The main surgical options for hallux rigidus include dorsal cheilectomy, arthroplasty and fusion. Compared to other surgical procedures dorsal cheilectomy involves relatively less bone loss, maintains joint motion and still leaves the potential for a further salvage procedure such as arthrodesis. The Manchester – Oxford Foot and Ankle Questionnaire (MOXFQ) has been endorsed by the British Foot and Ankle Society and recommended as a tool to measure surgical outcome. The aim of this study was to prospectively follow-up patients following dorsal cheilectomy for hallux rigidus using the patient-reported outcome measure, the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had symptoms of dorsal impingement (painful restriction of terminal dorsiflexion of the hallux), with absence of pain in the mid-range of passive movement (indicative of end stage arthritis), and dorsal osteophytes on radiographs. Twenty five patients with a mean age of 62 years (range: 39 – 80 years) and comprising 17 females underwent dorsal cheilectomy for hallux rigidus. At a mean follow-up of 17 months (range 9–27 months), the mean MOXFQ score improved from 33/64 (95% CI: 27 – 38) pre-operatively to 9/64 (95% CI: 6 – 13) post-operatively. Eighty-four percent of patients had a clinically significant improvement in their walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients were deemed failures: three patients underwent subsequent arthrodesis for persisting pain, and one patient had no improvement in any domain of the MOXFQ. In conclusion, this study has provided further evidence of the success of dorsal cheilectomy as a reliable treatment option for hallux rigidus. It has also demonstrated the sensitivity of the patient focused reporting instrument the MOXFQ in assessing surgical outcomes in foot surgery.

intraoperative use, the bucket is enclosed in a sterile bag (usually a Mayo table cover) and secured with tape. The bucket is then placed underneath the distal femur on its side (Fig. 2). The position of the bucket can be moved to aid reduction. Rolling the bucket proximally causes the fracture to flex, and rolling distally causes it to extend. The tapered shape of the bucket is utilized to aid in correction of coronal malalignment by having the narrow diameter either medially or laterally. Application of traction to the knee over the bucket causes distraction of the fracture.

Compared with other surgical procedures for hallux rigidus, dorsal cheilectomy involves relatively less bone removal, maintains joint motion, and leaves the potential for further salvage surgery. The Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) has a maximum score of 64 (worst foot health) and has been endorsed by the British Foot and Ankle Society to measure surgical outcome. We prospectively assessed patient-reported outcomes after dorsal cheilectomy for hallux rigidus using the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had painful restriction of terminal dorsiflexion, with absence of pain in the mid-range of passive movement, and radiographic evidence of dorsal osteophytosis. Twenty-five patients with a mean age of 62 years (range, 39-80 years), including 17 (68%) women, underwent dorsal cheilectomy for hallux rigidus. The mean preoperative MOXFQ score was 33.0 (95% confidence interval = 27.4-38.6), and, at a mean of 17 months (range, 9-27 months) follow-up, the mean postoperative score was 9.6 (95% confidence interval = 6.0-13.2). Eighty-four percent of patients experienced clinically significantly improved walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients failed cheilectomy, including 3 who subsequently underwent arthrodesis for persistent pain and 1 who experienced no improvement in any domain of the MOXFQ. This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery.

AlexAnder 'Alec' Cottrell of Wendell road, Shepherd Bush, who died on december 13 at the age of 95, was the last surviving member of the Old Contemptibles Associa- tion 1914. A fixture at the Shepherds

This paper discusses developments in the last five to six years in the provision of operational flood forecasting in En-land, Wales. and Scotland. Before the formation of the Environment Agency (EA) in England and Wales and the Scottish Environment Protection Agency (SEPA), flood forecasting capabilities were fragmented. Just over a decade ago both organisations received governmental mandates for the provision of flood forecasting and warning nationally, and have as a result in recent years established systems providing national coverage: the National Flood Forecasting System, and Flood Early Warning System (FEWS) Scotland. These have facilitated a rapid expansion of catchments for which forecasts are provided, and the common framework used has enabled a more rapid introduction of scientific advances in forecasting techniques. This paper gives an overview of some of these recent developments, as well as providing an outlook to further developments to be undertaken in the near future. Copyright (C) 2009 Royal Meteorological Society

