Asymmetrical traumatic bilateral hip dislocations with hemodynamic instability and an unstable pelvic ring: Case report and review of literature

Simultaneous anterior and posterior traumatic dislocations of both hips are very rare. Only 33 cases have been previously reported in the English language literature. Although they were all due to high-energy injuries, they were hemodynamically stable and had a stable pelvic ring. We report a unique case of asymmetrical hip dislocations with an unstable pelvic ring and hemodynamic instability. A 40-year-old man was injured in a high-energy motor vehicle accident. He was hemodynamically unstable when he presented in the emergency department. Radiolographs showed asymmetrical dislocations of both hips with an unstable pelvic ring. Under general anesthesia, he had closed reduction of the dislocations of both hips, followed by temporary stabilization with an external fixator. Transcatheter arterial embolization was performed to stop active pelvic bleeding. Delayed open reduction and internal fixation was performed 12 d later with anterior and posterior plates. The patient recovered well with an uneventful post-operative course. Asymmetrical bilateral hip dislocations with pelvic ring instability caused by trauma, as presented in this case, is very rare and potentially life threatening. Prompt treatment can give a good outcome.

Critical evaluation of American categorization of fetal heart rate (FHR) decelerations and three tier classification—Shortcomings, contradictions, remedies and need for debate

Fetal heart rate (FHR) decelerations are the commonest aberrant feature on cardiotocograph (CTG) thus having a major influence on classification ofFHRpatterns into the three tier system. The unexplained paradox of early decelerations (head compression—an invariable phenomenon in labor) being extremely rare [1] should prompt a debate about scientific validity of current categorization. This paper demonstrates that there appear to be major fallacies in the pathophysiological hypothesis (cord compression—baroreceptor mechanism) underpinning of vast majority of (variable?) decelerations. Rapid decelerations during contractions with nadir matching peak of contractions are consistent with “pure” vagal reflex (head compression) rather than result of fetal blood pressure or oxygenation changes from cord compression. Hence, many American authors have reported that the abrupt FHR decelerations attributed to cord compression are actually due to head compression [2-6]. The paper debates if there are major fundamental fallacies in current categorization of FHR decelerations based concomitantly on rate of descent (reflecting putative aetiology?) and time relationship to contractions. Decelerations with consistently early timing (constituting majority) seem to get classed as “variable” because of rapid descent. A distorted unscientific categorization of FHR decelerations could lead to clinically unhelpful three tier classification system. Hence, the current unphysiological classification needs a fresh debate with consideration of alternative models and re-evaluation of clinical studies to test these. Open debate improves patient care and safety. The clue to benign reflex versus hypoxic nature of decelerations seems to be in the timing rather than the rate of descent. Although the likelihood of fetal hypxemia is related to depth and duration ofFHRdecelerations, the cut-offs are likely to be different for early/late/variable decelerations and it seems to be of paramount importance to get this discrimination right for useful visual or computerized system of CTG interpretation.

Imperative for improvements and international convergence of intrapartum fetal monitoring: A bird's eye view

Intrapartum fetal monitoring has been criticized for the lack of evidence of improvement in fetal outcome despite causing increased operative intervention. Paradoxically, cardiotocography （CTG） has been a major driver for litigation for neonatal neurological injury. This analytical review tries to explore why extensive clinical studies and trials over 50 years have failed to demonstrate or bring about signifcant improvement in intrapartum fetal monitoring. There seems a need for significant reform. International congruence on most aspects of CTG interpretation [defnitions of fetal heart rate （FHR） parameters, CTG recording speed, 3-tier systems, etc .] is highly desirable to facilitate future meaningful clinical studies, evaluation and progress in this field. The FHR changes are non-specific and poor surrogate for fetal well-being. As a compromise for maintaining low false-negative results for fetal acidemia, a high false-positive value may have to be accepted. The need for redefning the place of adjuvant tests of fetal well-being like fetal blood sampling or fetal electrocardiography （ECG） is discussed. The FHR decelerations are often deterministic （center-stage） in CTG interpretation and 3-tier categorization. It is discussed if their scientifc and physiological classifcation （avoiding framing and confirmation biases） may be best based on time relationship to uterine contractions alone. This may provide a more sound foundation which could improve the reliability and further evolution of 3-tier systems. Results of several trials of fetal ECG （STAN） have been inconclusive and a need for a fresh approach or strategy is considered. It is hoped that the long anticipated Computer-aided analysis of CTG will be more objective and reliable （overcome human factors） and will offer valuable support or may eventually replace visual CTG interpretation. In any case, the recording and archiving all CTGs digitally and testing cord blood gases routinely in every delivery would be highly desirable for future research. This would facilitate well designed retrospective studies which can be very informative especially when prospective randomised controlled trials are often diffcult and resource-intensive.

