Royal Hospital Haslar

In 13 unloaded living knees we confirmed the findings previously obtained in the unloaded cadaver knee during flexion and external rotation/internal rotation using MRI. In seven loaded living knees with the subjects squatting, the relative tibiofemoral movements were similar to those in the unloaded knee except that the medial femoral condyle tended to move about 4 mm forwards with flexion. Four of the seven loaded knees were studied during flexion in external and internal rotation. As predicted, flexion (squatting) with the tibia in external rotation suppressed the internal rotation of the tibia which had been observed during unloaded flexion.

Highly sensitive assays have been developed that enable 25-hydroxycholecalciferol (25-hydroxyvitamin D3) and 25-hydroxyergocalciferol (25-hydroxyvitamin D2) to be measured in the same serum sample. With these assays it has been shown that endogenously produced cholecalciferol (vitamin D3) is important in man; the findings further emphasize the role of vitamin D metabolites as hormones rather than vitamins in the traditional sense. Dietary sources of vitamin D appear to be inadequate and vitamin D deficiency has been shown to be the cause of rickets and osteomalacia in Asian immigrants to Britain. This condition may be readily treated with small doses of vitamin D. In addition, sub-clinical deficiency was found in the Asian community. In the elderly, also, vitamin D deficiency was established as an important cause of osteomalacia and again evidence for the existence of a sub-clinical deficiency state was found. It is therefore suggested that the present prophylactic practices should be reviewed. Secondary hyperparathyroidism (reflected by elevated concentrations of circulating immunoassayable parathyroid hormone) was shown to be the rule rather than the exception in vitamin D deficiency. Some patients, however, had failed to respond to a hypocalcaemic stimulus. In others, there were high concentrations of parathyroid hormone despite normal serum calcium concentrations. Thus the relationship between parathyroid hormone and metabolites of vitamin D may not be mediated through changes in serum calcium alone, and it is postulated that metabolites of vitamin D may directly affect the secretion of parathyroid hormone.

AIMS: Seventy-five skin tumours were studied to investigate the value of immunohistochemistry in differentiating basal cell, squamous cell and basosquamous carcinomas of the skin. METHODS AND RESULTS: Archived paraffin-embedded tissue samples of basal cell carcinomas (n = 39), squamous cell carcinomas (n = 23) and basosquamous carcinomas (n = 13) were stained immunohistochemically using a panel of antibodies. All of the basal cell carcinomas stained positively for Ber EP4, in contrast to the group of squamous cell carcinomas, that showed no staining. Basosquamous carcinomas all showed at least some areas of Ber EP4 positivity. None of the basal cell carcinomas, but most of the squamous cell carcinomas (22 of 23) expressed epithelial membrane antigen (EMA). Only one of the basosquamous carcinomas expressed EMA positivity focally. CAM 5.2, carcinoembryonic antigen (CEA) and 34betaE12 antibodies lacked specificity in relation to the different tumour types. CONCLUSION: Distinction of basal and squamous cell carcinomas of the skin can be readily achieved with routine immunohistochemistry using Ber EP4 and EMA. Identification of basosquamous carcinoma is also facilitated with this method.

OBJECTIVE: To determine whether occupational therapy focused specifically on personal activities of daily living improves recovery for patients after stroke. DESIGN: Systematic review and meta-analysis. DATA SOURCES: The Cochrane stroke group trials register, the Cochrane central register of controlled trials, Medline, Embase, CINAHL, PsycLIT, AMED, Wilson Social Sciences Abstracts, Science Citation Index, Social Science Citation, Arts and Humanities Citation Index, Dissertations Abstracts register, Occupational Therapy Research Index, scanning reference lists, personal communication with authors, and hand searching. REVIEW METHODS: Trials were included if they evaluated the effect of occupational therapy focused on practice of personal activities of daily living or where performance in such activities was the target of the occupational therapy intervention in a stroke population. Original data were sought from trialists. Two reviewers independently reviewed each trial for methodological quality. Disagreements were resolved by consensus. RESULTS: Nine randomised controlled trials including 1258 participants met the inclusion criteria. Occupational therapy delivered to patients after stroke and targeted towards personal activities of daily living increased performance scores (standardised mean difference 0.18, 95% confidence interval 0.04 to 0.32, P=0.01) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio 0.67, 95% confidence interval 0.51 to 0.87, P=0.003). For every 100 people who received occupational therapy focused on personal activities of daily living, 11 (95% confidence interval 7 to 30) would be spared a poor outcome. CONCLUSIONS: Occupational therapy focused on improving personal activities of daily living after stroke can improve performance and reduce the risk of deterioration in these abilities. Focused occupational therapy should be available to everyone who has had a stroke.

