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Using a simple mathematical formulation, the relationship between the position of the lag screw tip (relevant to both intramedullary and extramedullary devices) and the concept of tip-apex distance (TAD) was derived. TAD is widely used in operating theaters as a surgical guideline in relation to the fixation of trochanteric fractures, and in clinical studies as a predictor of lag screw cut-out. In order to visualize better this concept, the locus of points having the same TAD was plotted and the dependence of TAD on the location of the lag screw tip was also reported. It was shown that TAD should be adjusted for the size of the femoral head (a variable which varies a lot according to the sex of the patient) while no correlation was found between TAD and bone morphometry indices obtained from micro-CT data (BV/TV and Tb.Th). Therefore, these results seem to suggest that TAD lacks mechanical justification and that predictors which are based on mechanical properties, such as bone density, should be investigated further.

In recent years, it has become increasingly recognized that acromegaly is associated with an increased prevalence of colorectal cancer and pre-malignant tubular adenomas. The aetiology of these tumours is unknown but is likely to reflect increased levels of both insulin-like growth factor I (IGF-I), which is implicated in the development of sporadic colorectal cancer, and environmental factors, such as the bile acid deoxycholic acid. There is also evidence to suggest that the prevalence of breast and perhaps haematological malignancies might be increased in acromegaly, although these associations have been based on mostly small epidemiological surveys and clarification will come in the future once large-scale epidemiological studies have been completed.

ObjectiveHealthcare faces the continual challenge of improving outcome while aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway.DesignDiscrete event simulation was used to model and analyse cost and resource utilisation with an activity-based costing approach. Data for a full comparison before the process change was unavailable so we used a modelling approach, comparing a virtual fracture clinic (VFC) with a simulated traditional fracture clinic (TFC).SettingThe orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study.Outcome measuresOur study focused exclusively on patients with non-operative trauma attending emergency department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries are presented in association with activity costs from the models.ResultsPatients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face (f2f) attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p≤0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI 21.74 to 23.92) per patient compared with £36.81 (95% CI 35.65 to 37.97) for the TFC pathway.ConclusionsOur results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional f2f clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings.

Acromegaly is characterised by excessive levels of circulating growth hormone and its tissue mediator, insulin-like growth factor (IGF)-I. Prior to effective treatment and lowering of growth hormone and IGF-I, the majority of patients with the disease died by the age of 60 years, largely due to diabetes mellitus, cardiovascular and cerebrovascular diseases. More recently, it has become apparent that patients with acromegaly may also have an increased prevalence of colorectal adenomas and cancer. This may be due to elevated IGF-I, which is implicated in the development of sporadic colorectal cancer, and environmental factors, such as the bile acid deoxycholic acid, the levels of which are also increased in acromegaly. There is some evidence to suggest that breast and prostatic malignancies might also be increased in acromegaly. However, these associations have been based mostly on small epidemiological surveys and circumstantial evidence. Large-scale epidemiological studies are required to clarify this issue.

IntroductionThe aim of the present study was to define the medium-term outcomes following total hip replacement (THR) for hip fracture. Methods We prospectively followed up 92 patients who underwent THR for a displaced hip fracture over a 3-year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford Hip Score, Short-Form 12 (SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously reported at 2 years to determine any significant differences.ResultsMean follow-up was at 5.4 years with a mean age at follow-up of 76.5 years. Seventy-four patients (80%) responded. Patients reported excellent functional outcomes and satisfaction (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2-year follow-up, there were no statistically significant adverse changes in outcome parameters.ConclusionsMedium-term outcomes for THR after hip fracture in fit older patients are excellent, and these results demonstrate that the early proven benefits of this surgery are sustained into the midterm.

The set point of cortisol-cortisone conversion is shifted in the direction of cortisone by the inhibition of the activity of 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) during adult GH replacement and in active acromegaly. Additionally, both fat mass and insulin may modulate 11beta-HSD1 and are both influenced by changes in GH status. This study examined the relative direct contribution of GH/IGF1 in modulating cortisol metabolism. Overall cortisol/cortisone conversion (ratio of urine 11-hydroxy-/11-oxo-cortisol metabolites; Fm/Em), insulin sensitivity (homeostatic model assessment; HOMA %S) and fat mass (DXA) were examined in parallel in 6 patients (mean age 53 years, range 42-76; 4 males, 2 females) with previously untreated active acromegaly during 6 months of therapy with Sandostatin LAR (20-30 mg i.m. 4 weekly). All but 1 patient had normal ACTH reserve. At baseline, Pearson correlation demonstrated an inverse relationship between serum GH (mean of a 5-point day curve) and Fm/Em (r = -0.83, p = 0.04) and a trend towards an inverse relationship between HOMA %S and Fm/Em (r = -0.79, p = 0.06) but no other patterns were evident. During the course of treatment, serum GH decreased from 9.9 +/- 6.4 (mean +/- SD) to 3.5 +/- 3.1 ng/ml (p < 0.01) and serum IGF-1 from 785 +/- 268 to 431 +/- 156 ng/ml (p < 0.005). Fm/Em increased from 0.52 +/- 0.1 to 0.75 +/- 0.08 (p < 0.03) consistent with increased 11beta-HSD1 activity. There were no significant changes in truncal fat percentage (33.0 +/- 9.0 vs. 33.0 +/- 8.2) or insulin sensitivity (HOMA %S: 37.1 +/- 8.6 vs. 52.8 +/- 33.7). Modulation of cortisol metabolism during treatment of active acromegaly is dependent on changes in GH/IGF-1 status and is not influenced by any individual change in body composition or insulin sensitivity.

