Search

Background: There is little international data on morbidity and mortality of surgery for perforated peptic ulcer (PPU). This study aimed to understand the global 30-day morbidity and mortality of patients undergoing surgery for PPU and to identify variables associated with these., Method: We performed an international study of adults (≥ 18 years) who underwent surgery for PPU from 1st January 2022 to 30th June 2022. Patients who were treated conservatively or had an underlying gastric cancer were excluded. Patients were divided into subgroups according to age (≤ 50 and > 50 years) and time from onset of symptoms to hospital presentation (≤ 24 and > 24 h). Univariate and Multivariate analyses were carried out to identify factors associated with higher 30-day morbidity and mortality., Results:  1874 patients from 159 centres across 52 countries were included. 78.3% (n = 1467) of the patients were males and the median (IQR) age was 49 years (25). Thirty-day morbidity and mortality were 48.5% (n = 910) and 9.3% (n = 174) respectively. Median (IQR) hospital stay was 7 (5) days. Open surgery was performed in 80% (n = 1505) of the cohort. Age > 50 years [(OR = 1.7, 95% CI 1.4-2), (OR = 4.7, 95% CI 3.1-7.6)], female gender [(OR = 1.8, 95% CI 1.4-2.3), (OR = 1.9, 95% CI 1.3-2.9)], shock on admission [(OR = 2.1, 95% CI 1.7-2.7), (OR = 4.8, 95% CI 3.2-7.1)], and acute kidney injury [(OR = 2.5, 95% CI 1.9-3.2), (OR = 3.9), 95% CI 2.7-5.6)] were associated with both 30-day morbidity and mortality. Delayed presentation was associated with 30-day morbidity [OR = 1.3, 95% CI 1.1-1.6], but not mortality., Conclusions: This study showed that surgery for PPU was associated with high 30-day morbidity and mortality rate. Age, female gender, and signs of shock at presentation were associated with both 30-day morbidity and mortality., (© 2024. Crown.)

Knowledge of the impact of paroxysmal and persistent atrial fibrillation (AF) after catheter ablation on in-hospital outcomes and 30-day readmission remains limited. This study aimed to evaluate the procedural outcomes and 30-day readmission rates among patients with paroxysmal or persistent AF who were hospitalized for AF ablation. Using the Nationwide Readmissions Database, our study included patients aged ≥18 years with AF who were hospitalized and underwent catheter ablation during 2017-2020. Then, we compared the in-hospital procedural outcomes and 30-day readmission rates between patients with paroxysmal and persistent AF, respectively. Our study included 7310 index admissions for paroxysmal AF ablation and 9179 index admissions for persistent AF ablation. According to our analysis, there was no significant difference in procedural complications-namely, cerebrovascular accident, vascular complications, major bleeding requiring blood transfusion, phrenic nerve palsy, pericardial complications, and systemic embolization-between the persistent and paroxysmal AF groups. There was also no significant difference in early mortality between these groups (0.5% vs. 0.7%; P = .22). Persistent AF patients had significantly higher rates of prolonged index hospitalization (9.9% vs. 7.2%; P < .01) and non-home discharge (4.8% vs. 3.1%; P < .01). The 30-day readmission rates were comparable in both groups (10.0% vs. 9.5%; P = .34), with recurrent AF and heart failure being two of the most common causes of cardiac-related readmissions. Catheter ablation among hospitalized patients with paroxysmal or persistent AF resulted in no significant difference in procedural complications, early mortality, or 30-day readmission. This suggests that catheter ablation of AF can be performed with a relatively similar safety profile for both paroxysmal and persistent AF., Competing Interests: The authors report no conflicts of interest for the published content. No funding information was provided., (Copyright: © 2024 Innovations in Cardiac Rhythm Management.)