Twenty-four hour intragastric acidity and nocturnal acid secretion were measured in 10 males with duodenal ulcer in four separate 24 hour studies, during which the subjects ate normal meals, had unrestricted physical activity, and consumed their customary quantities of tobacco. The medication consisted of either placebo, cimetidine 200 mg tds and 400 mg at night, or ranitidine 150 mg bd, or 200 mg bd. Ranitidine 150 mg bd decreased mean 24 hour hydrogen ion activity from 41.8 mmol/l to 13.1 mmol/l (-69%, P less than 0.001) and nocturnal acid output from 6.1 mmol/h to 0.6 mmol/h (-90%, P less than 0.01). This degree of inhibition was significantly greater than that due to cimetidine (P less than 0.001 for 24 hours acidity, less than 0.05 for night time acid output). Plasma concentrations of ranitidine were greater than the IC50 for more than eight hours after the 150 mg dose. Ranitidine 200 mg conferred no additional advantage. Ranitidine 150 mg bd should be tested in therapeutic trials.

Antibody capture radioimmunoassays were developed for detecting virus specific IgM (MACRIA) and IgG (GACRIA) to measles, mumps, and rubella and used to investigate saliva as an alternative specimen to serum for diagnosis. Saliva was collected from 63 patients with measles, 19 with mumps, and 150 with rubella, which were all clinically diagnosed and serologically confirmed. Virus specific IgM was detected in 92% of measles, 75% of mumps, and 100% of rubella saliva samples collected during the first week of illness. Between 1 and 5 weeks after onset virus specific IgM was detected in 100% of saliva specimens. After the 5th week the proportion of reactive specimens declined. The specificity of the MACRIA tests was established by testing saliva samples collected from blood donors for measles (88), mumps (88), and rubella IgM (91). All of the saliva specimens tested for measles and rubella specific IgM were unreactive, 1/88 specimens tested for mumps specific IgM contained significant reactivity. Saliva specimens collected from acute cases of MMR were tested in all 3 MACRIAs. A small proportion of saliva samples contained detectable IgM of more than one virus infection. Rubella and measles specific IgG was detected in the saliva of all cases from the 4th or 5th day of illness, respectively. Detection of mumps specific IgG was less successful. We have demonstrated that virus specific IgM can be reliably detected in saliva samples collected from acute cases of measles, mumps, and rubella and identified 1-5 weeks after onset of illness as the optimum time for collection of samples.

The study of left ventricular (LV) hypertrophy is hindered by problems with LV mass measurement by echocardiography. Both the M-mode and 2D area-length formulas for calculating LV mass assume a fixed geometric shape, which may be a source of error. We examined this hypothesis by using cardiovascular magnetic resonance images to eliminate the confounding effects of acoustic access and image quality. LV mass was measured directly in 212 healthy subjects by means of a standard 3D cardiovascular magnetic resonance technique. LV mass was also calculated by using the cube-function and area-length formulas with measurements from the magnetic resonance images. A comparison of serial measurements was made by examining the changes in LV mass by all 3 techniques in those completing an exercise program (n=140). The cube-function technique showed a consistent underestimation of LV mass of 14.3 g, and there were wide 95% limits of agreement (+/-57.6 g and +/-46.3 g for cube-function and area-length techniques, respectively) when compared with 3D measurement. There were similarly wide limits of agreement for the change in mass (+/-55.2 g and +/-44.8 g for cube-function and area-length, respectively). The assumption of geometric shape in the cube-function and area-length formulas resulted in significant variation in LV mass estimates from direct measurement by using a 3D technique. The technique cannot be recommended either at a single time point or for serial studies in small populations; 3D imaging techniques, such as cardiovascular magnetic resonance, are preferable.