BACKGROUND:Although adult respiratory distress syndrome is an important early complication of blunt trauma, the epidemiology and risk factors for its development remain poorly defined. The aims of this study were to determine the prevalence and demographics of this complication in a prospective cohort series of patients admitted to the hospital following injury. We also assessed the contribution of the severity and pattern of the injury to the risk of this complication developing. By identifying factors associated with the highest risk of the development of adult respiratory distress syndrome, we aimed to produce guidelines to facilitate earlier detection. METHODS:We prospectively studied 7192 patients admitted to a single university hospital, over an eight-year period, for treatment of a traumatic injury. With the exception of patients who had sustained a hip fracture or who had been discharged within seventy-two hours after admission, all patients who required hospital admission following trauma, were older than thirteen years of age, and were a resident within the catchment area were included in the analysis. The prevalence and demographics of posttraumatic adult respiratory distress syndrome were identified for patients who had sustained musculoskeletal, thoracic, abdominal, and head injuries, either in isolation or in combination. The relative risks of this condition developing were calculated according to the injury pattern. Multiple logistic regression analysis was performed to identify the most highly significant predictors of the development of adult respiratory distress syndrome. RESULTS:Adult respiratory distress syndrome developed in thirty-six (0.5%) of the patients. The prevalence was significantly higher among younger patients (p = 0.002), and 83% of the cases followed high-energy trauma. The prevalence of adult respiratory distress syndrome after isolated thoracic, head, abdominal, or extremity injury was <1%. Patients with injuries to two anatomical regions had a higher prevalence (up to 2.9%), and those with injuries to three anatomical regions had an even higher prevalence (up to 10.2%). Multiple logistic regression analysis showed the Injury Severity Score, the presence of a femoral fracture, the combination of abdominal and extremity injuries, and observations of compromised physiological function on admission each to be an independent predictor of the later development of adult respiratory distress syndrome. CONCLUSIONS:The prevalence of adult respiratory distress syndrome increases with injury severity and combinations of injuries to more than one anatomical region. We have been able to quantify the importance and relative risks associated with these injuries. The implications of our findings with regard to facilitating early detection of this complication are discussed. LEVEL OF EVIDENCE:Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

To evaluate the efficacy of lanreotide Autogel, a depot preparation of a long-acting somatostatin analogue, in patients with acromegaly who were previously treated with octreotide. In a prospective single-center, open-label, comparative study, 13 patients were switched from octreotide treatment (baseline) to lanreotide Autogel therapy at a fixed dosage of 90 mg/4 wk. After 6 injections, the dosage was titrated to 60, 90, or 120 mg/4 wk, on the basis of growth hormone (GH) levels, for a further 6 injections. Mean GH and insulinlike growth factor-I (IGF-I) levels were determined at baseline, during treatment (to 48 weeks), and up to 8 weeks after the last injection. There was no significant change in the proportion of patients with GH and IGF-I control from baseline to week 48 (GH, 85% to 89%; IGF-I, 46% to 62%). Mean GH levels changed little from baseline, but mean IGF-I levels were significantly lower after 32 weeks (P<.05) and 48 weeks (P<.02). Data collected at 6 and 8 weeks after the last injection suggested that the efficacy of lanreotide Autogel can persist for longer than 4 weeks. This small study suggests that lanreotide Autogel is at least as effective as octreotide in the control of acromegaly and may last for longer than the recommended 4 weeks. It appears to be a useful alternative to long-acting octreotide in the treatment of acromegaly.

Introduction Questionnaires are used commonly to assess functional outcome and satisfaction in surgical patients. Although these have in the past been administered through written forms, there is increasing interest in the use of new technology to improve the efficiency of collection. The aim of this study was to assess the availability of internet access for a group of orthopaedic patients and the acceptability of online survey completion. Methods A total of 497 patients attending orthopaedic outpatient clinics were surveyed to assess access to the internet and their preferred means for completing follow-up questionnaires. Results Overall, 358 patients (72%) reported having internet access. Lack of access was associated with socioeconomic deprivation and older age. Multivariable regression confirmed increased age and greater deprivation to be independently associated with lack of internet access. Out of the total group, 198 (40%) indicated a preference for assessment of outcomes via email and the internet. Conclusions Internet access was not universal among the patients in our orthopaedic clinic. Reliance on internet collection of PROMs may introduce bias by not including results from patients in older age groups and those from the more deprived socioeconomic groups.