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Background Our objective was to identify acetabular fractures in the elderly population (over 60 years of age), treated with open reduction and internal fixation (ORIF), and to examine their outcomes, primarily the risk for need for further surgery in the form of a total hip arthroplasty (THA), and factors associated with it. Additional outcomes such as infection, avascular necrosis (AVN) of the femoral head, and heterotopic ossification (HO) were also investigated. Methods Following institutional review board (IRB) approval, a retrospective analysis of all consecutive patients presenting to a Level I Trauma Centre over a 13-years period (January 2003–February 2016) was conducted. Patients were excluded if their initial treatment was conservative or simultaneous ORIF with THA. Results A total of 62 patients with an age of 71.5 ± 8.04 years were included (14 female; follow-up 54.2 months, range 1–195 months). Sixteen patients required a THA as a secondary procedure due to symptomatic post-traumatic arthritis (25.8%), five (8.1%) of whom having a THA within a year from the original trauma (three patients presenting with loss of reduction and two patients with early AVN). No associations with progression to THA were identified. Surgical approach (ilioinguinal) was the only factor associated with increased risk of development of HO (p = 0.010). The median post-operative survival following an acetabular fracture treated with ORIF was calculated at 90.1 months (95% CI 72.9–107.2). Conclusion Acetabular fractures ORIF in the elderly, is a safe and reliable option. The relatively incidence of development of severe post-operative arthritis was 45.2%. Conversion to THA was 25.8%, with 8.1% having the arthroplasty procedure within a year of the original trauma surgery. Level of evidence III.

The incidence of hip fractures and subtrochanteric fractures in particular is increasing, along with the globally expanding aging population. Intramedullary nailing remains the 'gold standard' of their treatment. Blood loss can be a result of the original trauma, but also secondary to the subsequent surgical insult, especially during the reaming of the intramedullary canal.The aim of our study was to report on the blood loss and incidence of blood transfusion in patients presenting with a subtrochanteric fracture treated with intramedullary nailing. Most importantly, we aim to identify factors associated with the need for transfusion within the first 48 h post-operatively.Following institutional board approval, 431 consecutive patients (131 males; age: 79.03 years old, SD 13.68 years) presenting in a Level 1 Trauma Centre with a subtrochanteric fracture treated with an intramedullary nail were retrospectively identified, over an 8-year period. Exclusion criteria included patients with high energy injuries, pathological fractures, primary operations at other institutions and patients lost to follow-up. To identify risk factors leading to increased risk of transfusion, we first compared patients requiring intra-operative transfusion or transfusion during the first 48 h post-operatively against those who did not require transfusion. This was then followed by multivariate regression analysis adjusted for confounding factors to identify the most important risk factors associated with need for transfusion within the first 48 h post-operatively.Incidence of blood transfusion was 6.0% pre-operatively, compared to 62.7% post-operatively. A total of 230 patients (52.3%) required either intra-operative transfusion or transfusion during the first 48 h following surgery. Patients having a transfusion within the first 48 h post-operatively had a higher incidence of escalation in their care (p = 0.050), LOS (p = 0.015), 30-day (p = 0.033) and one-year mortality (p = 0.004). Multivariate regression analysis adjusted for confounding factors identified that the most important association of a need for transfusion within the first 48 post-operative hours was a pre-operative Hb100 g/L (OR 6.64); a nail/canal ratio70% (OR 3.92), followed by need for open reduction (OR 2.66). Fracture involving the lesser trochanter was also implicated with an increased risk (OR 2.08). Additionally, pre-operative moderate/severe renal impairment (OR 4.56), as well as hypoalbuminaemia on admission (OR 2.10) were biochemical predictors of an increased risk of transfusion. Most importantly, the need for transfusion was associated with an increase in 30-day mortality (OR 12.07).Several patient, fracture and surgery related factors are implicated with an increased risk for transfusion within the first 48-h post-operatively. Early identification, and where possible correction of these factors can potentially reduce blood loss and risk of transfusion, along with all the associated sequelae and mortality risk.III.