Friction in fixed appliance systems has received considerable attention in the recent literature, although that attributable to the type of ligation used has not been fully investigated. This in vitro study of 0.022 x 0.028 inch slot Minitwin, Activa ('A' Company, San Diego, California, USA), and SPEED brackets (Strite Industries Ltd., Cambridge, Ontario, Canada), investigates friction in two forms of self-ligating brackets and in two methods of ligating Minitwin straight wire brackets with polyurethane elastomeric ligatures. The resistance to sliding of rectangular archwires through the ligated brackets was measured on a vertically mounted Instron testing machine. The stainless steel archwires used were straight lengths of 0.016" x 0.022", 0.017" x 0.025", 0.018" x 0.025", and 0.019" x 0.025" Nubryte Gold (GAC International Inc., Central Islip, New York, USA). The results showed a significant reduction (P < 0.01) in frictional resistance in the Activa brackets compared with SPEED brackets by a factor of approximately 15. When the SPEED brackets were compared to Minitwin brackets, the reduction in friction was by 50-70 per cent (P < 0.01). The placing of 'figure-of-eight' elastomeric ties increased friction by a factor of 70-220 per cent compared to conventional elastomeric ties (P < 0.01) except for 0.016" x 0.022" archwires. The results indicate that self-ligating brackets require less force to produce tooth movement because they apply less frictional contact to the archwire than conventionally tied siamese brackets.

Summary for social mediaVitamin D is essential for good health, especially bone and muscle health. Many people have low blood levels of vitamin D, especially in winter or if confined indoors, because summer sunshine is the main source of vitamin D for most people. Government vitamin D intake recommendations for the general population are 400 IU (10 µg) per day for the UK7 and 600 IU (15 µg) per day for the USA (800 IU (20 µg) per day for >70 years) and the EU.9 Taking a daily supplement (400 IU /day (10 µg/day) in the UK) and eating foods that provide vitamin D is particularly important for those self-isolating with limited exposure to sunlight. Vitamin D intakes greater than the upper limit of 4000 IU (100 µg) per day may be harmful and should be avoided unless under personal medical/clinical advice by a qualified health professional.

The purpose of this study was to quantify the metabolic demand of simulated shipboard fire-fighting procedures currently practised by men and women in the Royal Navy (RN) and to identify a minimum level of cardiovascular fitness commensurate with satisfactory performance. Thirty-four males (M) and 15 females (F) volunteered as subjects for this study (n=49). Maximal oxygen uptake (VO2max) and heart rate (fcmax) of each subject was assessed during a standardized treadmill test. During the main trials, volunteers were randomly assigned to complete several 4-min simulated shipboard fire-fighting tasks (boundary cooling (BC), drum carry (DC), extinguisher carry (EC), hose run (HR), ladder climb (LC)), at a work rate that was endorsed as a minimum acceptable standard. Heart rate (fc) and oxygen uptake (VO2) were recorded at 10-s intervals during rest, exercise and recovery. Participants completed all tasks within an allocated time with the exception of the DC task, where 11 subjects (all females) failed to maintain the endorsed work rate. The DC task elicited the highest (p<0.01) group mean peak metabolic demand (PMD) in males (43 ml min(-1) kg(-1)) and females (42 ml min(-1) kg (-1)) who were able to maintain the endorsed work rate. The BC task elicited the lowest PMD (23 ml min(-1) kg(-1)), whilst the remaining three tasks elicited a remarkably similar PMD of 38-39 ml min(-1) kg(-1). The human endurance limit while wearing a self-contained breathing apparatus (SCBA) dictates that RN personnel are only able to fire-fight for 20-30 min, while wearing a full fire-fighting ensemble (FFE) and performing a combination of the BC, HR and LC tasks, which have a group mean metabolic demand of 32.8 ml min(-1) kg(-1). Given that in healthy subjects fire-fighting can be sustained at a maximum work intensity of 80% VO2max when wearing SCBA for this duration, it is recommended that all RN personnel achieve a VO2max of 41 ml min(-1) kg(-1) as an absolute minimum standard. Subjects with a higher VO2max than the above quoted minimum are able to complete the combination of tasks listed with greater metabolic efficiency and less fatigue.

