The association of meniscal pathologic changes with cartilage loss in symptomatic knee osteoarthritis

OBJECTIVE

To explore the role of meniscal tears and meniscal malposition as risk factors for subsequent cartilage loss in subjects with symptomatic osteoarthritis (OA).

METHODS

Study subjects were patients with symptomatic knee OA from the Boston Osteoarthritis of the Knee Study. Baseline assessments included knee magnetic resonance imaging (MRI) with followup MRI at 15 and 30 months. Cartilage and meniscal damage were scored on MRI in the medial and lateral tibiofemoral joints using the semiquantitative whole-organ magnetic resonance imaging score. Tibiofemoral cartilage was scored on MR images of all 5 plates of each tibiofemoral joint, and the meniscal position was measured using eFilm Workstation software. A proportional odds logistic regression model with generalized estimating equations was used to assess the effect of each predictor (meniscal position factor and meniscal damage as dichotomous predictors in each model) on cartilage loss in each of the 5 plates within a compartment. Models were adjusted for age, body mass index (BMI), tibial width, and sex.

RESULTS

We assessed 257 subjects whose mean +/- SD age was 66.6 +/- 9.2 years and BMI was 31.5 +/- 5.7 kg/m2; 42% of subjects were female, and 77% of knees had a Kellgren/Lawrence radiographic severity grade > or = 2. In the medial tibiofemoral joint, each measure of meniscal malposition was associated with an increased risk of cartilage loss. There was also a strong association between meniscal damage and cartilage loss. Since meniscal coverage and meniscal height diminished with subluxation, less coverage and reduced height also increased the risk of cartilage loss.

CONCLUSION

This study highlights the importance of an intact and functioning meniscus in patients with symptomatic knee OA, since the findings demonstrate that loss of this function has important consequences for cartilage loss.

Relation of synovitis to knee pain using contrast-enhanced MRIs

BACKGROUND

It has been suggested that synovitis causes joint pain. On non-contrast-enhanced MRIs synovial thickening cannot be assessed and on these images synovitis has been inconsistently associated with pain.

OBJECTIVE

To assess synovial thickening in relation to knee pain severity among subjects in the Multicenter Osteoarthritis Study (MOST) using contrast-enhanced (CE) MRI.

METHODS

MOST is a cohort study of people who have, or are at high risk of, knee osteoarthritis (OA). An unselected subset of 535 participants who volunteered underwent CE 1.5 T MRI of one knee. Synovitis was scored in six compartments and a summary score was created. Knee pain severity was assessed using the maximum item score on the Western Ontario and McMaster Osteoarthritis Index (WOMAC) pain scale. The association between synovitis and pain severity was examined using a logistic regression model adjusting for age, sex, body mass index (BMI), MRI bone marrow lesions and effusions in the whole sample and in a subgroup without radiographic OA.

RESULTS

454 of the 535 subjects undergoing CE MRI had complete data on synovitis and WOMAC pain. Mean age was 59 years, mean BMI 30 and 48% were women. In knees with moderate pain, 80% had synovitis. For knee pain, synovitis conferred a 9.2-fold increased odds compared with those without synovitis. In knees without radiographic OA (n=329), there was also an association of synovitis with an increased prevalence of pain.

CONCLUSION

Synovitis has a strong relation with knee pain severity, an association detected more clearly with CE MRI than suggested by previous studies using non-CE MRI measures of synovitis.

Is obesity a risk factor for progressive radiographic knee osteoarthritis?

OBJECTIVE

To examine whether obesity increases the risk of progression of knee osteoarthritis (OA).

METHODS

We used data from the Multicenter Osteoarthritis Study, a longitudinal study of persons with or at high risk of knee OA. OA was characterized at baseline and 30 months using posteroanterior fixed-flexion radiographs and Kellgren/Lawrence (K/L) grading, with alignment assessed on full-extremity films. In knees with OA at baseline (K/L grade 2 or 3), progression was defined as tibiofemoral joint space narrowing on the 30-month radiograph. In knees without OA at baseline (K/L grade 0 or 1), incident OA was defined as the development of radiographic OA at 30 months. Body mass index (BMI) at baseline was classified as normal (<25 kg/m(2)), overweight (25-<30 kg/m(2)), obese (30-<35 kg/m(2)), and very obese (>or=35 kg/m(2)). The risk of progression was tested in all knees and in subgroups categorized according to alignment. Analyses were adjusted for age, sex, knee injury, and bone density.