Continuous data collection on all new isolates of MRSA via CoSurv has taken place in Wales since January 1996. In order to audit this data collection, and to address some of the issues that it does not include, a survey of MRSA was carried out. Questionnaires were completed by infection control teams. Rates were calculated using hospital throughput denominators. Results from the one-day prevalence survey, the two-week incidence survey, and the follow-up survey carried out on new MRSA patients identified in the incidence survey, are presented. Results were found to be broadly similar to those collected via routine surveillance. MRSA was found frequently and disproportionately in the elderly, with higher rates in male than female patients. The highest incidence of total and invasive MRSA was in males aged 75 and over (total: 12.5/1000 finished consultant episodes; invasive: 2.8/1000). Although there was a large community reservoir of MRSA, most appeared to have been acquired in hospital, since most patients had a history of hospitalization, often with multiple hospital admissions. Community-based isolates from cases with no hospital history tended to have been from ulcers. Prevalence and incidence of MRSA was relatively low compared with hospital throughput (mean prevalence: 2.4/100 occupied beds; mean incidence: 3.6/1000 finished consultant episodes), there was also quite large variation between sites, even when screening samples were removed. Patients with MRSA had strikingly long stays before isolation of the organism (prevalence survey: 39 days; incidence survey: 31 days) and highest incidence occurred in elderly care wards. The outcome survey showed that approximately half of the patients were treated with some type of antimicrobial therapy for MRSA. Decontamination therapy was associated with clearance of MRSA only when controlling for sex of the patient. The majority of patients were discharged still with MRSA, mostly to their own homes. The survey emphasizes the need to continue surveillance to detect any changes, to allow guidelines based on evidence to be developed and to monitor the effectiveness of such guidelines.

A recent resurgence in serious infections due to Haemophilus influenzae type b (Hib) has been observed in the United Kingdom. More information on Hib transmission in the population is required in order to better understand the mechanism of this increase. The Public Health Laboratory Service (subsumed into the Health Protection Agency since April 2004) conducted four cross-sectional studies of asymptomatic oropharyngeal Hib carriage in children attending day-care nurseries in England and Wales in 1992, 1994, 1997 and 2002. These demonstrated a marked reduction in the prevalence of Hib colonization over time since vaccine introduction (3·98% in 1992; 0·70% in 1994; 0% in 1997; 0% in 2002), which did not explain the increase in invasive disease reports from 1999 onwards. We believe that a reduction in antibody levels over the first 5 years of life in immunized children in recent years has fuelled the rise in reported cases in the absence of an obvious increase in transmission.

SummaryThis survey defined the pattern of invasiveHaemophilus influenzaeinfections during 1990–2 in six regions in England and Wales during the pre-vaccination era providing a baseline against which any changes in patterns of disease due to the introduction of theHaemophilus influenzaetype b vaccination programme can be monitored. A total of 946 cases of invasiveHaemophilus influenzaewere recorded during the survey period of which almost 90 % were due to type b and most of the remainder were non-typeable. Type b infections occurred predominantly in children less than 5 years of age (88%) with the highest attack rate in male infants in the 6–11 month age group. Diagnostic category varied with both age and serotype; meningitis was the commonest presentation overall but pneumonia and bacteraemia were more common in adults and non-typeable isolates. Mortality was highest in neonates and the elderly (over 65 years of age) who were more likely to have an underlying predisposing condition than older children and adults. Children under 5 years of age had a higher case fatality rate for non-typeable than for type b infections. Ampicillin resistance was 15% and there were no cefotaxime resistant type b isolates.

This paper deals with future subaqueous tunnels: first, by describing briefly some of the bored tunnelling opportunities that are being considered at the present; and then by suggesting ways in which technology may need to be developed in order to carry out these projects. The paper also considers the financial implications of such research and development.