Twenty four hour intragastric acidity and nocturnal acid output have been measured over five separate 24 hour periods in each of 12 patients with duodenal ulcer receiving either placebo, cimetidine 400 mg bd, cimetidine 300 mg nocte, ranitidine 150 mg bd, or ranitidine 300 mg nocte. In these doses ranitidine was significantly more effective at decreasing intragastric acidity and nocturnal acid output than cimetidine. There was no significant difference between twice daily ranitidine and night time ranitidine or between twice daily cimetidine and night time cimetidine in the reduction of intragastric acidity. Nocturnal acid output was controlled significantly better with ranitidine at night, twice daily dosage of ranitidine, and cimetidine at night, than by the twice daily dosage of cimetidine. It is suggested that a single nocturnal dose of cimetidine or ranitidine should be evaluated in a clinical trial.

The complications of 100 stapled anastomoses onto the rectum or anus are reviewed. Anastomotic leakage in very low cases is the major problem; no leak occurred if the anastomosis was performed above 7 cm, but 3 leaks in 17 patients occurred if the anastomosis was performed between 5.5 and 7 cm, and 10 leaks occurred in 52 patients if the anastomoses was less than 5 cm from the anal margin. A covering colostomy is essential for these lower anastomoses, and for those not covered by a colostomy, an immediate colostomy with a distal loop washout is performed, if a leak develops. Attention to technique is mandatory, with a good blood supply, absence of tension and the elimination of the pelvic cavity being of great importance.

PURPOSE: We prospectively studied the effect of finasteride on chronic hematuria associated with benign prostatic hyperplasia. MATERIALS AND METHODS: We prospectively evaluated 57 patients with chronic intermittent hematuria who were randomized to a finasteride treated or a control arm. RESULTS: In the untreated control group hematuria recurred in 17 patients (63%) within a year but in only 4 (14%) in the finasteride group, which was a statistically significant difference (p <0.05). Surgery was required for bleeding in 7 controls (26%), while no patient on finasteride required surgery. CONCLUSIONS: Hematuria secondary to prostatic bleeding may be significant if not treated. Finasteride appears to be effective for suppressing hematuria caused by benign prostatic hyperplasia and should be considered as treatment.