OBJECTIVE:The purpose of this study was to describe an air transport service's protocol for direct transport of patients with abdominal aortic aneurysm leak (AAAL) into receiving hospital operating rooms (ORs). METHODS:This retrospective consecutive-case analysis examined AAAL patients undergoing nurse-paramedic Boston MedFlight (BMF) transport during 1999-2004, who were taken directly into ORs at four academic centers. BMF uses a rotating roster system to assign receiving hospitals when referring physicians have no preidentified receiving facility, but this practice may prolong patient transport or be associated with less diagnostic certainty, and thus more delay, at receiving hospitals. Thus, the study compared "Roster" versus "Non-roster" patients' time and outcome end points. Continuous nonparametric data (e.g., time intervals) were described with median and interquartile range (IQR). Chi-square and Kruskal-Wallis tests were used for univariate comparisons; regression analysis assessed dependent variables while adjusting for covariates (e.g., transport mileage). RESULTS:There were 29 direct-to-OR transports, with median distance of 30 miles. All patients had AAAL diagnosis confirmed; 51.7% survived. System performance for end points was similar as assessed between Roster versus Non-roster patients. CONCLUSIONS:Interfacility direct-to-OR transport of AAAL patients is feasible. Use of a roster system allows for timely transport facilitation for patients needing specialized care; roster patients achieve similar end points as did patients who had already-identified receiving hospitals upon air medical transport request.

OBJECTIVES:Studies finding adverse outcomes associated with emergency medical services intubation (ETI) have prompted recommendations for prehospital services to improve tracking of oxygenation during airway management. Our goals were to 1) implement a documentation requirement for helicopter EMS (HEMS) crews, entailing tracking and notation of the lowest SpO2 value (peri-ETI SpO2 nadir) occurring during HEMS crew ETI, and 2) assess the findings associated with the peri-ETI SpO2 documentation parameter. METHODS:This was a prospective study conducted at an urban HEMS program with flight nurse/flight paramedic staffing and protocol-driven care. There were 200 consecutive cases undergoing HEMS ETI between April 2004 and July 2005. Univariate logistic regression with odds ratio (OR) was used to assess for association between ETI-related hypoxemia (decrease in SpO2 value to < 90% during ETI) and patient/intubator characteristics. RESULTS:HEMS crew ETI was successful in 189 (95.4%) of the 200 patients. The lowest peri-ETI SpO2 value was specifically documented in 170 patients (85%) in the study group. In univariate analysis, successful crew ETI was correlated with avoidance of crew-recorded SpO2 value decreasing to < 90% (OR, 0.23; 95% confidence interval, 0.07-0.83). Similarly, requirement for multiple attempts at ETI was correlated with higher likelihood that crews recorded peri-ETI SpO2 value decreasing to < 90% (OR, 7.8; 95% confidence interval, 3.2-18.8). However, in nearly two thirds of cases in which multiple attempts were executed, the peri-ETI SpO2 value remained > 90%. Of the seven patients in whom rescue laryngeal mask airways were placed, the peri-ETI SpO2 value remained > 90% in three (42.9%). CONCLUSION:Documentation of crew-recorded peri-ETI SpO2 nadir is a useful and practical prehospital data point.

