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Streptococcus agalactiae (group B Streptococcus) colonizes the genital tract of approximately 20% of pregnant women. In the absence of intervention, approximately 1% of infants born to colonized mothers exhibit a clinical infection. This has led to implementation of screening and intervention in the form of intrapartum antibiotic prophylaxis in many countries, including the United States. However, screening has not been introduced in a substantial minority of other countries because of the absence of supportive level 1 evidence, the very large number needed to treat to prevent 1 case, and concerns about antimicrobial resistance. Optimal screening would involve rapid turnaround (to facilitate intrapartum testing) and report antibiotic sensitivity, but no such method exists. There is significant scope for a personalized medicine approach, targeting intrapartum antibiotic prophylaxis to cases at greatest risk, but the pathogen and host factors determining the risk of invasive disease are incompletely understood. Epidemiologic data have indicated the potential of prelabor invasion of the uterus by group B Streptococcus, and metagenomic analysis revealed the presence of group B Streptococcus in the placenta in approximately 5% of pregnant women at term before onset of labor and membrane rupture. However, the determinants and consequences of prelabor invasion of the uterus by group B Streptococcus remain to be established. The vast majority (98%) of invasive neonatal disease is caused by 6 serotypes, and hexavalent vaccines against these serotypes have completed phase 2 trials. However, an obstacle to phase 3 studies is conducting an adequately powered trial to demonstrate clinical effectiveness given that early-onset disease affects approximately 1 in 1000 births in the absence of vaccination.

The critical shoulder angle (CSA) is a surrogate marker of the coronal plane morphology of the scapula. CSA differences between scapulae could be due to differences in glenoid inclination (GI) or the location of the most lateral part of the acromion relative to the inferior glenoid, or both. An understanding of the hierarchy of the scapular morphological changes associated with glenohumeral osteoarthritis (GHOA) and rotator cuff (RC) tears would allow accurate biomechanical modeling.A prospective observational case control study was undertaken in which the GI, "nonglenoid"-CSA, acromial vertical offset index, acromial horizontal offset index, acromial horizontal-vertical offset index, and coronal plane angulation of the acromion (CPAA-m) were measured on high-quality radiographs to compare coronal plane scapular anatomy in: (1) patients with asymptomatic atraumatic full-thickness RC tears, (2) patients with symptomatic primary GHOA, and (3) a control group with no RC tear or GHOA treated for glenohumeral instability or symptomatic labral pathology. Intraobserver reliability of the measurements was performed.In the GHOA group, the GI was lower (less superiorly inclined) than the RC tear group (difference between the means: -4.8°, 95% confidence interval [CI] [-8.8°, -0.9°], P = .014) and the control group (difference between the means: -7.9°, 95% CI [-11.8°, -3.9°], P = .000); there was no difference in the acromial measurements. In the RC tear group, the nonglenoid-CSA was higher (difference between the means: 7.7°, 95% CI [3.0°, 12.3°], P = .001), the acromial vertical offset index was lower (difference between the means: -0.13, 95% CI [-0.24, -0.01], P = .026), and the acromial horizontal-vertical offset index was higher (difference between the means: 0.15, 95% CI [0.01, 0.28], P = .030) than the control group; there was no difference in the acromial horizontal offset index or the GI. The CPAA-m was lower (greater coronal plane downslope of the acromion) in both GHOA (difference between the means: -9.6°, 95% CI [-18.6°, -0.5°], P = .036) and RC tears (difference between the means: -9.9°, 95% CI [-19.0°, -0.9°], P = .029) compared with the control group. The intraclass correlation coefficients for intraobserver reliability demonstrated excellent reliability for the measurements (all0.900).Scapulae associated with GHOA have lower GI, but no spatial differences in the location of the lateral acromion compared with a normal population. Scapulae associated with RC tears have a lower vertical offset of the lateral acromion, but no difference in horizontal offset or GI compared with a normal population. The downslope of the acromion in the coronal plane is greater (lower CPAA-m) in both RC tears and GHOA than the normal population.

