Search

INTRODUCTION Tuberculosis (TB) remains the most common cause of death from infectious disease world-wide. In the UK, the incidence of TB has risen by 25% over the last 10 years; extrapulmonary diagnosis remains challenging and can be delayed. This study evaluates the epidemiology of musculoskeletal tuberculosis in a large multi-ethnic UK city. PATIENTS AND METHODS A review of prospectively recorded data of incidence, anatomical site, ethnic distribution, treatment and drug resistance of musculoskeletal tuberculosis over a 6-year period was performed. RESULTS From January 1999 to December 2004, there were 729 TB notifications; 61 cases (8.4%) had musculoskeletal involvement. Of the patients, 74% were immigrants from the Indian subcontinent; nearly 50% had spinal involvement; 24 patients underwent surgical intervention; 29 were subjected to either diagnostic or therapeutic radiological intervention; and resolution of symptoms was achieved in 59 out of 61 cases. CONCLUSIONS This study highlights the high proportion of musculoskeletal TB in immigrant patients in an area with a relatively large at-risk population, but will also serve to alert physicians, in areas with smaller at-risk populations, of the possibility of musculoskeletal TB.

We measured the scattered radiation received by theatre staff, using high-sensitivity electronic personal dosimeters, during fixation of extracapsular fractures of the neck of the femur by dynamic hip screw. The dose received was correlated with that received by the patient, and the distance from the source of radiation. A scintillation detector and a water-filled model were used to define a map of the dose rate of scattered radiation in a standard operating theatre during surgery. Beyond two metres from the source of radiation, the scattered dose received was consistently low, while within the operating distance that received by staff was significant for both lateral and posteroanterior (PA) projections. The routine use of lead aprons outside the 2 m zone may be unnecessary. Within that zone it is recommended that lead aprons be worn and that thyroid shields are available for the surgeon and nursing assistants.

In previous experiments in our laboratories, chickens that are chimeric in their gamete, melanocyte, and blood cell populations have been produced by injection of dispersed stage X blastodermal donor cells into the subgerminal cavity of stage X recipient embryos. In some experiments, donor cells were transfected with reporter gene constructs prior to injection as a preliminary step in the production of transgenic birds. Chimerism was assessed by test mating, observation of plumage, and DNA fingerprinting. Methods were sought that would provide a relatively rapid analysis of the spatial distribution of descendants of donor cells in chimeras to assess the efficacy of various methods of chimera construction. To date, the sex of donor and recipient embryos was not known and, therefore, numerous mixed sex chimeras must have been constructed by chance, since donor cells were usually collected from several embryos rather than from individual embryos. The presence of female-derived cells was determined by in situ hybridization using a W-chromosome-specific DNA probe, using smears of washed erythrocytes from 16 phenotypically male chimeric chickens ranging in age from 4 days to 42 months posthatching. The proportion of female cells detected in the erythrocyte samples was zero (eight samples) or very low (0.020–0.083%), although 1% of the erythrocytes from a phenotypically male chick that was killed 4 days after hatch were female-derived. The low proportions of female-derived cells were surprising, considering that most of these chimeras had been produced by the injection of cells pooled from several donor embryos and most recipients had been exposed to γ irradiation prior to injection, thus dramatically enhancing the level of incorporation of donor cells into the resulting chimeras. By contrast, 0–100% of the erythrocytes were female-derived in blood samples taken at 10 days of incubation from the chorioallantois of seven phenotypically normal male embryos that resulted from the injection of blastodermal cells pooled from five embryos into irradiated recipient embryos. Approximately 70% of the erythrocytes in a blood sample from a phenotypically normal female chimeric embryo were female-derived, and 100% of the erythrocytes examined from an intersex embryo bearing a right testis and a left ovary were female-derived. These results indicate that female-derived cells can contribute to the formation of erythropoietic tissue during the early development of what will become a phenotypically male chimeric embryo. It would appear, therefore, that female-derived cells are blocked in development or destroyed, or certain male–female combinations of cells may be lethal prior to hatching. In future, chimeras will be produced from individual donors, or pools will be made of either male or female donor cells identified by in situ hybridization of smears of dispersed blastodermal cells using the W-chromosome-specific probe.Key words: chimera, chicken, W chromosome, in situ hybridization, transgenic.