Background: The real-world data on the safety profile of transvenous lead extraction (TLE) for infected cardiac implantable electronic devices (CIED) among elderly patients is not well-established. This study aimed to evaluate the hospital outcomes between patients of different age groups who underwent TLE for infected CIED., Method: Using the Nationwide Readmissions Database, our study included patients aged ≥18 years who underwent TLE for infected CIED between 2017 and 2020. We divided the patients into four groups: Group A. Young (<50 years), Group B. Young intermediate (50-69 years old), Group C. Older intermediate (70-79 years old), and Group D. Octogenarian (≥80 years old). We then analyzed the in-hospital outcome and 30-day readmission between these age groups., Results: A total of 10,928 patients who were admitted for TLE of infected CIED were included in this study: 982 (9.0%) patients in group A, 4,234 (38.7%) patients in group B, 3,204 (29.3%) patients in group C and 2,508 (23.0%) of patients in group D. Our study demonstrated that the risk of early mortality increased with older age (Group B vs. Group A: OR: 1.92, 95% CI: 1.19-3.09, p < .01; Group C vs. Group A: OR: 2.47, 95% CI: 1.51-4.04, p < .01; Group D vs. Group A: OR: 2.82, 95% CI: 1.69-4.72, p < .01). The risk of non-home discharge also increased in elderly groups (Group B vs. Group A: OR: 1.89; 95% CI: 1.52-2.36; p < .01; Group C vs. Group A: OR: 2.82; 95% CI 2.24-3.56; p < .01; Group D vs. Group A: OR: 4.16; 95% CI: 3.28-5.28; p < .01). There was no significant difference in hospitalization length and 30-day readmission between different age groups. Apart from a higher rate of open heart surgery in group A, the procedural complications were comparable between these age groups., Conclusion: Elderly patients had worse in-hospital outcomes in early mortality and non-home discharge following the TLE for infected CIED. There was no significant difference between elderly and non-elderly groups in prolonged hospital stay and 30-day readmission. Elderly patients did not have a higher risk of procedural complications., (© 2024 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals LLC.)

Background: The real-world data on the safety profile of ventricular tachycardia (VT) ablation among elderly patients is not well-established. This study aimed to evaluate the procedural outcomes among those aged 18-64 years versus those aged ≥65 years who underwent catheter ablation of VT., Method: Using the Nationwide Readmissions Database, our study included patients aged ≥18 years who underwent VT catheter ablation between 2017 and 2020. We divided the patients into non-elderly (18-64 years old) and elderly age groups (≥65 years old). We then analyzed the in-hospital procedural outcome and 30-day readmission between these two groups., Results: Our study included 2075 (49.1%) non-elderly patients and 2153 (50.9%) elderly patients who underwent VT ablation. Post-procedurally, elderly patients had significantly higher rates of prolonged index hospitalization (≥7 days; 35.5% vs. 29.3%, p  < .01), non-home discharge (13.4% vs. 6.0%, p  < .01), 30-day readmission (17.0% vs. 11.4%, p  < .01), and early mortality (5.5% vs. 2.4%, p  < .01). There was no significant difference in the procedural complications between two groups, namely vascular complications, hemopericardium/cardiac tamponade, cerebrovascular accident (CVA), major bleeding requiring blood transfusion, and systemic embolization. Through multivariable analysis, the elderly group was associated with higher odds of early mortality (OR: 7.50; CI 1.86-30.31, p  = .01), non-home discharge (OR: 2.41; CI: 1.93-3.00, p  < .01) and 30-day readmission (OR: 1.58; CI 1.32-1.89, p  < .01)., Conclusion: Elderly patients have worse in-hospital outcome, early mortality, non-home discharge, and 30-day readmission following catheter ablation for VT. There was no significant difference between elderly and non-elderly groups in the procedural complications., Competing Interests: Authors declare no conflict of interests for this article., (© 2024 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society.)