Purpose The objective of this study was to compare the biomechanics of using a double layered human dermal allograft to a single layered human dermal allograft in superior capsular reconstruction. Methods Five cadaveric shoulders were tested. The superior translation of the humerus and the subacromial contact pressure were measured at 0°, 30° and 60° of glenohumeral abduction in the following six conditions: (1) intact rotator cuff, (2) irreparable supraspinatus tear, (3) superior capsular reconstruction using a double layered human dermal allograft with and (4) without posterior suturing, (5) superior capsular reconstruction using a single human dermal allograft with and (6) without posterior suturing. Results There was a significant increase in superior translation of the humerus and subacromial contact pressure when comparing torn supraspinatus to intact shoulder. All superior capsular reconstruction repairs lead to a reduction in superior translation and subacromial contact pressures compared to after the supraspinatus tear except for single layered superior capsular reconstruction repair without posterior suturing. There was no difference in superior translation and subacromial contact pressures comparing the intact shoulder to any of the superior capsular reconstruction constructs. Conclusion Superior capsular reconstruction using a single or double layered human dermal allograft improves superior translation after supraspinatus repair. There is some biomechanical benefit of a double layered human dermal allograft technique over a single layered graft technique in superior capsular reconstruction. Level of Evidence IV

To determine whether a high critical shoulder angle (CSA) is associated with symptomatic full-thickness rotator cuff (RC) tears and/or whether a low CSA is associated with primary glenohumeral osteoarthritis (GHOA).A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All observational studies that examined an association between CSA and full-thickness RC tears and/or primary GHOA were included. A primary meta-analysis was performed including all studies that met the inclusion criteria regardless of radiographic quality. A secondary meta-analysis was performed to explore the hypothesis that radiographic quality was a source of heterogeneity, which excluded those studies in which radiograph quality was not strictly defined and controlled.For the primary meta-analysis, 11 studies met the inclusion criteria for RC tears and 5 for primary GHOA. The CSA was greater in the RC tear group than the control group (mean difference 4.03°, 95% confidence interval 2.95°-5.11, 95% prediction interval 0.0487°-8.01°; P.001). The CSA was lower in the GHOA group than the control group (mean difference -3.98°, 95% confidence interval -5.66° to -2.31°, 95% prediction interval -10.2° to -2.19°; P.001).A high level of heterogeneity was observed in the RC tear analysis (IThere is a reciprocal change in magnitude of the CSA when evaluating symptomatic full-thickness RC tears versus primary GHOA as compared with control subjects. Radiographic quality is a source of heterogeneity in studies that investigate a link between CSA and RC tears and primary GHOA.Level III, systematic review and meta-analysis of Level III studies.

To compare the axial plane orientation and width and length of the acromial resections required to reduce the critical shoulder angle (CSA) using lateral acromioplasty (LA) techniques that are based on the lateral acromial border with an ideal resection that is oriented parallel to the glenoid.This was a retrospective observational cohort study of symptomatic patients that were investigated for shoulder pain, instability, or fracture with high-quality computed tomography (CT). The CT scan data were used to create 3-dimensional meshes, and a series of LA resection planes were mapped. The orientation, width, and length of each resection based on the lateral acromial border (lateral, anterolateral, posterolateral, and image guided) to reduce the measured CSA to 35° or 30° was compared with an ideal resection that was oriented parallel to the glenoid.23 models had CSA 30.1° to 35°, and 13 had CSA35°. In the models with CSA35°, there was no angular difference between the resection planes of the lateral, anterolateral, or image-guided resections compared with the ideal technique; there were differences in the required width and length of the resections to reduce the CSA to 35° (additional width/length: lateral, 3.2/14.8 mm; anterolateral, 2.8/10.6 mm; posterolateral, 6.9/19.2 mm; image guided, 2.4/10.3 mm). Width and length differences were also present in the models with CSA30° when the resections aimed to reduce the CSA to 30° (additional width/length: lateral, 2.5/12.5 mm; anterolateral, 1.9/8.8 mm; posterolateral, 7.4/19.0 mm; image guided, 1.6/8.8 mm).LA techniques based on the lateral acromial border did not replicate the ideal resection and may lead to excessive deltoid release which could adversely affect clinical results.Our findings do not support LA techniques based on the lateral acromial border.

Importance The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence. Objective To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older. Design, Setting, and Participants In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses. Intervention Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR). Main Outcomes and Measures The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use. Results In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI −5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48;P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69;P = 0.02). Conclusions and Relevance This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people. Trial Registration http://anzctr.org.auidentifier: ACTRN12616000969460

Accurate insertion of a guidewire under image intensifier guidance is a fundamental skill required by orthopaedic surgeons. This study investigated how image intensifier distortion, which is composed of pin-cushion and sigmoidal components, changed the apparent trajectory of a guidewire, and the resulting deviation between the intended and actual guidewire tip position. Intraoperative image intensifier images for 220 consecutive patients with hip fractures were retrospectively corrected for distortion using a global polynomial method. The deviation between the intended and actual guidewire tip positions was calculated. Additional distortion parameters were tested using an image intensifier produced by a different manufacturer, and a flat-panel c-arm. Deviation was approximately 1 cm if the guidewire was aimed from the extremity of the image and almost 0 if the entry point was only 20% from the centre (p