RESULTS

Among the 2,623 subjects (5,159 knees), 60% were women, and the mean +/- SD age was 62.4 +/- 8.0 years. More than 80% of subjects were overweight or obese. At baseline, 36.4% of knees had tibiofemoral OA, and of those, only one-third were neutrally aligned. Compared with subjects with a normal BMI, those who were obese or very obese were at an increased risk of incident OA (relative risk 2.4 and 3.2, respectively [P for trend < 0.001]); this risk extended to knees from all alignment groups. Among knees with OA at baseline, there was no overall association between a high BMI and the risk of OA progression; however, an increased risk of progression was observed among knees with neutral but not varus alignment. The effect of obesity was intermediate in those with valgus alignment.

CONCLUSION

Although obesity was a risk factor for incident knee OA, we observed no overall relationship between obesity and the progression of knee OA. Obesity was not associated with OA progression in knees with varus alignment; however, it did increase the risk of progression in knees with neutral or valgus alignment. Therefore, weight loss may not be effective in preventing progression of structural damage in OA knees with varus alignment.

Point of care testing: randomised controlled trial of clinical outcome

OBJECTIVES

To describe the proportion of patients attending an accident and emergency department for whom blood analysis at the point of care brought about a change in management; to measure the extent to which point of care testing resulted in differences in clinical outcome for these patients when compared with patients whose samples were tested by the hospital laboratory.

DESIGN

Open, single centre, randomised controlled trial. Blood samples were randomly allocated to point of care testing or testing by the hospital's central laboratory.

SETTING

The accident and emergency department of the Bristol Royal Infirmary, a large teaching hospital which cares for an inner city population.

SUBJECTS

Representative sample of patients who attended the department between April 1996 and April 1997 and who required blood tests. Data collection was structured in 8 hour blocks so that all hours of the day and all days of the week were equally represented.

MAIN OUTCOME MEASURES

The proportion of patients for whom point of care testing brought about a change in treatment in which timing was considered to be critical to clinical outcome. Mortality, the length of stay in hospital, admission rate, the amount of time spent waiting for results of blood tests, the amount of time taken to decide on management plans, and the amount of time patients spent in the department were compared between patients whose samples were tested at the point of care and those whose samples were sent to the laboratory.

RESULTS

Samples were obtained from 1728 patients. Changes in management in which timing was considered to be critical occurred in 59 out of 859 (6.9%, 95% confidence interval 5.3% to 8.8%) patients in the point of care arm of the trial. Decisions were made 74 minutes earlier (68 min to 80 min, P < 0.0001) when point of care testing was used for haematological tests as compared to central laboratory testing, 86 minutes earlier (80 min to 92 min, P < 0.0001) for biochemical tests, and 21 minutes earlier (-3 min to 44 min, P = 0.09) for analyses of arterial blood gases. There were no differences between the groups in the amount of time spent in the department, length of stay in hospital, admission rates, or mortality.

CONCLUSION

Point of care testing reduced the time taken to make decisions on patient management that were dependent on the results of blood tests. It also brought about faster changes in treatment for which timing was considered to be critical in about 7% of patients. These changes did not affect clinical outcome or the amount of time patients spent in the department.

Cigarette smoking and the risk for cartilage loss and knee pain in men with knee osteoarthritis

OBJECTIVE

To examine the effects of smoking on cartilage loss and pain at the knee in individuals with knee osteoarthritis.

METHODS

159 men with symptomatic knee osteoarthritis who participated in a 30-month, prospective, natural history study of knee osteoarthritis were examined. The more symptomatic knee was imaged using magnetic resonance imaging (MRI) at baseline, and again at 15 and 30 months of follow-up. Cartilage was scored using the Whole-Organ MRI Score semiquantitative method at the medial and lateral tibiofemoral joints and at the patellofemoral joint. At baseline and follow-up visits, the severity of knee pain was assessed using a Visual Analogue Scale pain score (0-100 mm).