The authors present a case of pyomyositis of the piriformis muscle. This case, the first in the English speaking literature of piriformis involvement in a juvenile, serves to illustrate the need for a high index of suspicion when treating children with symptoms related to impalpable pathology deep in the pelvis and the usefulness of MRI in early diagnosis and treatment before abscess formation. It also shows the potentially wide differential diagnosis in which the signs and symptoms may be misleading due to the close relationship of the pelvic muscles with the hip joint and adjacent viscera.

We measured the scattered radiation received by theatre staff with high sensitivity dosimeters, during dynamic hip screw fixation for extracapsular neck of femur fractures. The dose received was correlated to the distance from the radiation source. Additionally, a scintillation monitor and a scattered water phantom were used to define a scattered radiation dose rate map of a standard operating theatre during dynamic hip screw fixation. Beyond two meters from the radiation source the scattered dose received was non-measurable, while within the operating distance it was consistently higher at neck level than at waist level. Routine use of lead gowns outside the two meters safe zone maybe unnecessary whilst within that zone they offer inadequate protection at neck level.

There are no published guidelines issued for the use of thyroid shields by either the Royal College of Radiologists or the British Orthopaedic Association. It has previously been demonstrated that a thyroid shield should be worn during fluoroscopic screening using a portable image intensifier. Scrub staff not wearing a thyroid shield are currently being exposed to ionising radiation on a regular basis, with potentially harmful effects. Of the 210 hospitals in England with orthopaedic departments, 179 were telephoned and the use and availability of thyroid shields was asked. The results demonstrated that 98 orthopaedic theatres had sufficient numbers of thyroid shields available. Of these 98 orthopaedic theatres, thyroid shields were routinely used in only 28 theatres during fluoroscopic screening on a regular basis. It is the authors' recommendation that thyroid shields should be worn during orthopaedic procedures involving the use of an image intensifier.

Focused rigidity casting was compared with standard casting in a randomised prospective study. Two hundred consecutive patients attending a fracture clinic were assigned to have either a standard cast consisting of synthetic or plaster of paris, or a focused rigidity cast of synthetic material. Patients were assessed using a specially developed scoring system termed the Bradford Plaster Index. In patients with fractures of the base of fifth metatarsal, focused rigidity casting proved superior to traditional techniques for ability score (p=0.0001), satisfaction score (p=0.0023), overall impairment of function (p=0.019), limitation of movement following cast removal (p=0.024) and in limitation of muscle strength following cast removal (p=0.001). In fractures of the distal radius, focused rigidity casting was superior for ability score (p=0.0002) and satisfaction score (p=0.00009). Patients with scaphoid fractures were better for satisfaction score (p=0.0483). Compared with the standard technique, focused rigidity casting has been shown to be superior to traditional methods with regard to satisfaction and functional scores without any detriment to clinical results.

We measured the scattered radiation received by theatre staff, using high-sensitivity electronic personal dosimeters, during fixation of extracapsular fractures of the neck of the femur by dynamic hip screw. The dose received was correlated with that received by the patient, and the distance from the source of radiation. A scintillation detector and a water-filled model were used to define a map of the dose rate of scattered radiation in a standard operating theatre during surgery. Beyond two metres from the source of radiation, the scattered dose received was consistently low, while within the operating distance that received by staff was significant for both lateral and posteroanterior (PA) projections. The routine use of lead aprons outside the 2 m zone may be unnecessary. Within that zone it is recommended that lead aprons be worn and that thyroid shields are available for the surgeon and nursing assistants.