Purpose To compare critical shoulder angle (CSA) measurements using high-quality radiographs in the following groups: Group 1: symptomatic atraumatic full-thickness rotator cuff (RC) tears; Group 2: symptomatic primary glenohumeral osteoarthritis (GHOA); and Group 3: no RC tear or primary GHOA being treated for glenohumeral instability or symptomatic labral pathology (control group). Methods A prospective observational case control study with 10 shoulders in each group was performed GHOA and full-thickness RC tears were diagnosed by radiographs and magnetic resonance imaging (MRI). For these three groups, the exclusion criteria were the following: Group 1) partial thickness RC tears, traumatic RC tears, isolated subscapularis tears, and advanced cuff tear arthropathy with erosion of the superior glenoid; Group 2) secondary causes of glenohumeral arthritis; coexistent full-thickness RC tear; and Group 3) glenoid bone lesions that may affect the CSA measurement. Only shoulders with adequate radiographic quality (Suter-Henninger type A and C) were eligible. A one-way ANOVA, followed by Tukey multiple pairwise-comparisons test, was performed to compare the groups. Interobserver and intraobserver reliability was assessed using Intraclass Correlation Coefficients (ICC). Results Mean CSA values were 37.4° ± 4.7 (RC tear group), 28.9° ± 2.4 (GHOA group), and 32.8° ± 1.1 (control group). The CSA of the RC group was higher than the control group (P = .006) and the GHOA group (P = .000). The CSA of the GHOA group was lower than the control group (P = .027). Intraobserver and interobserver reliabilities for the CSA measurement were excellent (Observer 1 [ICC]: .986 [95% CI .970-.993]; Observer 2 [ICC]: .976[95% CI .951-.989]; and Observer 1v2: 0.968[95% CI .933-.985]). Conclusions There is a difference in the CSA between patients with symptomatic atraumatic full-thickness RC tears (4.6° higher than the control group), symptomatic GHOA (3.8° lower than the control group), and glenohumeral instability or labral pathology with no RC tear or GHOA. Level of Evidence Level 2, prospective observational case control diagnostic study

The self-reinforcement mechanism after double row suturebridge rotator cuff repair generates increasing compressive forces at the tendon footprint with increasing tendon load. Passive range of motion is usually allowed after rotator cuff repair. The mechanism of self-reinforcement could be adversely affected by shoulder abduction. Rotator cuff tears were created ex vivo in nine pairs of ovine shoulders. Two different repair techniques were used. One group was repaired using a double row ‘suturebridge’ construct with tied horizontal medial row mattress sutures (Knotted repair group). The other group was repaired identically except that medial row knots were not tied (Knotless repair group). Footprint compression was measured at varying amounts of abduction and under tendon loads of 0, 10, 20, 30, 40, 50 and 60N. The rate of increase of contact pressure (degree of self-reinforcement) was calculated for each abduction angle. Abduction diminishes footprint contact pressure in both knotted and knotless double row suturebridge constructs. Progressive abduction from 0 to 40 abduction in the knotless group and 0–30 in the knotted group results in a decrease in self-reinforcement. Abduction beyond this does not cause a further decrease in self-reinforcement. There was no difference in the rate of increase of footprint contact pressure at each angle of abduction when comparing the knotted and knotless groups. In the post-operative period, high tendon load combined with minimal abduction would be expected to generate the greatest amount of footprint compression which may improve tendon healing. Therefore, to maximize footprint compression the use of abduction pillows should be avoided while early isometric strengthening should be used.