Background: Acromioclavicular joint (AC joint) disruption is a common injury with considerable variation with regards to surgical management. The Lockdown™ procedure (previously known as Surgilig™), Modified Weaver-Dunn procedure, Arthroscopic AC joint stabilization and Ligament Augmentation and Reconstruction system (LARS) procedure have all been described for treatment of this injury with varying outcomes., Purpose: To measure the functional and radiological outcomes following all cases of AC joint reconstruction using the Lockdown™ technique over the last 10 years at Medway Maritime Hospital., Methods: Data on a total of 53 patients who underwent AC joint reconstruction between 2012 and 2021 were collected. Electronic records were used to extract data regarding patient characteristics, surgery details, and duration of follow-up. Telephonic interviews of patients were conducted to collect data on hand dominance, surgical complications, and responses to Oxford shoulder score (OSS) and QuickDASH score questionnaires. Hospital PACS data were reviewed to record preoperative injury severity and postoperative acromioclavicular joint reduction., Results: Results for 42 patients were available and analysed as 10 could not be contacted and 1 patient sadly passed away. Of the patients reviewed, 92.9% were males with a mean age of 42.2 years (Range 16-67 years) and mean follow up of 68 months (12-119.1 months). The injury involved the dominant arm in 59.5%cases. Majority of the cases were Rockwood type V injuries (71.43%) while the rest were either type III(19.05%) or type IV(9.52%).The mean preoperative OSS was 21.3/48 which improved to 44.3/48 in the postoperative period. Similarly, the mean QuickDASH score was 50.6 preoperatively, that improved to 9.1 postoperatively.The most common patient reported complication was prominent metalwork seen in 5 cases (11.6%) followed by stiffness seen in 3 cases (7%) and superficial infection seen in 1 case (2.3%). The AC joint remained reduced radiologically in 81% of cases, while a resubluxation between 50 and 100% was seen in the rest of the cases. Patients with radiological resubluxation did not report this as a complication in 87.5% of the cases. Overall, 38 patients reported their outcome as excellent, 2 patients rated it good while 1 patient reported it as fair and 1 as poor., Conclusion: The Lockdown™ technique for stabilization of AC joint has excellent or good patient satisfaction in 95.2% of cases in long term follow up of more than 5.7 years. Prominent metalwork and stiffness are the commonest clinical complications. Radiological resubluxation can be seen in a fifth of the cases but does not directly lead to patient dissatisfaction., Level of Evidence: Level IV Retrospective case series., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Pleomorphic adenomas (PA) are the most common benign salivary gland tumors. They arise from the major salivary glands, as well as the minor salivary glands. They may arise rarely from the palate, oral cavity, neck, and nasal cavity also. Yet, the fourth, fifth, and sixth decades of life are the most common for them to manifest. Forty percent of them occur in males and 60% in females. It is a benign mixed tumor, which has three components: an epithelial component, a myoepithelial cell component, and a mesenchymal component. A fibrous capsule separates these cells from the surrounding tissues. It generally presents as a slowly progressing painless swelling, which is well-delineated, nonsymptomatic, and not involving the facial nerve. Salivary gland tumors can be accurately diagnosed before surgery using fine-needle aspiration (FNA), ultrasonography (USG), and computed tomography (CT) scan. Calponin, cluster of differentiation 9 (CD9), glial fibrillary acidic protein (GFAP), Mcl-2, metastasis suppressor gene (NM23), p63, S-100, smooth muscle actin (SMA), and SRY-box transcription factor 10 (SOX10) exhibit the majority of the positive reactions in pleomorphic adenomas. The diagnostic marker pleomorphic adenoma gene 1 (PLAG1) is frequently employed since it is specific for pleomorphic adenoma. Although benign, these epithelial tumors have a propensity to recur and undergo malignant transformation if incompletely excised, leading to increased morbidity in these patients. A review of the consensus guidelines and literature was conducted, and the online literature on the subject from 2002 was included. This article is not a complete review of all the available literature; rather, it is a comprehensive review of the topic., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kalwaniya et al.)

Introduction Inguinal hernia is a common surgical problem throughout the world. Currently, the management options available are open mesh hernioplasty and laparoscopic mesh repair. Laparoscopic mesh repair can be performed by either transabdominal preperitoneal (TAPP) repair or totally extraperitoneal (TEP) repair. Many studies comparing the two procedures have been unable to establish the superiority of one procedure over the other and have yielded conflicting results. Thus, we performed this study to compare TAPP and TEP. Aim The aim of this study is to compare the clinical outcomes and safety of laparoscopic TEP and laparoscopic TAPP for inguinal hernia repair. Materials and methods Patients were randomly divided into two groups on the basis of surgical procedures. The first group of patients underwent laparoscopic TAPP mesh repair, and the second group of patients underwent laparoscopic TEP mesh repair. Their intraoperative and postoperative findings were noted. Patients were followed up at regular intervals for up to six months. Results The mean age and mean weight distribution between the two groups were not significant. The duration of surgery needed (in minutes) for TAPP was found to be significantly less compared to TEP. In the TEP group, conversion to open occurred for three subjects (6.7%) while there was no conversion in the TAPP group. Postoperative pain at 24 hrs was found to be higher in TAPP subjects compared to that in TEP subjects, but the difference was statistically insignificant. Tolerance to a liquid diet started few hours after surgery was found to be the same in both groups. Association of the duration of hospital stays with the type of surgery was not significant. Six subjects (13.2%) showed hematoma in the TEP group while five subjects (11%) in the TAPP group showed hematoma after one week of surgery. Eight subjects (17.6%) showed seroma in the TEP group while three subjects (15.4%) in the TAPP group showed seroma after one week of surgery. Two subjects (4.4%) showed superficial wound infection in both the TEP group and TAPP group after one week of surgery. Four subjects each (8.9%) showed scrotal edema in the TEP group as well as the TAPP group after one week of surgery. No subject showed port site hernia without closure of the sheath at one-week, one-month, and six-month follow-up visits. Two subjects (4.4%) each showed groin pain in the TEP group as well as the TAPP group after one week of surgery. There were no instances of bowel obstruction or mesh infection. Conclusion TEP is a more skill-demanding procedure as compared to TAPP and thus takes more time to perform. However, it is superior on account of not breaching the peritoneum. TAPP is favorable for larger hernias. The choice of procedure should be individualized according to the patient's characteristics and surgeon's preference., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Jaiswal et al.)

