Background There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems. Methods Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence. Results Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1). Conclusions Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

Introduction The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures. Materials and methods This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust’s submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre. Results A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015). Discussion The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed. Conclusion While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

IntroductionProsthetic joint infections (PJIs) generate significant clinical and socio-economic pressures on the health service. Recent advances in the diagnosis of PJIs, with biomarkers and sonifi...

BACKGROUND Infections in prosthetic joints are an uncommon (but disastrous) complication of arthroplasty. Infections associated with hemiarthroplasty for intracapsular fractures of the femoral neck can be fatal. Polymethylacrylate cement can be used to deliver antibiotics directly to an area of infection, thereby reducing the need for long-term administration of antibiotics. This method is used commonly in twostage revision arthroplasty for infected total hip replacements.

The fast ion and alpha-particle diagnostic is based on collective Thomson scattering of high power 140 GHz radiation.The main aim of the system will be the determination of the spatially resolved velocity distribution of fast ion populationsin JET plasmas, by measuring the frequency spectrum of scattered radiation. A spatial profile of the velocity distribution,with resolution <10 cm, can be determined by scanning the scattering volume (the overlap of the antenna patterns of thelaunch and receive antennas) over the plasma, using steerable launch and receive mirrors. The diagnostic will be used tomeasure fast ion populations produced by the heating systems, and will be particularly important in the tritium phase ofJET when, by a measurement of the velocity distribution of alpha particles created by fusion reactions, the efficiency ofalpha particle heating can be established. It is expected that their velocity distribution can be determined between 0.5MeV (limited because at low frequency shift the spectrum is dominated by the thermal ion feature) and their birth energy(3.5 MeV) with a typical time resolution of 0.1 s. The principal components of the diagnostic are shown schematically infigure 1. They are: a high power long pulse gyrotron and associated equipment, a heterodyne receiver system andtransmission lines. The RF transmission and the receiver system are described in accompanying papers1,2. The physicsprinciples of the diagnostic are described elsewheree.g. 3'4.

The diagnosis and treatment of periprosthetic joint infection (PJI) remains challenging and, with a current reported rate of 0.7%, is an ever-increasing burden on the NHS. Although some patients present with clear evidence of infection, many present insidiously. Techniques to improve the diagnosis of PJI are being developed constantly, including the use of biomarkers. Positive periprosthetic cultures are a diagnostic criterion for PJI, with a consensus on three to six distinct intraoperative samples collected from the joint interface for analysis. As PJIs are associated with biofilm bacterial growth and acute planktonic phases, deep canal sampling should aid microbiological diagnosis, as the canal provides a finite space for bacterial proliferation.

With the patient in the lithotomy position, a 26Fr resectoscope is inserted transurethrally, followed by percutaneous suprapubic puncture.The suprapubic tract is dilated and a 30Fr Amplatz sheath inserted for nephroscope access.Through a 6Fr ureteric catheter, a 365µm laser fibre is passed via the nephroscope.Holmium yttrium aluminium garnet laser (2J and 5Hz) is used to break the larger stones into smaller fragments, which are removed by rigid graspers through the nephroscope.Residual debris is cleared by Ellick evacuation through the resectoscope.A 16Fr suprapubic and urethral catheter is inserted, and removed after 24 hours.Computed tomography prior to and following the procedure is shown in Figure 1.The total operative time is less than 60 minutes. DISCUSSIONThis approach has been described previously in the literature but was advocated for the treatment of large bladder stones with two urologists working simultaneously with separate video monitors and equipment. 2 We believe laser lithotripsy is the most effective bladder stone fragmentation method because it enables stone fixation against the bladder wall.The combined endoscopic technique is safe, quick and effective for patients with multiple intermediate sized bladder stones.

Fusion: The Energy of the Universe, 2/e is an essential reference providing basic principles of fusion energy from its history to the issues and realities progressing from the present day energy crisis. The book provides detailed developments and applications for researchers entering the field of fusion energy research. This second edition includes the latest results from the National Ignition Facility at the Lawrence Radiation Laboratory at Livermore, CA, and the progress on the International Thermonuclear Experimental Reactor (ITER) tokamak programme at Caderache, France. This title features comprehensive coverage - basic principles, detailed developments and practical applications. It offers wide accessibility, but with sufficient detail to keep the technical reader engaged. It details the initial discovery of nuclear fusion, current attempts to create nuclear fusion here on earth and today's concern over future energy supply. It features color illustrations and examples. It includes technical notes for aspiring physicists.

Introduction The Sernbo score uses four factors (age, social situation, mobility and mental state) to divide patients into a high-risk and a low-risk group. This study sought to assess the use of the Sernbo score in predicting mortality after an intracapsular hip fracture. Methods A total of 259 patients with displaced intracapsular hip fractures were included in the study. Data from prospectively generated databases provided 22 descriptive variables for each patient. These included operative management, blood tests and co-mobidities. Multivariate analysis was used to identify significant predictors of mortality. Results The mean patient age was 85 years and the mean follow-up duration was 1.5 years. The one-year survival rate was 92% (±0.03) in the low-risk group and 65% (±0.046) in the high-risk group. Four variables predicted mortality: Sernbo score >15 (p=0.0023), blood creatinine (p=0.0026), ASA (American Society of Anaesthesiologists) grade >3 (p=0.0038) and non-operative treatment (p=0.0377). Receiver operating characteristic curve analysis showed the Sernbo score as the only predictor of 30-day mortality (area under curve 0.71 [0.65–0.76]). The score had a sensitivity of 92% and a specificity of 51% for prediction of death at 30 days. Conclusions The Sernbo score identifies patients at high risk of death in the 30 days following injury. This very simple score could be used to direct extra early multidisciplinary input to high-risk patients on admission with an intracapsular hip fracture.

Fusion reactor fuel cycles based on the D–3He and D–D reactions have been advocated as alternatives to deuterium and tritium (D–T). In this paper we make a careful assessment of the feasibility of burning these alternative fuels in a fusion reactor. A zero-dimensional model of the energy balance including radial profile effects for plasma temperature and density with accurate algorithms for synchrotron and bremsstrahlung radiation losses is used to calculate the required plasma conditions. Radiation losses and other factors severely restrict the choice of fuel mixtures that can be brought to ignition—and even under the most favourable assumptions, ignition requires plasma conditions in terms of energy confinement time, density, temperature and beta that are significantly more demanding than the conditions required to burn D–T. These requirements are far beyond the best conditions that have been reached in any present-day magnetic confinement experiments. A very serious issue is the stringent limit on the maximum concentrations of impurities and helium ash that can be tolerated. We consider the extent to which neutrons are reduced and briefly discuss the prospects for direct conversion. Finally we look at the serious problem of supplying 3He fuel in sufficient quantities to sustain a worldwide fusion energy programme and discuss the limitations of lunar sources and the difficulties of manufacturing 3He from D–D.