A comparison of self-reinforcement and footprint compression between standard- and wide-diameter suture material in double-row SutureBridge repair techniques has not been performed. The aim of this study was to compare the self-reinforcement and footprint contact pressure generated under progressive tensile loads between 2 double-row SutureBridge rotator cuff repair techniques: 1 performed with FiberWire and 1 performed with FiberTape in a knotless technique.Rotator cuff repairs were performed in 10 pairs of ovine shoulders. One group underwent a double-row SutureBridge repair using FiberWire. The other group underwent an identical repair with FiberTape. Footprint contact pressure was measured from 0° to 60° of abduction under loads of 0-60 N. Pull-to-failure tests were then performed.In both repair constructs at 0° of abduction, each 10-N increase in rotator cuff tensile load led to a significant increase in footprint contact pressure (P.05). The rate of increase in footprint contact pressure was greater in the FiberTape construct (ratio, 1.68; P = .00035). In both repair constructs, the highest values for footprint contact pressure were seen at 0° of abduction. No difference in pull to failure, peak load, or total energy was found between the groups.Self-reinforcement was seen in both double-row SutureBridge repairs with standard- and wide-diameter suture material but was greater in the repair with the wide-diameter suture material construct. Footprint compression is greater in a knotless double-row SutureBridge repair with wide-diameter suture material than in a knotted double-row SutureBridge repair with standard-diameter suture material at 20° of abduction.

Background The aim of the present study was to describe the clinical outcomes and activity levels of young patients after distal humeral hemiarthroplasty (DHH). Methods Six patients under 55 years (mean 44 years; range 29 years to 52 years) treated with DHH at a mean postoperative time of 81 months (range 24 months to 133 months) were studied retrospectively. Two other patients had been revised for aseptic loosening and were excluded. Results The mean Mayo Elbow Score (MEPS) (88), Subjective Elbow Value (SEV) (89), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) (12) and American Shoulder and Elbow Surgeons (ASES) elbow pain (6), function (23) and satisfaction scores (9) were satisfactory. The mean University of California, Los Angeles (UCLA) activity score was 7.2. Conclusions Although only rarely indicated, DHH has satisfactory clinical outcomes in young patients and allows a higher level of function than is generally advised after total elbow arthroplasty.

Background The aim of this study was to describe for the first time the medium to long-term outcome after distal humeral hemiarthroplasty (DHH). Methods Twenty-six patients (mean age, 62; range, 29-92 years) treated with DHH for intra-articular distal humeral fractures and its sequelae were studied retrospectively. Results Four patients had died and 4 had been revised to total elbow arthroplasty: 2 for periprosthetic fractures and 2 for primary component loosening (all in prostheses without an anterior flange). Six other complications had occurred: ulnar neuritis, 4; stiffness, 1; and wound necrosis, 1. Seventeen patients underwent assessment at a mean of 80 months after surgery. The mean values of the American Shoulder and Elbow Surgeons (ASES) elbow score (pain, 9.93; function, 25; satisfaction, 9.06); Mayo Elbow Performance Score (90); Quick Disabilities of Arm, Shoulder and Hand (19), and EuroQol EQ5D (Index, 0.84; Visual Analog Scale, 80) outcome measures demonstrated good function and satisfaction with little pain. The mean flexion extension arc was 116°. There was no evidence of instability. Radiologic evidence of ulnar wear was seen in 13 patients and may be related to prosthetic design to some extent. Worse wear was associated with a higher ASES pain score, lower satisfaction score, and lower EuroQoL Visual Analog Scale of quality of life. Degree of wear correlates with time after surgery but not with age at the time of surgery. Conclusion DHH offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome.

Background Several different techniques have been described for repairing a lesser tuberosity osteotomy in shoulder arthroplasty, although all have potential drawbacks. We describe a novel repair technique and its radiological results. Methods All patients undergoing a total shoulder arthroplasty using a resurfacing humeral component from 2008 to date were identified retrospectively. Anteroposterior (AP) and axial radiographs at a minimum of 3 months postoperatively were used to assess union of the osteotomy fragment. Results Seventy-six total shoulder replacements in 65 patients were eligible for review. Seven were excluded as a result of inadequate radiographs. Sixty-six of 69 had united (95.6%). There were two cases (2.9%) of a complete non-union that was undisplaced. In one patient (1.4%), the osteotomy fragment had displaced and this was apparent on the initial postoperative AP radiograph. Conclusions The modified union jack repair technique is simple, fast, economical and reliable.