RESULTS

Among the 159 men, 19 (12%) were current smokers at baseline. Current smokers were younger (mean (standard deviation (SD)) age 62 (9) v 69 (9) years) and leaner (mean (SD) body mass index (BMI): 28.9 (3.2) v 31.3 (4.8) kg/m(2)) than men who were not current smokers. When adjusted for age, BMI and baseline cartilage scores, men who were current smokers were found to have an increased risk for cartilage loss at the medial tibiofemoral joint (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.0 to 5.4) and the patellofemoral joint (OR 2.5, 95% CI 1.1 to 5.7). Current smokers also had higher adjusted pain scores at baseline (60.5 v 45.0, p<0.05) and at follow-up (59.4 v 44.3, p<0.05) than men who were not current smokers.

CONCLUSIONS

Men with knee osteoarthritis who smoke sustain greater cartilage loss and have more severe knee pain than men who do not smoke.

Coronal decompensation produced by Cotrel-Dubousset "derotation" maneuver for idiopathic right thoracic scoliosis

From 1985 to 1987, 82 patients with idiopathic scoliosis followed 12 to 44 months underwent selective fusion and correction of their right thoracic curves by Cotrel-Dubousset instrumentation using the "derotation" maneuver. Preoperative, postoperative, and follow-up standing anteroposterior roentgenograms of the spine were analyzed. For curves in which there was deviation from the midline (plumb line) and rotation of the lumbar segments, an increased incidence of decompensation was produced after surgery, when posterior Cotrel-Dubousset instrumentation and fusion were carried to the "stable" vertebra with one rod bend and hook alignment on the left sided derotation rod. Previous guidelines established for selective fusion with conventional posterior instrumentation (Harrington or Luque rods) may not be applicable to derotation with Cotrel-Dubousset instrumentation.

Awareness and use of the Ottawa ankle and knee rules in 5 countries: can publication alone be enough to change practice?

STUDY OBJECTIVES

We evaluate the international diffusion of the Ottawa Ankle and Knee Rules and determine emergency physicians' attitudes toward clinical decision rules in general.

METHODS

We conducted a cross-sectional, self-administered mail survey of random samples of 500 members each of the American College of Emergency Physicians, Canadian Association of Emergency Physicians, British Association for Accident and Emergency Medicine, Spanish Society for Emergency Medicine, and all members (n=1,350) of the French Speaking Society of Emergency Physicians, France. Main outcome measures were awareness of the Ottawa Ankle and Knee Rules, reported use of these rules, and attitudes toward clinical decision rules in general.

RESULTS

A total of 1,769 (57%) emergency physicians responded, with country-specific response rates between 49% (United States and France) and 79% (Canada). More than 69% of physicians in all countries, except Spain, were aware of the Ottawa Ankle Rules. Use of the Ottawa Ankle Rules differed by country with more than 70% of all responding Canadian and United Kingdom physicians reporting frequent use of the rules compared with fewer than one third of US, French, and Spanish physicians. The Ottawa Knee Rule was less well known and less used by physicians in all countries. Most physicians in all countries viewed decision rules as intended to improve the quality of health care (>78%), a convenient source of advice (>67%), and good educational tools (>61%). Of all physicians, those from the United States held the least positive attitudes toward decision rules.

CONCLUSION

This constitutes the largest international survey of emergency physicians' attitudes toward and use of clinical decision rules. Striking differences were apparent among countries with regard to knowledge and use of decision rules. Despite similar awareness in the United States, Canada, and the United Kingdom, US physicians appeared much less likely to use the Ottawa Ankle Rules. Future research should investigate factors leading to differences in rates of diffusion among countries and address strategies to enhance dissemination and implementation of such rules in the emergency department.

Association between patella alta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis: the multicenter osteoarthritis study

OBJECTIVE

To examine the relationship between patella alta and the prevalence and worsening at followup of structural features of patellofemoral joint (PFJ) osteoarthritis (OA) on magnetic resonance imaging (MRI).