THE ROLE OF UMBRELLA AGREEMENTS IN ACHIEVING SUSTAINABILITY GOALS:ENERGY EFFICIENCY AT THE EMPIRE STATE BUILDING

In this paper we investigate whether innovative and flexible contractual arrange-ments can support the process of achieving ambitious sustainability goals.We explore this question through an analysis of the role of umbrella agreements in driving energy savings in the building sector.Drawing on a case study of the iconic Empire State building,we examine the typical challenges faced by clients and con-tractors in devising suitable agreements that facilitate managing contractual and performance risks,as well as the sharing of responsibilities and cooperation between multiple project stakeholders.We find that the project arrangements appear to exhibit the adoption of the key characteristics commonly found in umbrella agree-ments which incorporate sustainability measures that maximize income through efficient delivery of outcomes.Specifically,this means that they need to enable stakeholders to manage repeated review cycles,complex perceptions and expecta-tions,and different tacit assumptions and codes of behaviour,as well as managing and communicating in networks and obtaining agreement also from non-contrac-tual parties.Moreover,we demonstrate that umbrella agreements can facilitate a network perspective of business relationships by emphasizing value co-creation and the embeddedness of firms within a network of interactions.

A systematic review of pre-hospital shoulder reduction techniques for anterior shoulder dislocation and the effect on patient return to function

Purpose:The majority of acute anterior shoulder dislocations are sustained during sports and wilderness activities.The management of acute dislocations in the pre-hospital setting is currently without guidelines based on the evidence.The study aims to assess the risk of acute complications in pre-hospital shoulder reduction and identify which pre-hospital reduction technique has the highest success rate in the published literature.Methods:The involved databases were Allied and Complementary Medicine,CENTRAL,CINAHL,Cochrane Database of Systematic Reviews,Embase,Europe PMC,Ovid MEDLINE®,Pedro,Proquest,Trip,and World Health Organization International Clinical Trials Registry platform.Only original research of high methodological quality was included,which was defined by the recently developed assessment tooleassessing the methodological quality of published papers(AMQPP)and investigated the management of acute anterior shoulder dislocations in the pre-hospital setting.Results:Two hundred and ninety-eight articles were identified and screened.A full text review was performed on 40 articles.Four articles published between 2015 and 2018 met the inclusion criteria.A total of 181 patients were included with the study duration ranging from 6 to 60 months.All studies reported zero immediate complication following pre-hospital reduction and there were no documented subsequent adverse events regardless of the technique used.Prompt resolution of neurological symptoms was observed following the early and successful pre-hospital reduction.First attempt success rate,when performed by skilled practitioners,ranged from 72.3%to 94.9%.Conclusion:Pre-hospital shoulder reduction appears to be a safe and feasible option when carried out with the appropriate expertise.A novel reduction technique adapted from the mountain medicine diploma course at the University of Paris North was found to have the highest first attempt reduction success rate of 94.9%.Other techniques described in the literature included Hippocratic,Stimson's,Counter-traction and external rotation with the success rates ranging from 54%to 71.7%.

糖尿病与降脂治疗:研究现状 现确信他汀类药物可减少2型糖尿病患者的心血管危险

中青年发病和死亡多由心血管疾病引起，吸烟、高血压和血脂异常是导致心血管疾病的主要原因，而这些危险因素都是可以控制的。糖尿病与心血管风险直接相关，糖尿病患者的心血管疾病风险与无糖尿病而有心肌梗死病史的患者相同。由于多数2型糖尿病患者10年内患心血管疾病的绝对危险≥20％，指南推荐采取积极措施来干预糖尿病患者的危险因素，包括他汀类药物治疗，使血清低密度脂蛋白胆固醇（LDL-C）水平降低至2mmol／L以下。本期杂志发表了Costa等对降脂治疗临床试验汇总分析的结果（见第291页），这些临床试验评价了降脂治疗在糖尿病和非糖尿病患者冠心病一级预防和二级预防中的作用。