Background Proximal humeral fractures are common in older patients. The majority are minimally displaced and are associated with good outcomes after nonoperative treatment. Poorer outcomes are associated with displaced, multipart fractures. There is no clear benefit from surgical fracture fixation compared to nonoperative treatment. Replacement of the fractured humeral head with a hemiarthroplasty is another treatment option, but has not been shown to be clearly superior to nonoperative treatment or internal fixation. Recently, reverse total shoulder arthroplasty has been used to treat these fractures, particularly in the older population with several case series demonstrating good outcomes. No comparative trial has been performed to test the effectiveness of reverse total shoulder arthroplasty against nonoperative treatment. Methods/design ReShAPE (Reverse Shoulder Arthroplasty for the treatment of Proximal humeral fractures in the Elderly) is a multicenter combined randomized and observational study. The primary objective is to compare pain and function 12 months post fracture using the American Shoulder and Elbow Society (ASES) score in patients aged 70 years or older with three- and four-part proximal humeral fractures treated by either reverse shoulder arthroplasty or nonoperative treatment. Secondary outcome measures will include the DASH (Disability of the Arm, Shoulder and Hand) score, the EQ-5D (EuroQol Health Survey), the EQ-VAS, pain, radiological parameters and complications. Discussion The study will assess the effectiveness of reverse shoulder arthroplasty for complex proximal humeral fractures and thereby guide treatment of a common injury in the older population. Trial registration World Health Organization Universal Trial Number (WHO UTN): U1111-1180-5452. Registered on 10 March 2016. Australian and New Zealand Clinical Trials Registry (ANZCTR): 12616000345482. Registered on 16 March 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1826-6) contains supplementary material, which is available to authorized users.

In double-row SutureBridge (Arthrex, Naples, FL, USA) rotator cuff repairs, increasing tendon load may generate progressively greater compression forces at the repair footprint (self-reinforcement). SutureBridge rotator cuff repairs using tied horizontal mattress sutures medially may limit this effect compared with a knotless construct.Rotator cuff repairs were performed in 9 pairs of ovine shoulders. One group underwent repair with a double-row SutureBridge construct with tied horizontal medial-row mattress sutures. The other group underwent repair in an identical fashion except that medial-row knots were not tied. Footprint contact pressure was measured at 0° and 20° of abduction under loads of 0 to 60 N. Pull-to-failure tests were then performed.In both repair constructs, each 10-N increase in rotator cuff tensile load led to a significant increase in footprint contact pressure (P .0001). The rate of increase in footprint contact pressure was greater in the knotless construct (P .00022; ratio, 1.69). The yield point approached the ultimate load to failure more closely in the knotless model than in the knotted construct (P = .00094). There was no difference in stiffness, ultimate failure load, or total energy to failure between the knotless and knotted techniques.In rotator cuff repair with a double-row SutureBridge configuration, self-reinforcement is seen in repairs with and without medial-row knots. Self-reinforcement is greater with the knotless technique.

The economic potential of kimberlite bodies is defined by the volume and diamond content of all their internal units which are summarised in three dimensional geological models. Canadian geological models reveal distinct types of kimberlite bodies characterised by fundamentally different emplacement processes and products. Data for representative samples of Canadian kimberlites are used to show that qualitative and quantitative macroscopic petrography (olivines and xenoliths) are powerful and practical techniques in assessing the economic implications of emplacement within individual phases of kimberlite. Kimberlite bodies result from the near-surface emplacement of multiple discrete batches of mantle-derived magmas, each carrying different diamond populations and, in some instances, subsequent resedimentation processes. Magmas containing ~ 25 modal % of olivine macrocrysts, the average maximum load of solids that can be carried to surface by a kimberlite magma, have the greatest potential to be significantly diamondiferous. Modifications to the abundance and size distribution of the olivine macrocrysts in each batch of magma commonly occur during emplacement. The modifications to the olivine macrocrysts, which vary with different emplacement processes and products, are mirrored in the macrodiamond content. Dilution by xenoliths is important in predicting diamond contents but it is also reflected in reduced olivine contents. Thus, olivine macrocrysts can act as a proxy for macrodiamonds. The abundance and size distribution data for olivine can improve the prediction of diamond grade and distribution within, and between, kimberlite units. Summary geological models and macroscopic petrography, together, improve the evaluation of newly discovered bodies resulting in enhanced resource estimates and increased degrees of confidence.

Haemangioma of infancy is a common birthmark. As spontaneous involution is the rule, it is usually treated conservatively. Periorbital haemangiomata may require intervention if symptomatic and this may be early or late, where plastic surgery may be required. It has not previously been recognised that deep periorbital lesions may lead to a baggy appearance of the eyelids because of excess fatty tissue. The management of this condition is described in different clinical presentations illustrated by three female patients with a history of infantile periorbital haemangioma. Two were treated by blepharoplasty, during which an excess of fatty tissue was found, deep to the orbital septum. Birthmark stigmata were eradicated and symmetry was achieved.

Background Systematic reviews of colorectal cancer surgical trials demonstrate significant heterogeneity of outcome measurement and evidence for selective outcome reporting. This weakens evidence synthesis by hindering metaanalyses, and undermines trial results through outcome reporting bias. This study developed a “core set” of outcomes to be used in trials of colorectal cancer surgery to minimise these limitations.