METHODS

The Multicenter Osteoarthritis Study is a cohort study of persons ages 50-79 years with or at risk for knee OA. Patella alta was measured using the Insall-Salvati ratio (ISR) on the baseline lateral radiograph, and cartilage damage, bone marrow lesions (BMLs), and subchondral bone attrition (SBA) were graded on MRI at baseline and at 30 months of followup in the PFJ. We examined the association of the ISR with the prevalence and worsening of cartilage damage, BMLs, and SBA in the PFJ using logistic regression.

RESULTS

A total of 907 knees were studied (mean age 62 years, body mass index 30 kg/m(2), ISR 1.10), 63% from female subjects. Compared with knees in the lowest ISR quartile at baseline, those in the highest quartile had 2.4 (95% confidence interval [95% CI] 1.7-3.3), 2.9 (95% CI 2.0-4.3), and 3.5 (95% CI 2.3-5.5) times the odds of having lateral PFJ cartilage damage, BMLs, and SBA, respectively, and 1.5 (95% CI 1.1-2.0), 1.3 (95% CI 0.9-1.8), and 2.2 (95% CI 1.4-3.4) times the odds of having medial PFJ cartilage damage, BMLs, and SBA, respectively. Similarly, those with high ISRs were also at risk for worsening of cartilage damage and BMLs over time than those with low ISRs.

CONCLUSION

A high ISR, indicative of patella alta, is associated with structural features of OA in the PFJ. Additionally, the same knees have an increased risk of worsening of these same features over time.

Isolation of genes expressed preferentially during sporulation in the yeast Saccharomyces cerevisiae

A library of Saccharomyces cerevisiae DNA in the vector lambda Charon 28 was probed for sequences complementary to cDNA made from poly(A)+ RNA isolated from the well-sporulating yeast strain AP1 a/alpha. The RNA was isolated from cells that had been incubated 7, 9, 11, and 13 hr in sporulation medium. DNA complementary to poly(A)+ RNA from alpha/alpha(nonsporulating) AP1 was used as a control, and 46 bacteriophage that gave a stronger response with a/alpha cDNA than with alpha/alpha cDNA were obtained in a screening of three yeast genomes worth of DNA. Two of the bacteriophage appeared to contain a/alpha-specific genes, in that they hybridized to cDNA from vegetative a/alpha RNA. The rest appeared to correspond to a/alpha genes expressed preferentially during sporulation. Restriction endonuclease analysis of four of the cloned sequences revealed a single major region of transcription in each; these regions ranged in size from 2.5 to 4.0 kilobases. RNA blot analysis showed that, in three of the four cases, transcripts of two different sizes were homologous to the cloned sequence. In all four cases, the homologous transcripts appeared at about 7 hr and were decreasing in amount by 13 hr. These results provide evidence for transcriptional control of genes expressed during sporulation and for at least one group of genes that is turned on at about the time of meiosis I in sporulation.

De novo synthesis of an intron by the maize transposable element Dissociation

The mechanisms by which introns are gained or lost in the evolution of eukaryotic genes remain poorly understood. The discovery that transposable elements sometimes alter RNA splicing to allow partial or imperfect removal of the element from the primary transcripts suggests that transposons are a potential and continuing source of new introns. To date, splicing events that precisely restore the wild-type RNA sequence at the site of insertion have not been detected. Here we describe alternative RNA splicing patterns that result in precise removal of a Dissociation (Ds) insertion and one copy of its eight-nucleotide host site duplication from an exon sequence of the maize shrunken2-mutabe1 (sh2-m1) mutant. In one case, perfect splicing of Ds was associated with aberrant splicing of an intron located 32 bp upstream of the insertion site. The second transcript type was indistinguishable from wild-type mRNA, indicating that Ds was spliced like a normal intron in about 2% of the sh2-m1 transcripts. Our results suggest that the transposition of Ds into sh2 in 1968, in effect, marked the creation of a new intron in a modern eukaryotic gene. The possibility of precise intron formation by a transposable element demonstrated here may be a general phenomenon of intron formation, since consensus intron splice sites can be explained by insertions that duplicate host sequences upon integration. A model is presented.