A variety of cutaneous disorders can present to the general surgeon either directly or by referral for surgical intervention. Some conditions are commonly seen and operated on by general surgeons which include lipoma, epidermoid cyst, etc. On the other hand, some are uncommon conditions like dermatofibrosarcoma protuberans and chondroid syringoma which require a high index of suspicion to diagnose. Most general surgeons are not familiar with the latest guidelines to treat such uncommon conditions. In this article, we provide a review of uncommon cutaneous disorders requiring surgical intervention that were encountered at our high-volume tertiary care center and a discussion about their etiology, presentation, diagnosis, management and follow-up with one case report of each condition. The objective of this article is to familiarize the general surgeon with these cutaneous disorders which though uncommon, will present in their practice at some point., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Tolat et al.)

Background: A varicocele can be defined as an abnormal venous dilatation and/or tortuosity of the pampiniform plexus. It is generally reported that varicoceles are present in 15% of the general male population and 35% of men as a cause of primary infertility and in up to 80% of men as a cause of secondary infertility. Differences in venous drainage anatomy between the left and right internal spermatic veins, venous valve incompetence resulting in venous blood reflux, and increased hydrostatic pressure are the most commonly cited theories. Various surgical and non-surgical techniques are in use for treating patients with varicocele. Here we used a modified Palamo procedure to treat the patients and observed the outcome., Methodology: A total of 40 patients with varicocele were recruited for the study. A preoperative evaluation, along with serum testosterone levels and semen analysis, was done. A modified Palomo technique was used to treat varicocele. A postoperative follow-up with serum testosterone levels and semen analysis was done to observe improvement., Results: The mean (±SD) left testis size, right testis size, testosterone, sperm concentration, sperm vitality and sperm progressive motility were found statistically significantly higher in patients after surgery as compared to patients before surgery (p<0.05). However, there was statistically insignificant mean difference in semen volume between patients before surgery and patients after surgery (p>0.05)., Conclusion: Modified Palomo procedure can be used to treat varicocele with good improvement in serum testosterone levels and semen parameters., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kalwaniya et al.)

Background Serum albumin is generally considered to be a predictor of patients' nutritional status. Previous studies have used serum albumin to assess postoperative morbidity, mortality, and various other surgical outcomes in cardiac surgeries and elective gastrointestinal surgeries. In this study, we used preoperative serum albumin levels to assess postoperative surgical site wound complications in patients who underwent emergency exploratory laparotomy. Methodology Preoperative serum albumin level was observed in 60 patients who underwent emergency exploratory laparotomy due to various pathological conditions and were divided into those with hypoalbuminemia (serum albumin level <3.5 g/dl and >3.5 g/dL). Postoperative surgical site infections, wound dehiscence, and various complications, such as duration of hospital stay, prolonged ileus, the incidence of enterocutaneous fistula, the incidence of anastomotic leak, and 30-day mortality, were assessed. Results In our study, about 65% of the patients had hypoalbuminemia. Among them, 56.4% of the patients had surgical site infections according to the Southampton grade, with a statistically significant p-value of <0.001. Moreover, 87.2% of the patients had wound dehiscence according to the World Union Wound Healing Societies Surgical Wound Dehiscence wound grading, with a statistically significant p-value of <0.001. In addition, statistical significance was noted between preoperative hypoalbuminemia and increased postoperative hospital stay, with a p-value of <0.001. Conclusions Preoperative serum albumin value is a formidable predictor of postoperative surgical site infections, wound dehiscence, and duration of hospital stay in patients who underwent emergency exploratory laparotomy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Naga Rohith et al.)