This study aims to identify the relationship of the radial nerve as it descends across the humerus with reference to a reliable soft tissue landmark, the tricipital aponeurosis. Following cadaveric dissection of 10 adult humerii, the radial nerve was located as it crossed the lateral midsagittal point of the humeral diaphysis. A horizontal line was then subtended medially from this point to another line subtended vertically from the lateral border of the tricipital aponeurosis. The vertical distance from this intersection to the lateral apex of the aponeurosis was recorded in three positions (full flexion, 90° of flexion and full extension). The location of the radial nerve on the posterior aspect of the humeral diaphysis to the medial apex of the tricipital aponeurosis was also noted. In 90° of flexion the radial nerve at the lateral midsagittal point of the humerus was 0.9 mm proximal to the lateral apex of the tricipital aponeurosis. Flexion and extension of the elbow changed the interval to 16.3 mm (nerve proximal) in full flexion and 7.1 mm in full extension (nerve distal). On the posterior aspect of the humerus the radial nerve was 21.8 mm proximal to the medial aspect of the tricipital aponeurosis. The aponeurosis provides a reference point from which the nerve can be easily located on the lateral aspect of the humerus intraoperatively in a range of positions, whilst the medial apex provides a guide to the location of the nerve on the posterior aspect of the arm.

Purpose To compare the cement mantle characteristics associated with use of a narrow nozzle cement gun versus the use of a 60-mL catheter tip syringe. Methods Twelve cadaveric distal humeri were cemented with either a cement gun or a syringe without canal occlusion. The humeri were sectioned and photographed. The corticocancellous junction and the outer margin of the cement mantle were analyzed digitally. The corticocancellous junction defined the available area for cement penetration. The outline of the cement mantle defined the actual area of penetration. The ratio of penetration to the available area was recorded for each slice. The mean ratio for each humerus was multiplied by the number of slices in that sample containing cement to calculate a cement index. Results The cement penetration ratios observed in cross-sections at the same level and the cement index were significantly greater with the use of the cement gun than with the use of the syringe. There was no difference in the number of slices that contained cement. Conclusions The use of a cement gun with a narrow nozzle improved cement mantle characteristics compared with the use of a syringe when measured in a cadaveric model in the absence of canal occlusion. Clinical relevance Improving cement mantle characteristics may decrease the incidence of aseptic loosening after total elbow arythroplasty.

We find a simple condition for a square matrix to provide a mapping that has an optimal property for cyclic permutations. The maximum length of a cycle with the optimum property gives an index of symmetry for the matrix.

Pathology of the biceps tendon can contribute to significant shoulder pain and dysfunction for which biceps tenodesis may be indicated. A variety of techniques tenodesing the biceps tendon have been described. Recently, tenodesis using a uni- or bicortical button has been advocated. This cadaveric study investigates the proximity of the axillary nerve to the position of bicortical drill passages during biceps tenodesis. Twelve cadaveric shoulder specimens were used. The axillary nerve was marked during a preparatory dissection using wire. Drills were passed through the humerus at the proximal and distal ends of the bicipital groove, and at the superior insertion point of pectoralis major (PM). These were left in situ. The distances between these drills and the axillary nerves were measured using computed tomography imaging. The drill bits placed at the superior insertion of PM were in closest proximity to the axillary nerve (3D distance mean 10.7 mm, 95 % confidence interval 7.2–14.2 mm). A drill placed at the distal end of the bicipital groove was a mean distance of 18.2 mm from the nerve. This study highlights the need for caution when drilling the posterior humeral cortex during biceps tenodesis, particularly during drilling at the superior insertion of PM as this is the location that poses the highest risk to the axillary nerve. To our knowledge, this is the first cadaveric study to radiologically assess the proximity of the axillary nerve to the positions of biceps tenodesis. Surgeons should therefore be cautious when performing bicortical drilling for biceps tenodesis, and a supero-lateral drill trajectory would pose a smaller risk to the axillary nerve.

HE PATIENT 42-year-old, right hand–dominant woman with wellontrolled rheumatoid arthritis presents with swan neck eformities (SNDs) of the index middle and ring finers. The proximal interphalangeal (PIP) joints have ull passive range of motion. There is no swelling or enderness over the volar aspect of the fingers. The rist and metacarpophalangeal joints are well aligned nd the deformity was initially evident at the PIP joint ith secondary deformity at the distal interphalangeal DIP) joint. She has difficulty with gripping objects in er work as a chef. Nonoperative treatment in the form f figure-of-8 splinting has not helped. Radiographs how that the joint is well preserved.