Intracerebroventricular administration of ethylcholine mustard aziridinium ion (AF64A) reduces release of acetylcholine from rat hippocampal slices

Ethylcholine mustard aziridinium ion (AF64A), or vehicle, was infused bilaterally (3 nmol/3 microliter per side) into the lateral ventricles of rats. The effect of such treatment on various cholinergic responses was measured in the hippocampus, cortex and striatum. Potassium-stimulated release of acetylcholine from superfused slices of hippocampus was reduced, 7 and 21 days after treatment with AF64A, to 24 and 35% of control, respectively. The activity of choline acetyltransferase in the hippocampus also decreased, to 42% of control, both 7 and 21 days after treatment with AF64A. Similarly, the activity of acetylcholinesterase and the high affinity transport of choline in the hippocampus were reduced, to 40 and 30% of control; and to 33 and 48% of control, respectively, 7 and 21 days after treatment with AF64A. Synthesis of acetylcholine in slices of hippocampus was also decreased after treatment with AF64A (71 and 51% of control, 7 and 21 days post-AF64A respectively). Only the binding of [3H]QNB in the hippocampus was unchanged at 7 days after treatment with AF64A, although a small reduction (11%) was noted 21 days after treatment with AF64A. The activity of choline acetyltransferase and acetylcholinesterase, the high-affinity transport of choline and the binding of [3H]QNB in cortex and striatum were unaffected by treatment with AF64A under the same experimental conditions. Using a substantially smaller dose than that earlier reported in mice, the earlier finding was thus confirmed, and extended, in rats, of a highly selective effect of AF64A on several components of the cholinergic system. Under the conditions of this study, these effects appeared to be confined to the hippocampus.

IME4, a gene that mediates MAT and nutritional control of meiosis in Saccharomyces cerevisiae

In the yeast Saccharomyces cerevisiae, sporulation occurs in response to nutritional and genetic signals. The process is initiated when nutrient availability limits mitotic growth, but only in MATa/MAT alpha diploid cells. Under these conditions, the cells express an activator of meiosis (IME1), which is required for the expression of early sporulation-specific genes. We describe a new gene, IME4, whose activity is essential for IME1 transcript accumulation and sporulation. The IME4 transcript was induced in starved MATa/MAT alpha diploids but not in other cell types. In addition, excess IME4 promoted sporulation in mat-insufficient cells. Thus, IME4 appears to activate IME1 in response to cell type and nutritional signals. We have also explored the interactions between IME4 and two genes that are known to regulate IME1 expression. Normally, cells that lack complete MAT information cannot sporulate; when such strains lack RME1 activity or contain the semidominant RES1-1 mutation, however, they can express IME1 and sporulate to low levels. Our results show that mat-insufficient strains containing rme1::LEU2 or RES1-1 bypass mutations still retain MAT control of IME4 expression. Even though IME4 levels remained low, the rme1::LEU2 and RES1-1 mutations allowed IME1 accumulation, implying that these mutations do not require IME4 to exert their effects. In accord with this interpretation, the RES1-1 mutation allowed IME1 accumulation in MATa/MAT alpha strains that contain ime4::LEU2 alleles. These strains still sporulated poorly, suggesting that IME4 plays a role in sporulation in addition to promoting IME1 transcript accumulation. IME4 is located between ADE5 and LYS5 on chromosome VII.

Simultaneous Detection of Seven Drugs of Abuse by the TriageTM Panel for Drugs of Abuse

This novel, competitive immunoassay simultaneously detects seven drugs of abuse in urine. A urine sample is placed in contact with lyophilized reagents, the reaction mixture is allowed to come to equilibrium (10 min), and then the whole mixture is applied to a solid phase that contains various immobilized antibodies in discrete drug-class-specific zones. After a washing step, the operator visually examines each zone for the presence of a red bar. The method incorporates present threshold concentrations that are independent for each drug. In the absence of drug or in the presence of drug in quantities less than the threshold concentration, no colored bar is visible. Samples containing drug(s) at or above the threshold concentration cause a red bar to appear for the appropriate drug(s). Positive and negative procedural control zones are incorporated into each determination. The performance of the assay methodology matches that of instrumented immunoassay systems.