We report our experience with the Orthofix external fixator in the management of closed and Gustilo grades 1 and 2 compound unstable tibial shaft fractures. Forty-four fractures were treated between January 1988 and December 1989. All the fractures united. Median time in hospital was 13 days. Median time to union was 21 weeks for closed and 22 weeks for compound fractures. A method of estimating the overall cost per patient is described. Using this method we compared the cost of using the Orthofix with that of intramedullary nailing and plating according to AO principles. The Orthofix fixator was cheaper than alternative methods in particular because no readmissions were required for implant removal.

Many authors recommend surgery to remove retropulsed bone fragments from the canal in burst fractures to 'decompress' the spinal canal. We believe, however, that neurological damage occurs at the moment of injury when the anatomy is most distorted, and is not due to impingement in the resting positions observed afterwards. We studied 20 consecutive patients admitted to our spinal injuries unit over a two-year period with a T12 or L1 burst fracture. There was no correlation between bony or canal disruption and the degree of neurological compromise sustained but there was a significant correlation between the energy of the injury (as gauged by the Injury Severity Score) and the neurological status (p0.001). This suggests that neurological injury occurs at the time of trauma rather than being a result of pressure from fragments in the canal afterwards and questions the need to operate simply to remove these fragments.

The results of long-term follow-up (range 9–19 years) are presented in a continuous series of patients treated for Dupuytren's contracture by one surgeon using the open palm technique. Mean preoperative total range of movement was 48% rising to 96% postoperatively. Mean total range of movement was 92% at follow-up. Survivorship analysis revealed 86% survival at 10 years and 77% survival at 19 years. There was one digital nerve injury and one case of algodystrophy. This technique gives good long-term results without the use of night splintage or physiotherapy.

Myositis ossificans is relatively uncommon; it causes calcification and later ossification in muscles or soft tissues. Two-thirds of cases are traumatic in origin and it has most often been described around the elbow, although it is equally common in the thigh and calf and is also reported in the foot, hand and scapular region (Nuovo et al 1992). We report a case of traumatic myositis ossificans which involved the entire anterior and part of the deep posterior compartments of the leg after an ischaemic injury (compartment syndrome). We are aware of no previous description. Case report. A 31-year-old man presented 14 years after a road-traffic accident in which he had sustained fractures of the lower third of the femur and the proximal tibia, with damage to the popliteal artery. The artery had been initially repaired using a saphenous vein graft, but an unsatisfactory result had required further exploration and the use of a dacron mesh graft. The fractures were treated in skeletal traction and had united after about seven months. During this time, the patient gradually developed an increasing equinus deformity which became worse in the next few years with fixed-flexion deformities of the toes. At 14 years after the injury, there was extreme limitation of ankle movements with some pain in the leg, particularly on walking. Radiography showed extensive myositis ossificans of the anterior compartment and the distal part of the

In writing El gesticulador, which marks the opening of the modern theatre in Mexico where it was first performed in 1947, Rodolfo Usigli (b. 1905) faced a number of problems, so that the play's technique represents a compromise between conflicting aims. The predominant aspect of the work is the expression of political protest and criticism; the plot hinges on the election of a new governor for a northern Mexican state. But Usigli described the drama in the year it was performed as the first serious attempt at tragedy in the modern Mexican theatre.

The clinical findings and treatment results in 27 patients, 11 to 20 years of age, with nasopharyngeal carcinoma were retrospectively reviewed. The histological diagnosis was lymphoepithelioma in 18 patients and undifferentiated carcinoma in nine patients. Seven patients (26%) presented with T4 lesions, 24 patients (89%) with clinically positive cervical nodes, and two patients (7%) with distant metastases. All patients received radiation therapy to the primary site; chemotherapy was employed as an adjuvant in six patients. Overall survival was 64% at five years and 57% at 10 years. Local control of the primary tumor and regional lymph nodes was 85%. Distant metastases were more frequent in patients with advanced primary disease and were associated wtih extremely poor prognoses. A moderate dose of radiotherapy is the recommended treatment for primary tumors and neck nodes. More effective adjuvant chemotherapy is suggested as a possible way to improve therapeutic results.