Vocational education and training (VET) is an important avenue for improving work-related skills, organizational effectiveness, productivity growth, and national competitiveness. VET also plays an important role in assisting disadvantaged members of society, including those with a disability. The balance between these two different emphases is one of the tensions in VET. People with disabilities face challenges in accessing and participating in VET; VET systems and providers face challenges in meeting the needs of people with disabilities. This article examines issues including the cost of VET for people with disabilities and appropriate funding models; student support and outcomes from VET. It also examines international developments and approaches.

A multinuclear NMR cell for the in situ study of heterogeneous catalysis is described. The cell is capable of operating over the temperature range 233 – 513 K and pressure range 0.001 – 300 bar. Catalyst activation is carried out in an appropriate gas stream inside the NMR cell. NMR studies may be performed either on the working or, after evacuation of the cell, on the activated catalyst dosed with suitable probe molecules. The adsorption of H2, or MeOH on a Cu/ZnO/Al2O3 catalyst has been studied by H-1, D-2 and C-13 NMR.

The use of fibre-reinforced polymer (FRP) composites in the pressure hulls of submersible vehicles is examined with reference to material and fabrication options, alternative structural configurations, evaluation of stresses, deformations and buckling behaviour and other aspects of design. The performance of FRP is contrasted with that of steel and light alloy construction. Reference is made to two illustrative trial designs, one corresponding to a manned submersible for shallow-water operation and the other to a deep-water autonomous underwater vehicle.

Changes to adhesion molecule expression and lymphocyte populations were evaluated in alveolar mammary tissue collected from cows following an immunisation protocol that involved intra-mammary inoculation to induce an IgA response in mammary secretions. The right quarters of the udder were immunised; the left side acted as a control. Antibody titres in secretions showed that at least two animals responded with antigen-specific IgA. Numbers of T-lymphocytes were 4-fold higher in immunised glands compared with controls (P < 0.05). IgA-, IgM- and IgG-positive cell numbers were significantly higher (P < 0.01) in immunised glands compared with controls in three of the four cows. No mucosal addressin molecule-1 (MAdCAM-1), vascular cell-adhesion molecule-1 (VCAM-1) or peripheral node addressin (PNAd) protein expression was detected on smaller venules that stained positively for von Willebrand factor in alveolar mammary tissues, from either immunised or control glands. Both VCAM-1 and PNAd were detected on smaller venules in supramammary lymph nodes, however, there was no significant difference between immunised and control glands. Quantification of MAdCAM-1 mRNA showed very low expression in both immunised and control alveolar tissue compared with Peyer's patch positive-control tissue. These findings suggest that the bovine mammary gland is capable of a mucosal antibody response; however, MAdCAM-1 is not involved with lymphocyte homing to the mammary gland in this species.

The use of implants is widespread in orthopaedic practice. In recent times screws and plates have increasingly been supplied individually pre-packaged. We hypothesised that there is a potential for an increased risk of infection associated with the practice of using individually packaged screws. In this study an attempt was made to recreate as closely as possible the standard practice of opening screw packets in the operating theatre. The exterior of 50 screw packets was cultured. The outer screw packets were then opened over a draped instrument table above a petri dish. As a control, petri dishes were left open to the air in the same theatre environment. The packet exteriors grew cultures of organisms in 24/50 cases. The act of opening the packets yielded a growth in 7/50 cases. There was no growth on the control petri dishes. The significance of the result and potential solutions are discussed.

Background The aim of this retrospective study was to review all patients diagnosed with gallbladder cancer over a 10‐year period to assess variables affecting survival. Methods Patients diagnosed with gallbladder cancer from January 1990 to December 1999 were identified from the Lothian Surgical Audit database and a case‐note review was performed. Results The 44 patients who were studied (33 women, 11 men) had a mean age of 66 years (range 42–90 years). The diagnosis was established preoperatively in 25 patients (57%), intraoperatively in 5 patients (11%) and incidentally following pathological examination of cholecystectomy specimens in 14 patients (32%). None of the 25 patients diagnosed preoperatively underwent curative operations (median survival 4 months). All five patients diagnosed at the time of attempted cholecystectomy had advanced irresectable disease (median survival 1 month). The overall median survival in 14 patients with an incidental diagnosis of gallbladder cancer was 16 months; however, in eight of these patients who were considered to have had a potentially curative resection, the median survival was 38 months. Discussion The prognosis for patients diagnosed preoperatively or at the time of cholecystectomy is very poor. Patients with an incidental finding of gallbladder cancer have a significantly better prognosis and should be considered for further radical re‐resection.