Background: Cardiac implantable electronic device (CIED) implantation is increasingly performed worldwide with improving safety. Outpatient CIED implantation has similar complication rates compared to those implants which are hospitalized. Here, we analyze patient preferences on discharge timing after CIED implantation., Objective: To identify and understand the factors contributing to patient preferences towards same-day or next-day discharge after CIED implantation., Methods: One hundred and two patients undergoing new CIED implants were included in the study at two separate hospitals in CT (CT group) and FL (FL group) from 2018-2019. A 7-question survey was administered to the patients after the procedure. Survey responses and demographic data were statistically analyzed., Results: Seventy-four percent of CT group and 58% of the FL group responded with a 10 score (0-10) that they were ready to be discharged home the same day (p=0.09). Both groups reported a low number of patients feeling safer by having a remote monitor provided at the time of discharge (44% CT group, 28% FL group; p=0.123). The mean distance of patients living from the hospital in CT group (21.6 miles) was significantly lower than that for the FL group (35.5 miles); p=0.01. Hypertension (86% vs 52%; p=0.0002) and Diabetes mellitus (44% vs 21%; p=0.013) were more prevalent in the FL group compared to the CT group., Conclusion: Despite the influence of local practices, the majority of patients preferred same-day discharge after CIED implantation. Improved patient education regarding the ability of remote monitors to provide real-time response to acute events is needed., Competing Interests: Declaration of competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2021 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.)

Background: Utilization of catheter ablation of ventricular tachycardia (VT) has steadily increased in recent years. Exploring short-term outcomes is vital in health care planning and resource allocation., Methods: The Nationwide Readmissions Database from 2010 to 2014 was queried using the ICD-9 codes for VT (427.1) and catheter ablation (37.34) to identify study population. Incidence, causes of 30-day readmission, in-hospital complications as well as predictors of 30-day readmissions, complications, and cost of care were analyzed., Results: Among 11 725 patients who survived to discharge after index admission for VT ablation, 1911 (16.3%) were readmitted within 30 days. Paroxysmal VT was the most common cause of 30-day readmission (39.51%). Dyslipidemia, chronic kidney disease (CKD), previous CABG, congestive heart failure (CHF), chronic pulmonary disease, and anemia predicted increased risk of 30-day readmissions. The overall in-hospital complication rate was 8.2% with vascular and cardiac complications being the most common. Co-existing CKD and CHF and the need for mechanical circulatory support (MCS) predicted higher complication rates. Similarly increasing age, CKD, CHF, anemia, in-hospital use of MCS or left heart catheterization, teaching hospital, and disposition to nursing facilities predicted higher cost., Conclusion: Approximately one in six patients was readmitted after VT ablation, with paroxysmal VT being the most common cause of the readmission. A complication rate of 8.2% was noted. We also identified a predictive model for increased risk of readmission, complication, and factors influencing the cost of care that can be utilized to improve the outcomes related to VT ablation., (© 2020 Wiley Periodicals, Inc.)

Non-surgical left atrial appendage occlusion has emerged as an alternative to anticoagulant therapy in the management of stroke risk in patients with atrial fibrillation. This review reports on some of the more common devices that are currently being used to manage patients in this challenging group., Competing Interests: The authors declare no conflict of interest.

Background: Implantable cardioverter defibrillator (ICD) implantation is being performed differently at many hospitals, with some keeping patients overnight after procedure while others discharge patients home same day. In addition, many centers are now performing ICD surgery while on warfarin anticoagulation. There are, however, limited data on outpatient ICD surgery on anticoagulated (AC) patients., Objective: We wished to evaluate the safety of performing outpatient ICD surgery with and without warfarin anticoagulation., Methods: We evaluated 866 patients who underwent outpatient ICD surgery between April 2010 and September 2014. Patients who were on novel oral anticoagulants, or did not have an international normalized ratio drawn within 24 hours of the procedure were excluded and the remainder were divided into two groups based on whether they were on (n = 230) or off (n = 518) warfarin anticoagulation. We evaluated both procedural and 30-day complications in both groups., Results: The complication rate at 30 days in the warfarin AC group was 4.3%, while in the nonanticoagulated (NAC) group was 2.9% and not significantly different (P = 0.31). However, the pocket hematoma rate in the warfarin anticoagulated group was 3.5%, as compared to the NAC group that was 0.4% (P = 0.001)., Conclusion: Complications from ICD surgery are low in the ambulatory setting on or off warfarin anticoagulation and appear to be comparable. However, warfarin use during ICD surgery is associated with an increased risk of pocket hematoma., (© 2016 Wiley Periodicals, Inc.)