BACKGROUND: The increased incidence of skin cancers after solid organ transplantation is well recognized. Skin cancers developing in transplant recipients are more aggressive in behaviour. Therapeutic options to reduce and/or delay the development of cutaneous neoplasms are therefore of interest. OBJECTIVES: The objective of this review was to summarize the available medical literature from randomized controlled trials on the use of oral retinoids as a preventive agent for skin cancers in the solid organ transplant population. METHODS: Three electronic databases were searched for relevant trials: MEDLINE (1966-October 2003), EMBASE (1980-week 44, 2003) and the Cochrane Controlled Trials Register (third quarter 2003). Randomized or quasi-randomized controlled clinical trials on subjects of any age or ethnic background who had received a solid organ transplant (cardiac, renal, liver, etc.) were evaluated. All titles and abstracts found by the search strategy were independently reviewed by two researchers for inclusion into the review. RESULTS: Eighty-one abstracts were identified through the electronic databases for consideration. Review of the abstracts identified three eligible trials. One cross-over trial involving 23 subjects treated with acitretin 25 mg daily for 12 months reported 46 squamous cell carcinomas (SCCs) developing in six subjects during acitretin treatment vs. 65 SCCs developing in 15 subjects during the drug-free period. Another trial involving 44 subjects treated with acitretin 30 mg daily or placebo for 6 months reported two of 19 subjects developing two SCCs in the treatment group vs. nine of 19 subjects developing 18 new skin cancers (15 SCCs, one Bowen's disease, two basal cell carcinomas) in the placebo group. One dose comparison trial involving 26 renal transplant recipients treated with acitretin did not find a significant difference in numbers of skin cancers developing at the doses examined. The major limitation to the use of acitretin was poor tolerance due to adverse events. Headaches, rash, musculoskeletal symptoms and hyperlipidaemia were the most common causes of withdrawal from treatment. No alterations in renal or liver function were detected during the periods of treatment or follow-up. CONCLUSIONS: The available data from a small number of randomized controlled trials suggest that acitretin may have a role in the management of solid organ transplant recipients with skin cancers. Tolerability of the drug is a major factor limiting its use. Appropriate selection of patients may help improve the risk-benefit ratio.

In July 1999, the Swinfen Charitable Trust in the UK established a telemedicine link in Bangladesh, between the Centre for the Rehabilitation of the Paralysed (CRP) in Dhaka and medical consultants abroad. This low-cost telemedicine system used a digital camera to capture still images, which were then transmitted by email. During the first 12 months, 27 telemedicine referrals were made. The following specialties were consulted: neurology (44%), orthopaedics (40%), rheumatology (8%), nephrology (4%) and paediatrics (4%). Initial email replies were received at the CRP within a day of referral in 70% of cases and within thee days in 100%, which shows that store-and-forward telemedicine can be both fast and reliable. Telemedicine consultation was complete within three days in 14 cases (52%) and within three weeks in 24 cases (89%). Referral was judged to be beneficial in 24 cases (89%), the benefits including establishment of the diagnosis, the provision of reassurance to the patient and referring doctor, and a change of management. Four patients (15% of the total) and their families were spared the considerable expense and unnecessary stress of travelling abroad for a second opinion, and the savings from this alone outweighed the set-up and running costs in Bangladesh. The latter are limited to an email account with an Internet service provider and the local-rate telephone call charges from the CRP. This successful telemedicine system is a model for further telemedicine projects in the developing world.

1. The present investigation was designed to examine human adaptation to intermittent severe cold exposure and to assess the effect of exercise on any adaptation obtained. 2. Sixteen subjects were divided into two equal groups. Each subject performed ten head-out immersions; two into thermoneutral water which was then cooled until they shivered vigorously, and eight into water at 15 degrees C for 40 min. During the majority of the 15 degrees C immersions, one group (dynamic group) exercised whilst the other (static group) rested. 3. Results showed that both groups responded to repeated cold immersions with a reduction in their initial responses to cold. The time course of these reductions varied, however, between responses. 4. Only the static group developed a reduced metabolic response to prolonged resting immersion. 5. It is concluded that repeated resting exposure to cold was the more effective way of producing an adaptation. The performance of exercise during repeated exposure to cold prevented the development of an adaptive reduction in the metabolic response to cold during a subsequent resting immersion. In addition, many of the adaptations obtained during repeated resting exposure were overridden or masked during a subsequent exercising immersion.