Introduction We describe a case of rapidly progressive and severely debilitating polyneuropathy in a patient with confirmed hypovitaminosis B1, consistent with dry beriberi. Crucially, this is a treatable condition, although sometimes with incomplete recovery, but it is probably under-recognized yet increasingly common given increasing levels of alcohol abuse in the western world. Case presentation A 49-year-old Caucasian British man presented with progressive weakness of both lower limbs of approximately seven months' duration. He noted difficulty climbing stairs. He also complained of lethargy, and loss of muscle bulk, including his thighs. He had a history of type 2 diabetes mellitus and admitted prior alcohol abuse but denied excessive alcohol intake in the five years prior to presentation. Initial clinical and neurophysiological examinations were consistent with a mild peripheral neuropathy and probable proximal myopathy. However, over the subsequent four months he evolved a marked tetraparesis, with profound sensory disturbance of all limbs. Repeat neurophysiology revealed a widespread polyneuropathy with extensive acute and sub-acute denervation changes in all four limbs, and reduced or absent sensory nerve action potentials. Hypovitaminosis B1 was confirmed (45 nmol/L, reference range 66-200 nmol/L). His rapid clinical deterioration was in keeping with dry beriberi. He was treated with thiamine. Subsequent follow-up revealed slow but significant improvement, such that by 15-16 months from the initial onset of symptoms, and approximately six months after the onset of his marked tetraparesis, he was able to stand independently and was gradually gaining confidence in walking pending a period of in-patient neurorehabilitation. Conclusion A potentially wide differential diagnosis exists for this type of presentation. Confirming hypovitaminosis B1 by requesting the assay prior to vitamin replacement ensures accurate diagnosis and appropriate ongoing treatment. An increasingly high index of suspicion is likely to be required in the context of increasing levels of alcohol abuse in the western world and the possible increasing prevalence of dry beriberi.

Resistance to fusidic acid among community methicillin susceptible Staphylococcus aureus (MSSA) isolates in the United Kingdom and prescriptions for fusidic acid have both doubled over the past 6 years. A retrospective case–control study was undertaken to test the hypothesis that the use of topical fusidic acid is associated with the isolation of resistant organisms. A statistically significant association was found between fusidic acid resistance in MSSA isolates and exposure to topical fusidic acid (odds ratio: 2.77, 95%CI 1.01–7.93, P =0.027). This study demonstrates for the first time an association between the use of topical fusidic acid and resistance at the individual patient level and supports the hypothesis that the observed increase in resistance is causally associated with the increased use of topical fusidic acid.

Since 1990 we have been monitoring strains of Haemophilus influenzae referred to the Public Health Laboratory Service Haemophilus Reference Laboratories from all cases of invasive H influenzae disease from five English regions and Wales. Methods of reporting and participating laboratories have remained constant over this period, which allowed us to compare the incidence of infection before and after the introduction of vaccination against H influenzae type b in October 1992. The case definition was a systemic infection in which culture of normally sterile body fluid revealed H influenzae, or the organism was detected by antigen to H influenzae type b. Organisms were identified and typed at the reference laboratories using both type specific antisera …

Editor—Crowcroft and Catchpole conclude from a study of death certificates that infections due to methicillin resistant Staphylococcus aureus are an increasing cause of mortality in England and Wales.1 That this was likely to have been the case in Wales over the period of their study, 1993-8, is supported by surveillance data, which show a large rise in bacteraemias caused by S aureus between 1991 and 1997 (figure). This can largely be attributed to increasing occurrence of methicillin resistant S aureus as a cause of these infections from 1993, although a smaller rise in methicillin sensitive S aureus bacteraemias was also recorded. The degree to which this increase in staphylococcal bacteraemias has affected outcomes in relation to the underlying clinical conditions is, however, unknown, and for the reasons pointed out by Liggett and Swift in their electronic response cannot be accurately inferred from data derived from death certificates.2 The Welsh surveillance data do not support the statement that the number of infections caused by methicillin resistant S aureus is continuing to increase every year in England and Wales and the supposition that mortality is also continuing to rise. The number of bacteraemias in Wales has changed little since 1997, and laboratory reports relating to overall numbers of isolates from infected and colonised patients reached a plateau in 2000 after a comparatively small rise between 1998 and 2000 (5650 to 6031 reports). Presumably the steady state that has been achieved reflects the interaction of the innate transmissibility and virulence of the S aureus clones circulating; the ability to prevent transmission and infection; and the selective pressure exerted by usage of antibiotics. To shift this steady state and reduce the overall burden of disease caused by S aureus new initiatives that prevent transmission and infection and reduce the selective pressure from using antibiotics will need to be introduced on a wide scale.