This study assessed frequency, safety and efficacy of prehospital fentanyl analgesia during 6 months’ adult and pediatric helicopter trauma scene transports (213 doses in 177 patients). We reviewed flight records for pain assessment and analgesia provision, effect, and complications. Analgesia was administered to 46/49 (93.9%) intubated patients. In non-intubated patients, pain assessment was documented in 112 of 128 (87.5%), and analgesia was offered, or there was no pain, in 97/128 (75.8%). Of the 67 non-intubated patients to whom analgesia was administered, post-analgesia pain assessment was documented in 62 (92.5%) and pain improved in 53 (79.1% of 67). Post-analgesia blood pressure dropped below 90 torr in 2/177 cases (1.1%, 95% confidence interval [CI] 0.1–4.0%). Post-analgesia SpO2 did not drop below 90% in any patients (95% CI 0–2.3%). In this study, prehospital providers performed well with respect to pain assessment and treatment. Fentanyl was provided frequently, with good effect and minimal cardiorespiratory consequence.

In patients with traumatic injuries, prehospital hypotension that resolves by Emergency Department (ED) arrival is of uncertain significance. We examined the impact of prehospital hypotension (PH) in normotensive ED patients with traumatic injuries on predicting mortality and chest/abdominal operative intervention. A retrospective cohort study was conducted of consecutive patients undergoing helicopter transport to two trauma centers between 1993 and 1997. Outcomes were mortality and chest or abdominal operative intervention. Of 545 scene transports, 55 (10.1%) patients were hypotensive on ED arrival, leaving 490 normotensive ED patients. Of 490 patients, 35 (7%) had PH and 455 (93%) had no PH. Multiple logistic regression showed the PH group to have a relative risk for death of 4.4 (95% CI: 1.2–16.6, p < 0.03) and for chest or abdominal operative intervention of 2.9 (1.1–7.6, p < 0.03). In this study of normotensive trauma center patients, prehospital hypotension was associated with increased risk of mortality and significant chest or abdominal injury.

BACKGROUND:Despite many studies addressing potential impact of helicopter transport on trauma mortality, debate as to the efficacy of air transport continues. METHODS:This retrospective study combined trauma registry data from five urban Level I adult and pediatric centers. Logistic regression assessed effect of helicopter transport on mortality while adjusting for age, sex, transport year, receiving hospital, prehospital level of care (Advanced Life Support vs. Basic Life Support), ISS, and mission type (scene vs. interfacility). RESULTS:The study database comprised 16,699 patients. Crude mortality for Air (9.4%) was 3.4 times (95% CI, 2.9-4.0, p < 0.001) that of Ground (3.0%) patients. In adjusted analysis, helicopter transport was found to be associated with a significant mortality reduction (odds ratio, 0.76; 95% CI, 0.59-0.98; p = 0.031). CONCLUSION:The results of this study are consistent with an association between helicopter transport mode and increased survival in blunt trauma patients.

The objective was to compare rates of successful endotracheal intubation (ETI) and requirement for multiple ETI attempts in patients receiving etomidate (ETOM) versus succinylcholine (SUX). This retrospective study analyzed adults in whom oral ETI was attempted by a helicopter EMS (HEMS) service between July 1997 to July 1999. Data were from records of the HEMS service, which uses a RN/EMTP crew; analysis was with chi-square and logistic regression (P = .05). ETI was successful in 269 (97.8%) of 275 patients, with multiple attempts occurring in 54 (20.1%) of 269. Success rates for SUX (209 of 213, 98.1%) and ETOM (60 of 62, 96.8%) were similar (P = .62). However, of 60 ETOM patients successfully intubated, 7 (11.7%) required rescue succinylcholine. When these patients are tallied as ETOM failures and SUX successes, resultant success rates for ETOM (86.9%) and SUX (98.2%) are different (P = .001). ETOM patients were more likely (P = .004) than SUX patients to require multiple attempts (33.3% versus 16.3%). ETI success rates were high in patients receiving SUX or ETOM as primary adjuncts for airway control, but initial success was more likely with SUX, and ETOM patients were more likely to require multiple attempts.

Rotor-wing aircraft have previously proven utility in disaster operations, but recent expert reviewers have identified areas of potential improvement in integration of helicopter emergency medical services (HEMS) resources into disaster planning and management. This paper discusses salient points regarding helicopter operations in disaster management, using prior reports regarding rotor-wing aircraft utilization as a basis upon which to provide a concise review of HEMS operations in disasters.