Sleep is thought to play an important role in memory consolidation. Here we tested whether sleep alters the subjective value associated with objects located in spatial clusters that were navigated to in a large-scale virtual town. We found that sleep enhances a generalization of the value of high-value objects to the value of locally clustered objects, resulting in an impaired memory for the value of high-valued objects. Our results are consistent with (a) spatial context helping to bind items together in long-term memory and serve as a basis for generalizing across memories and (b) sleep mediating memory effects on salient/reward-related items., (© 2015 Javadi et al.; Published by Cold Spring Harbor Laboratory Press.)

Introduction: Direct excision of a symptomatic ununited hook of hamate fracture is the gold standard, most frequently via a Guyon space approach. The open carpal tunnel approach is another option, which has not previously been commonly considered and not reported in a peer review journal. Our study aims to highlight the carpal tunnel approach as a successful technique in a consecutive series of ununited hook of hamate fractures., Patients and Methods: Seven patients (all male and mean age 30.7 years) were reviewed with symptomatic ununited fractures following a period of cast immobilization. All the patients operated on underwent excision of the hook of hamate fragment via the open carpal tunnel approach., Results: All patients successfully returned to their pre-injury level of functioning after 8-12 weeks and there were no complications., Conclusions: Our study highlights the open carpal tunnel approach as a successful technique for open excision of symptomatic ununited hook of hamate fractures, because of its familiarity, ease of performance, excellent visualization and low morbidity. Level of Evidence IV Case Series., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

An athletic 43-year-old man presented with symptomatic bradycardia and atrial flutter after being diagnosed with HLA B27 associated spondyloarthropathy several months earlier. The patient was admitted and underwent electrophysiology evaluation with ablation of his atrial flutter and eventually underwent pacemaker implantation. His cardiac workup showed a structurally normal heart and strongly suggested that his HLA B27 associated spondyloarthropathy was responsible for his presentation. A review of the literature suggests that HLA B27 spondyloarthropathy related heart block may be an often overlooked cause of heart block in otherwise healthy patients.

Injury to the superior gluteal artery as a result of pelvic fracture is well recognized. Superior gluteal artery bleed leading to gluteal compartment syndrome without fracture of the pelvis has been reported but is extremely rare. Similarly, acute compartment syndrome of the thigh is rare. As far as is known, no previous case has been reported where a combination of pelvic fracture and superior gluteal artery bleed has led to acute gluteal and thigh compartment syndrome. We report on such a patient who developed these complications and highlight the importance of early detection, which may be difficult in an unconscious or comatose patient.

The objective of this study was to measure the normal variation of QT dispersion (QTd) with respect to age and gender. The QT interval is a measure of the duration of ventricular depolarization and repolarization, while the QTd is a measure of the variability of the ventricular recovery time. The QTd has been suggested as a means of identifying those patients at risk for sustained ventricular tachyarrythmias and sudden cardiac death (SCD). A total of 250 patients (120 women, 130 men; age range 20-86 years) were recruited for this study. The QT intervals were measured in each of the 12 standard leads of the electrocardiogram. Data are presented as mean (mu) +/- SD. The QTd did not vary significantly within the same gender. A significant difference (P < 0.001) was noted in QTd between men (age [mu] = 53.3 +/- 15.6 years, QTd = 0.044 +/- 0.019 s) and women (age [mu] = 52.1 +/- 15.1 years, QTd = 0.034 +/- 0.015 s). Overall, men had a greater QTd, while women had a longer QT. In conclusion, we found that men had a longer QTd, which may explain the increased risk of SCD. However, women have a longer QT interval with a smaller QTd. A longer QTmin, as opposed to a longer QTmax, is responsible for the shorter QTd in women. This longer QTmin in women may predispose to an increased risk of drug induced torsades de pointes.

