with lorazepam (median time of 5 minutes). These preliminary results suggest that iv lorazepam may be as effective as iv diazepam.

Human immunodeficiency virus-1 infection requires pertussis toxin sensitive G-protein-coupled signalling and mediates cAMP downregulation

The human immunodeficiency virus-1 (HIV-1) utilises CD4 and certain beta-chemokine receptors, mainly CCR-5 and CXCR4, for attachment and virus entry into T-lymphocytes and monocytes/macrophages. CD4 and beta-chemokine receptors participate in intracellular signalling via protein tyrosine kinases and G-protein-coupled signalling. The factors which influence HIV-1 replication and the intracellular signalling mechanisms elicited by the virus are not well understood. In this study, it was demonstrated that exposure of peripheral blood lymphocytes (PBLs) to a T-cell tropic strain of HIV-1 evokes signal(s) which results in downregulation of intracellular cAMP. In addition, pre-incubation of PBLs with the Gi-protein inhibitor Pertussis toxin mediated a significant inhibition of HIV-1 replication. These data strongly suggest that HIV-1 employs CD4 receptors and Gi-coupled proteins for entry into target cells and that productive HIV-1 infection is dependent on an active signalling event.

Role of catalase and hydroxyl radicals in the oxidation of methanol by rat liver microsomes

In view of the presence of adventitious catalase in isolated microsomes, and the requirement for H2O2, it has been suggested that NADPH-dependent oxidation of methanol by rat liver microsomes was mediated exclusively by the peroxidatic activity of catalase. However, H2O2 may also serve as a precursor of the hydroxyl radical, and methanol reacts with hydroxyl radicals to produce formaldehyde. Inhibition of H2O2 production should therefore decrease methanol oxidation by either a hydroxyl radical-dependent pathway or a catalase-dependent pathway. To attempt to clarify some of the controversies concerning the roles of H2O2 and catalase in the microsomal pathway of oxidation of short chain alcohols, studies were carried out to determine the nature of the pathway responsible for methanol oxidation by isolated microsomes. In the absence of the catalase inhibitor azide, methanol may be oxidized primarily by the peroxidatic activity of catalase since there was little effect on methanol oxidation by competing hydroxyl radical scavengers. Azide, which inhibited catalase activity greater than 95%, inhibited NADPH-dependent oxidation of methanol by 30-50%. The azide-insensitive (catalase-independent) pathway of methanol oxidation was inhibited by scavengers of hydroxyl radicals. The inhibition of the scavengers reflected the rate constant for interaction with hydroxyl radicals and was greater at lower concentrations of methanol than at higher concentrations, suggesting competition between the scavengers and methanol. The addition of H2O2 stimulated the oxidation of methanol in the presence of azide; H2O2 may serve as a precursor of the hydroxyl radical. Iron-EDTA, which is known to increase hydroxyl radical production, stimulated the oxidation of methanol in the absence and presence of azide. The stimulation by iron-EDTA was blocked by the competing hydroxyl radical scavengers even in the absence of azide, suggesting that the added iron-EDTA favorably with microsomal catalase for H2O2 to produce hydroxyl radicals (or a species with the oxidizing power of the hydroxyl radical). These results suggest that in microsomes, depending on the absence or presence of azide, methanol may be oxidized by two primary pathways, one involving the peroxidatic activity of catalase, and the other in which hydroxyl radicals, generated from microsomal electron transfer, play a role. In view of the crucial role played by H2O2 in both pathways, inhibition of H2O2 formation should not be interpreted solely as evidence for a role for catalase in the microsomal oxidation of alcohols.

Violence against physicians

OBJECTIVE

To ascertain the incidence of violence against internists.

SETTING

A county-operated tertiary care center in Nassau County, New York.

DESIGN AND PARTICIPANTS

Questionnaires were distributed to 100 internal medicine residents and attending physicians. They were asked to report: whether they had ever been assaulted or battered either by patients or by relatives of patients; the point in their medical training at which such episodes had occurred; the nature and severity of the violent episodes; and the circumstances surrounding such episodes.