Difficult airway equipment in English emergency departments

The need for tracheal intubation in the emergency department is often unpredictable and precipitous in nature. When compared with the operating room, a higher incidence of difficult intubation is observed. There are currently no accepted guidelines with respect to the stocking of difficult airway equipment in the emergency department. We have conducted a telephone survey to determine the availability of equipment for the management of the difficult airway in English emergency departments. Overall, the majority of units held a curved laryngoscope blade (100%), gum elastic bougie (99%) and surgical airway device (98%). Of alternative devices for ventilation, a laryngeal mask airway was kept by 65% of departments, a needle cricothyroidostomy kit by 63% and an oesophageal-tracheal twin-lumen airway (Combitube) by 18%. Of alternative devices for intubation, fewer than 10% held a retrograde intubating kit, intubating laryngeal mask, bronchoscope or lighted stylet. Seventy-four per cent of departments held an end-tidal carbon dioxide detector.

Increased gene expression by the first intron of maize shrunken-1 locus in grass species

The first intron of the shrunken-1 (Sh1) locus of maize was incorporated into constructs containing the chloramphenicol acetyltransferase gene (CAT) coupled with the nopaline synthase 3' polyadenylation signal. Transcription was driven with the 35S promoter of the cauliflower mosaic virus (CaMV) or the Sh1 promoter of maize. Transient gene expression was monitored following electroporation into protoplasts of Panicum maximum (guineagrass), Pennisetum purpureum (napiergrass), or Zea mays (maize). The 1028 base pair intron increased gene expression in cells of each species when transcription was driven with the 35S promoter. Eleven to 91-fold increases were observed. Expression levels observed in maize were two and eight times those observed in napiergrass and guineagrass, respectively. The 35S promoter gave CAT activity 10 to 100 times that observed with the Sh1 promoter. Whereas expression driven by the 35S promoter was reproducible, that observed with the Sh1 promoter proved quite variable. In similar constructs the first intron of the alcohol dehydrogenase-1 (Adh1) gene of maize led to increased gene expression of only 7 to 10% of that observed with the Sh1 first intron. The increased level of gene expression caused by the Sh1 first intron is approximately 10 times higher than that caused by any other plant introns that have been used. Thus, the Sh1 first intron may prove quite useful in increasing expression of foreign genes in monocots and possibly other plants.

Index finger pollicization for congenital aplasia or hypoplasia of the thumb

Sensation, strength, dexterity, length, and range of motion were evaluated after index finger pollicization in 10 patients (14 hands). Diagnoses included congenital absence of the thumb (10 hands) and hypoplasia (4 hands). Average age at operation was 7 years, and follow-up averaged 9 years. Patients with unilateral pollicization averaged 67% grip strength, 60% lateral pinch, 56% palmar pinch, and 39% three-point pinch as compared with the normal contralateral hand. Manual dexterity averaged 70% efficiency as compared with normal standards defined according to age and sex. However, 55% of the patients, when stressed, used side-to-side pinch. It was noted that in those patients who used side-to-side pinch performance averaged 54% of normal standards, compared with 93% in patients who used tip-to-tip pinch for prehension.

The SPR3 gene encodes a sporulation-specific homologue of the yeast CDC3/10/11/12 family of bud neck microfilaments and is regulated by ABFI