OBJECTIVE:To analyze flight crew airway management in four different settings (in flight, at trauma scenes, in ambulance, and in referring hospitals) and in two different aircraft used by the same helicopter EMS (HEMS) service. The null hypothesis was that there was no association between practice setting, or aircraft, and airway practices or success rate. METHODS:This retrospective study analyzed all patients in whom advanced airway management was attempted by the HEMS service during the study period October 1991 through October 1997. Data used were from flight records of Boston MedFlight Critical Care Transport Service, which uses a nurse/paramedic crew and had a paralytic-assisted intubation protocol in place. Data were analyzed with chi-square and Fisher's exact testing, risk ratio analysis, and logistic regression. RESULTS:Advanced airway management was attempted in 722 patients, with an airway placed in 705 (97.8%). Intubation success was unrelated to site of airway management (p = 0.14), but patients were more likely to have intubation attempted prior to flight (as opposed to in flight) if the crew were in the AS365N2 Dauphin as compared with the BK-117 (p<0.0001). In addition, patients were 0.77 times as likely (95% confidence interval, 0.68-0.88) to receive paralytic-facilitated intubation if airway management occurred in the hospital setting as compared with other sites. CONCLUSIONS:While HEMS crew airway management success rates are equally high in all practice settings, airway management decision making and practice appear to be significantly influenced by practice setting and aircraft type. These data support contentions that nonphysician HEMS crews can effectively manage airways in a variety of circumstances.

Modern operating systems provide multiple mechanisms for developing concurrent applications. Synchronous multithreading is a popular mechanism for developing applications that perform multiple operations simultaneously. However, threads often have high performance overhead and require deep knowledge of synchronization patterns and principles. Therefore, an increasing number of operating systems support asynchronous mechanisms that provide the benefits of concurrency while alleviating much of the overhead and complexity of multi-threading. The Proactor pattern presented in this paper describes how to structure applications and systems that effectively utilize asynchronous mechanisms supported by operating systems. When an application invokes an asynchronous operation, the OS performs the operation on behalf of the application. This allows the application to have multiple operations running simultaneously without requiring the application to have a corresponding number of threads. Therefore, the Proactor pattern simplifies concurrent programming and improves performance by requiring fewer threads and leveraging OS support for asynchronous operations.

Modern operating systems provide multiple mechanisms for developing concurrent applications. Synchronous multi- threading is a popular mechanism for developing applica- tions that perform multiple operations simultaneously. How- ever, threads often have high performance overhead and re- quire deep knowledge of synchronization patterns and prin- ciples. Therefore, an increasing number of operating systems support asynchronous mechanisms that provide the benefits of concurrency while alleviating much of the overhead and complexity of multi-threading. The Proactor pattern presented in this paper describes how to structure applications and systems that effectively uti- lize asynchronous mechanisms supported by operating sys- tems. When an application invokes an asynchronous opera- tion, the OS performs the operation on behalf of the appli- cation. This allows the application to have multiple opera- tions running simultaneously without requiring the applica- tion to have a corresponding number of threads. Therefore, the Proactor pattern simplifies concurrent programming and improves performance by requiring fewer threads and lever- aging OS support for asynchronous operations.

In theory, multi-threading an application can improve performance (by executing multiple instruction streams simultaneously) and simplify program structure (by allowing each thread to execute synchronously rather than reactively or asynchronously). In practice, multi-threaded applications often perform no better, or even worse, than single-threaded applications due to the overhead of acquiring and releasing locks. In addition, multi-threaded applications are hard to program due to the complex concurrency control protocols required to avoid race conditions and deadlocks. This paper describes the Thread-Specific Storage pattern, which alleviates several problems with multi-threading performance and programming complexity. The Thread-Specific Storage pattern improves performance and simplifies multithreaded applications by allowing multiple threads to use one logically global access point to retrieve thread-specific data without incurring locking overhead for each access.