RESULTS

Questionnaires were returned by 63 physicians (response rate, 63%). Ten physicians (16% of the respondents) reported that they had been battered, three (5%) on multiple occasions. Twenty-six physicians (41%) reported that they had been assaulted, 15 (24%) on multiple occasions. The majority (54%) of violent episodes had been instigated either by intoxicated patients or by patients with psychiatric histories. In this small sample, no injury was reported.

CONCLUSIONS

Violence against medical residents and attending physicians exists and is most commonly associated with patients who are intoxicated or who have psychiatric histories.

Postoperative radiographs following hip fracture surgery. Do they influence patient management?

There is still much debate on the appropriateness of taking postoperative radiographs following hip fracture surgery. In our unit, it is routine practice to request postoperative radiographs after hip hemiarthroplasty but not after internal fixation. An audit conducted in our unit highlighted the low acute implant-related complications. This prompted us to conduct a national audit on current UK practice regarding the use of check radiographs following hip fracture surgery. Retrospective case note review of all patients undergoing hip fracture surgery at our hospital, from 2002 to 2004, was performed. Patients undergoing revision surgery in the same admission were identified to determine whether check radiograph influenced the decision. Subsequently a postal performa was sent to 450 randomly chosen UK Orthopaedic Consultants. The performa was designed to determine practice relating to postoperative radiographs. It also attempted to determine whether postoperative radiographs (when requested) influenced the subsequent clinical management of the patient. A total of 1265 hip fractures treated surgically were reviewed locally. Average length of stay was 29.5 days. There were five acute implant-related complications. One revision was performed for a long hip screw which was obvious on the intra-operative image intensifier films. Only one decision to revise (because of incongruous reduction of a hip hemiarthroplasty) was based on a problem identified on a routine check radiograph. All patients undergoing revision were clinically symptomatic. We received 300 responses. Ninety-six per cent routinely took postoperative radiographs following hip hemiarthroplasty of which 83% allowed the patient to mobilise before checking the radiograph. Following dynamic hip screw (DHS)/dynamic condylar screw (DCS) fixation, 61% took check radiographs of which 75% allowed the patient to mobilise prior to reviewing the radiograph. Following cannulated screw (CS) fixation, 58% routinely performed check radiographs of which 67% allowed the patient to mobilise before reviewing the radiograph. The study highlights the lack of national consensus on the use of postoperative radiographs. We recommend that following DHS/DCS fixation and CS fixation, the use of postoperative radiographs should only be undertaken when clinically indicated. Postoperative radiographs following hip hemiarthroplasty should only be undertaken if there are operative concerns or postoperative complications.

Solid-phase radioimmunoassay for antibodies to flavivirus structural and nonstructural proteins

A micro-solid-phase radioimmunoassay (SPRIA) is described for quantitation of antibodies to purified flaviviruses as well as to the purified envelope glycoprotein and 80,000-molecular-weight viral nonstructural protein. Sera from mice experimentally infected with Saint Louis encephalitis (SLE) virus or from humans after a primary SLE virus infection reacted more specifically with the major viral envelope protein in the SPRIA test than with antigens conventionally used in the complement fixation (CF) and hemagglutination inhibition tests. A high degree of correlation (P is less than 0.05) was observed between SPRIA anti-immunoglobulin G binding values with the 80,000-molecular-weight nonstructural protein of SLE virus and antibody titers obtained by plaque reduction neutralization and CF with the nonstructural protein. In five of seven human sera in which CF antibody titers to the nonstructural protein were 4 or less, SPRIA testing revealed significant titers of IgG immunoglobulin reactive with this viral protein. The SPRIA test for antibodies reactive with group B togavirus nonstructural protein is as specific and sensitive as the plaque reduction neutralization test for titrating viral antibody in human and animal sera. Antibodies reactive with viral envelope proteins are broadly cross-reactive by the Spria technique, demonstrating both group- and complex-reactive antigenic determinants. The SPRIA test, using wells precoated with antigen, can be completed in 1 day, providing a rapid, highly sensitive test which can be adapted to use in testing a large number of sera.