Four patients had magnetic resonance imaging (MRI) after a clinical diagnosis of a flexor digitorum profundus tendon rupture of the hand. The delay before presentation ranged from 1 to 5 weeks. Three patients had closed ruptures and one had a minor laceration which had healed. MRI showed proximal retraction of the profundus tendon to the palm in two patients and limited retraction in the other two. MRI provides important preoperative information for surgical decision-making and planning in patients who present late with closed flexor tendon injuries of the hand.

Fifty preserved cadaver wrist specimens were studied. The anatomy of the distal radioulnar joint is complex, with varying configurations in the transverse and midcoronal planes. There is disparity in the radii of curvature of the sigmoid notch and the ulna-articular surface in the transverse plane, with resultant articular incongruity. Motion at the distal radioulnar joint is, hence, likely to be a combination of sliding and rotation with a small area of true appositional contact. The palmar osteocartilaginous lip of the sigmoid notch, along with the interosseous membrane, may be of importance in distal radioulnar stability. Palmar and dorsal radioulnar ligaments may act as "check-rein" ligaments, especially when seen with the "flat face" (type A) sigmoid notch.

A total of 43 patients (49 hands; 424 flexor tendons), who had rheumatoid arthritis of more than 15 years duration at the time of surgery, were clinically assessed at a mean follow-up of 5.7 years (range, 1.2-12 years). Pain and inability to flex actively despite a good passive range of motion were the main surgical indications. The results suggest that the patients had excellent sustained pain relief (mean score = 0.9) and were highly satisfied with the outcome of the procedure (mean score = 2.2). 81% had adequate pulp-to-pulp and key pinch. Range of finger motion (total active motion, TAM) was excellent to good in 45% and fair in 22%. Thirty-three per cent were graded as poor and these were found to be multifactorial in origin, with associated significant joint disease, preoperative tendon ruptures, extensive digital surgery, readhesions and combinations of operative procedures which adversely affect the rehabilitation programme. Flexor tenosynovectomy with tenolysis is a useful procedure with a low rate of recurrence.

A comparative analysis of the DNA sequences of primary and secondary IgM, fluorescein-specific antibodies was performed. These antibodies were secreted by hybridomas generated following fusion of immunized BALB/c mouse lymphocytes and SP2/0 myeloma cells. Our results show that primary and secondary fluorescein-specific IgM antibodies use a variety of segments from the variable region of the immunoglobulin heavy chain locus (VH), with members of the J558 and 7183 VH gene families predominating in both populations. D regions from the DF116 and DSP2 families were used exclusively in our primary antibody sample and predominated in the secondary response. In the primary antibodies, 15 out of 18 definable D regions were transcribed in reading frame one, but in the secondary antibodies the three reading frames were used stochastically. Secondary IgM antibodies showed a higher frequency of somatic mutation than their primary counterparts, but we could detect no evidence of selection for mutations in the complementarity determining regions as compared with the framework regions. It appears that fusion of secondary cells, 3-6 days after immunization, is able to 'capture' the IgM-producing population of B cells at a stage in their development following mutation but prior to antigenic selection.

We report a long-term follow-up of 6 to 11.8 years (mean = 8 years) of our first 50 Swanson wrist arthroplasties. All patients had long standing sero-positive rheumatoid arthritis with a mean age of 48 years. A detailed clinical and radiologic assessment was carried out on all the wrists. There was excellent sustained pain relief (mean score = 1.7) with improved activities of daily living. A mean range of wrist movement of 25 degrees of extension and 31 degrees of flexion was obtained. The prosthetic fracture rate was 22% of which 14% were symptomatic and needed re-operation. Carpal collapse was seen in all wrists, but was often symmetrical and accompanied by radial new bone formation on X-ray (86%). We feel that our long-term results justify the continued selective use of the Swanson wrist in the low-demand patient with quiescent disease who desires pain-free limited mobility and sophisticated grasp.

A technique is described of increasing the length of a palmaris longus tendon graft by including palmar aponeurosis. The additional 5 cm is often useful in treating high flexor tendon ruptures, especially at the wrist level, without the need for an additional incision.

Five cases of symptomatic acquired positive ulnar variance are described. All cases occurred due to premature physeal closure of the growth plate in teenage girl gymnasts. All cases demonstrated ulnocarpal impingement, for which we describe a clinical test. Arthroscopic assessment of the wrist allowed us to assess the integrity of the TFCC (triangular fibrocartilaginous complex) and decide on the most appropriate surgery. Two patients needed distal ulna recession and one needed shaving for a TFCC perforation, with a good result.