Plasma fibrinogen was assayed in 4837 plasma specimens from women who took part in the Scottish Heart Health Study and the Scottish WHO MONICA survey. These samples included 13 women taking oral contraceptives, 210 women who had taken the pill, 2192 women still menstruating, and 2619 post-menopausal women. 66 women were taking hormone replacement medications (HRT). Fibrinogen levels did not differ significantly between current and former pill users. Menstruating women also had lower fibrinogen levels than postmenopausal women. The 66 women taking HRT, after than women not taking hormone replacement therapy, and had lower total cholesterol, blood pressure, and body mass index. Former oral contraceptive users had significantly lower fibrinogen than never users, even when age and smoking were controlled (p 0.001). Pill users also had significantly lower cholesterol, blood pressure and body mass index than never users, and a higher proportion of smokers. Premenopausal women had lower total and HDL cholesterol, blood pressure, body mass index than postmenopausal women. Some of these results could be accounted for by selection of healthier women for either oral contraception or HRT.

Disposing of low-level waste (LLW) is a concern for many states throughout the United States. A common disposal method is below-grade concrete vaults. Performance assessment analyses make predictions of contaminant release, transport, ingestion, inhalation, or other routes of exposure, and the resulting doses for various disposal methods such as the below-grade concrete vaults. Numerous assumptions are required to simplify the processes associated with the disposal facility to make predictions feasible. In general, these assumptions are made conservatively so as to underestimate the performance of the facility. The objective of this report is to describe the methodology used in conducting a performance assessment for a hypothetical waste facility located in the northeastern United States using real data as much as possible. This report consists of the following: (a) a description of the disposal facility and site, (b) methods used to analyze performance of the facility, (c) the results of the analysis, and (d) the conclusions of this study.

The effects of cyclosporin A (CSP) on tumor necrosis factor-alpha (TNF-alpha) RNA levels and protein production in human B cells and a B cell line were studied. The ability of CSP to block induction of RNA was compared to its inhibition of protein production in response to anti-IgM, phorbol ester (PMA) and platelet-activating factor (PAF). PAF is a phospholipid which has recently been found to activate human B cells. CSP blocks PAF-induced TNF-alpha RNA from the Ramos cell line, as well as inhibiting the enhancement of TNF protein production from both freshly isolated and Ramos B cells. CSP also blocks anti-Ig induced TNF-alpha RNA and protein but does not inhibit PMA-induced TNF-alpha. We conclude that B cells, like T cells, have CSP-independent and CSP-dependent signaling pathways and that PAF signaling is dependent upon a CSP-sensitive factor.

This document presents methods and results of benchmark testing (i.e., code-to-code comparisons) and partial validation testing (i.e., tests which compare field data to the computer generated solutions) of the FLASH computer code, Version 3.0, which were conducted to determine if the code is ready for performance assessment studies of the Radioactive Waste Management Complex. Three test problems are presented that were designed to check computational efficiency, accuracy of the numerical algorithms, and the capability of the code to simulate diverse hydrological conditions. These test problems were designed to specifically test the code`s ability to simulate, (a) seasonal infiltration in response to meteorological conditions, (b) changing watertable elevations due to a transient areal source of water, (i.e., influx from spreading basins), and (c) infiltration into fractured basalt as a result of seasonal water in drainage ditches. The FLASH simulations generally compared well with the benchmark codes, indicating good stability and acceptable computational efficiency while simulating a wide range of conditions. The code appears operational for modeling both unsaturated and saturated flow in fractured, heterogeneous porous media. However, the code failed to converge when a unsaturated to saturated transition occurred. Consequently, the code should not be used when this condition occurs ormore » is expected to occur, i.e. when perched water is present or when infiltration rates exceed the saturated conductivity of the soil.« less

The prevalence of smoking amongst a group of 77 diabetic teenagers aged 11-18 years attending two paediatric clinics was determined using a questionnaire and urine cotinine assay. Five individuals were identified as definite smokers with two further individuals being probable smokers, all of whom were aged 15 years or more. This low prevalence (9%) is in contrast to a 48% prevalence in a young adult diabetic clinic. Many diabetic teenagers appear to acquire a regular smoking habit after leaving the paediatric clinic so it is important that health education is targeted at this group.