The SPR3 gene is selectively activated only during the sporulation phase of the Saccharomyces cerevisiae (Sc) life cycle. The predicted amino acid (aa) sequence has homology to microfilament proteins that are involved in cytokinesis and other proteins of unknown function. These include the products of Sc cell division cycle (CDC) genes involved in bud formation (Cdc3p, Cdc10p, Cdc11p and Cdc12p), Candida albicans proteins that accumulate in the hyphal phase (CaCdc3p and CaCdc10p), mouse brain-specific (H5p) and lymphocyte (Diff6p) proteins, Drosophila melanogaster (Dm) protein Pnutp (which is localized to the cleavage furrow of dividing cells), a Diff6p homologue (DmDiff6p), and the Sc septin protein (Sep1hp), a homologue of the 10-nm filament proteins of Sc. One strongly conserved region contains a potential ATP-GTP-binding domain. Primer extension analysis revealed six major transcription start points (tsp) beginning at -142 relative to the ATG start codon. The sequence immediately upstream from the tsp contains consensus binding sites for the HAP2/3/4 and ABFI transcription factors, a T-rich sequence and two putative novel elements for mid to late sporulation, termed SPR3 and PAL. Electrophoretic mobility shift assay (EMSA) and footprint analyses demonstrated that the ABFI protein binds to a region containing the putative ABFI site in vitro, and site-directed mutagenesis showed that the ABFI motif is essential for expression of SPR3 at the appropriate stage in sporulating cells.

Computer tomography evaluation of Cotrel-Dubousset instrumentation in idiopathic scoliosis

In 30 adolescent patients with 36 structural curves undergoing posterior spinal arthrodesis using Cotrel-Dubousset (CD) instrumentation, computer tomography (CT) was performed to evaluate the change in rotation and in the sagittal plane. The average preoperative Cobb angle was 51.7 degrees, and improved to 18.7 degrees postoperatively, or 64.9%. The angle of rotation of the apical vertebra relative to the anterior midline of the body (RAML) improved from 27.9 degrees preoperatively to 21.5 degrees postoperatively (23.9%). The angle of rotation relative to the sagittal plane (RAsag) improved from 15.2 degrees preoperatively to 13.4 degrees postoperatively (14.3%). The kyphotic angle increased an average of 10.6 degrees in the 14 patients whose preoperative angle was less than 25 degrees. As measured by CT, CD instrumentation improves both the rotational and sagittal plane deformities better than that reported for other systems.

The portable laboratory: an evaluation of the accuracy and reproducibility of i-STAT

The i-STAT point-of-care testing analyser, which utilizes single-use multisensor cartridges, was evaluated. Two cartridges were assessed: the 6+ and the G3+, which provide results for urea, glucose, sodium, potassium, chloride, haematocrit, pH, PCO2, PO2 and various calculated parameters. The results for all analytes agreed well with the analysers in routine use in the laboratory. The reproducibility was comparable even when analysis was carried out by a nurse with only 5 min training. The system was found to be reliable, easy to use and required no maintenance (only a 2-min daily check of the electronics). These features, together with portability and the storage capacity for results, make the i-STAT suitable for point-of-care use, particularly in critical care units.

Fibrodysplasia ossificans progressiva

Three hundred fifty-three previously reported cases of fibrodysplasia ossificans progressiva were reviewed and six new cases were analyzed radiologically. Characteristic findings of fibrodysplasia ossificans progressiva were confirmed and radiographic signs of the disease were demonstrated, including medial cortical thickening of the proximal tibia, narrow lumbar spinal canal, accessory epiphysis of the second phalanx of the fifth finger, and decreased humeral/epicondylar angle.

In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature

It is well known that laryngeal instrumentation and endotracheal intubation is associated with a marked, transient rise in intracranial pressure (ICP). Patients with head injury requiring endotracheal intubation are considered particularly at risk from this transient rise in ICP as it reduces cerebral perfusion and thus may increase secondary brain injury. The favoured method for securing a definitive airway in this patient group is by rapid sequence intubation (RSI). In the United States the Emergency Airway Course teaches emergency physicians to routinely administer intravenous lidocaine as a pre treatment for RSI in this patient group in an attempt to attenuate this rise in ICP. A literature search was carried out to identify studies in which intravenous lidocaine was used as a pretreatment for RSI in major head injury. Any link to an improved neurological outcome was also sought. Papers identified were appraised in the manner recommended by the evidence based medicine group to ensure validity. There were no studies identified that answered our question directly and, furthermore, it is our belief that no such study, at present, exists in the literature. Six valid papers were found, which individually contained elements of the question posed and these are presented in a narrative and graphic form. There is currently no evidence to support the use of intravenous lidocaine as a pretreatment for RSI in patients with head injury and its use should only occur in clinical trials.