1alpha, 25-Dihydroxy-22-oxacalcitriol (maxacalcitol) is a vitamin D3 analogue which displays approximately 10 times greater efficacy at suppressing keratinocyte proliferation in vitro than calcipotriol and tacalcitol. To determine clinical efficacy, a phase II double-blind, randomized, left vs. right, concentration-response study was performed with once-daily topical maxacalcitol in patients with mild to moderate chronic plaque psoriasis. Primary efficacy parameters were psoriasis severity index (PSI) based on sum of scores for erythema, scaling and induration and investigators' overall assessment of patients' response to therapy at 8 weeks of treatment. One hundred and forty-four patients participated. All concentrations of maxacalcitol ointment (6, 12.5, 25 and 50 microg/g) were significantly more effective at reducing PSI than placebo (P < 0.01), with greatest effect noted for maxacalcitol 25 microg/g. Calcipotriol ointment 50 microg/g once daily as active comparator had a similar effect. Marked improvement or clearance of psoriasis was greatest for maxacalcitol 25 microg/g (55% of subjects) which compared favourably with calcipotriol (46%). Improvement continued throughout the study period, with no plateau at week 8. Investigators' and patients' side preference (secondary efficacy parameters) rated maxacalcitol more effective than placebo and 25 microg/g maxacalcitol better than calcipotriol (P < 0.05 for investigators' assessment). Twelve patients withdrew from the study due to adverse events, of which four were judged to be due to study medication. This study indicates that once-daily maxacalcitol ointment is effective in the management of plaque psoriasis, with greatest effect noted at 25 microg/g. As no response plateau was noted at 8 weeks, these data suggest that further benefit might be obtained if maxacalcitol ointment were applied for longer. Finally, investigators' overall assessment and side preference suggest that maxacalcitol 25 microg/g may be more effective than once-daily calcipotriol.

AIM: To test the hypothesis that measures of aerobic fitness, body mass and indices of body composition will influence the metabolic and cardiovascular demands of simulated load-carriage tasks. METHOD: Twenty-eight healthy male volunteers, following assessment of maximal oxygen uptake (O(2)max) and body composition, walked on a treadmill at 4 kph (1.11 m/s) for 60 min on gradients of 0, 3, 6 and 9% whilst carrying backpack loads of 0, 20 and 40 kg. During the final 3 min of each 5-min exercise bout, indirect respiratory calorimetry and heart rate data were collected and the 'steady-state' metabolic O(2) and cardiovascular (heart rate) demands quantified. RESULTS: Absolute O(2)max (ml/min) produced the strongest correlation (r = -0.64, P < 0.01) with the metabolic demand of heavy load-carriage (40 kg). The body composition index lean body mass/(fat mass + external load) produced a moderate correlation (r = -0.52, P < 0.01) with the metabolic demand of heavy load-carriage. The increases in metabolic and cardiovascular demands were greater when the load carried increased from 20 to 40 kg compared with 0 to 20 kg at all four gradients. A model incorporating anthropometric and physiological characteristics with gradient and load explains 89% of the variability in the metabolic demands of load-carriage compared with 82% using gradient and load alone. CONCLUSION: The results show that indices of body composition as well as absolute aerobic power influence the relative metabolic demands of load-carriage. Application of these measurements would ensure selection criteria for load-carriage occupations are based on lean muscle mass rather than running speed.

it is difficult to explain how successful resuscitation is possible after 40 minutes' submersion.2The reduced oxygen requirement in profound hypothermia has been suggested by some authors as the mechanism by which tissue viability is maintained in these circumstances,2 but this alone is an incomplete explanation, as for the submerged body to cool to a degree at which oxygen requirements are sufficiently reduced, heat transfer by mass flow-that is, circulation -must be present (a dead body cools relatively slowly).The degree of cooling encountered in our cases can be explained only by the fact that circulation was maintained for some or all of the period of submersion.The persistence of cardiac activity during such a pro- longed period of apnoea supports the hypothesis that some protective mechanism may be present.We do not know whether ventricular fibrillation was present before resuscitative efforts were started and must concede that these efforts alone may have initiated the arrhythmia.Our cases show yet again that successful resuscitation is possible after long periods of immersion and emphasise the importance of performing electrocardiography early in the immersion incident, preferably at the accident site, before death is pronounced.

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis. Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C). We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01). Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.