Both-bone forearm fractures in children

Treatment of both-bone forearm fractures remains a difficult dilemma for the orthopedist. We assessed the results of 33 children treated with closed reduction and a long-arm cast using traction with finger traps in neutral rotation. Patients were grouped according to age and analyzed for residual angulation and range of motion (ROM). Despite some residual angulation and loss of rotation, all patients were fully active with no functional restriction at follow up. For patients 10 years old or younger with less than 30 degrees of post-casting angulation, full ROM and minimal residual angulation on radiograph can be expected. For patients ages 11 to 15 years (the oldest patient in this series was 15), residual angulation is likely and approximately 60% of patients will have residual loss of less than or equal to 30 degrees of rotation. In spite of this, we found no evidence of functional loss at follow up. Our series supports the continued use of closed manipulation as an effective treatment in children with both-bone forearm fractures.

Familial relationships of allusive thinking in university students and their parents

Rapaport (1945) was the first worker to advance evidence that at least two types of formal thought disorder contributed to the disturbance of thinking found in schizophrenia; and furthermore that neither of these types of thinking was specific to schizophrenia. Rapaport administered the Bolles Goldstein Object Sorting Test to 217 psychiatric patients and to a control group of 54 patrolmen. He found that schizophrenics showed a tendency to function more at a concrete level and less at an abstract conceptual level, as described first by Vigotsky (1934). This tendency was also shown by depressives and by persons who were not mentally ill but had a poor cultural background.

Juvenile idiopathic scoliosis followed to skeletal maturity

The authors reviewed 43 patients with the onset of idiopathic scoliosis between 4 and 9 years who were followed to skeletal maturity to document the natural history, effects of bracing, and factors associated with progression. Average age at onset was 7.1 years for female and 6.7 for male patients. Twelve were treated with observation only; six improved, five progressed, and one refused an orthosis and required surgery. Thirty-one patients wore an orthosis; five patients improved or were unchanged, and 26 progressed, including 13 who subsequently required surgery. All patients treated with observation had a rib vertebral angle difference (RVAD) of less than 10 degrees; whereas patients progressing despite orthosis and all but one patient requiring operation had an RVAD greater than 10 degrees. Thoracic hypokyphosis (less than 20 degrees) was present in 20% of observed patients, 64% of those treated with an orthosis, and 78% of those requiring operation.

An observational survey of emergency department rapid sequence intubation

OBJECTIVES

To study the current practice of rapid sequence intubations (RSIs) in four different emergency medicine training programmes in the UK.

METHODS

Observational study design involving four regional training programmes (Wessex, North West, Yorkshire, Avon). Data were collected in real time using a previously piloted survey tool. Data were collected by specialist registrars in emergency medicine over a continuous 28 day period. Data collected included: indications for RSI; key timings of RSI procedures; details of RSI practitioner; complications and outcome of procedure.

RESULTS

Data from 60 RSIs were recorded and collected. The majority of decisions to perform RSIs were made by emergency physicians (74% cases). Over 50% of the RSIs occurred after 4 pm. Emergency physicians performed 26% of RSIs although the majority were performed by anaesthetists. Most of the given indications for RSIs were based on an assessment of airway protection. Hypoxia was an uncommon reason for RSI in this study (5%). In two thirds of cases the time taken from the decision being made to perform an RSI, to the achievement of successful intubation, was greater than 20 minutes. No failed intubations were recorded, although six other complications (all minor problems) were recorded. There was no significant difference in the response times between anaesthetists and emergency physicians.

CONCLUSIONS

This study shows that emergency physicians are currently performing RSIs in emergency departments in the UK. It also suggests improvements could be made to patient care. In particular, standards of care should be agreed for the provision of RSI in the emergency department, including the personnel involved and the appropriate training of individuals. RSI activity in emergency departments in the UK should be audited nationally using an agreed audit tool.