Randomized feasibility trial of replacing or discarding the nail plate after nail-bed repair in children.

BACKGROUND: Nail-bed injuries are the most common hand injury in children. Surgical dogma is to replace the nail plate after repairing the nail bed. Recent evidence suggests this might increase infection rates and returns to clinic. The aim of this feasibility trial was to inform the design and conduct of a definitive trial comparing replacing or discarding the nail plate after nail-bed repair. METHODS: This study recruited participants from four hand units in the UK between April and July 2015. Participants were children under the age of 16 years with a nail-bed injury requiring surgery. They were randomized to either having the nail plate replaced or discarded after nail-bed repair. The follow-up method was also allocated randomly (postal versus clinic). Information was collected on complications at 2 weeks and 30 days, and on nail-plate appearance at 4 months using the Zook classification. Two possible approaches to follow-up were also piloted and compared. RESULTS: During the recruitment phase, there were 156 potentially eligible children. Sixty were randomized in just over 3 months using remote web-based allocation. By 2 weeks, there were two infections, both in children with replaced nail plates. The nail-replaced group also experienced more complications. There was no evidence of a difference in return rates between postal and clinic follow-up. CONCLUSION: Recruitment was rapid and nail-bed repair appeared to have low complication and infection rates in this pilot trial. The findings have led to revision of the definitive trial protocol, including the mode and timing of follow-up, and modification of the Zook classification.

Chemistry, mineralogy, and grain properties at Namib and High dunes, Bagnold dune field, Gale crater, Mars: A synthesis of Curiosity rover observations.

The Mars Science Laboratory Curiosity rover performed coordinated measurements to examine the textures and compositions of aeolian sands in the active Bagnold dune field. The Bagnold sands are rounded to subrounded, very fine to medium sized (~45-500 µm) with ≥6 distinct grain colors. In contrast to sands examined by Curiosity in a dust-covered, inactive bedform called Rocknest and soils at other landing sites, Bagnold sands are darker, less red, better sorted, have fewer silt-sized or smaller grains, and show no evidence for cohesion. Nevertheless, Bagnold mineralogy and Rocknest mineralogy are similar with plagioclase, olivine, and pyroxenes in similar proportions comprising >90% of crystalline phases, along with a substantial amorphous component (35% ± 15%). Yet Bagnold and Rocknest bulk chemistry differ. Bagnold sands are Si enriched relative to other soils at Gale crater, and H2O, S, and Cl are lower relative to all previously measured Martian soils and most Gale crater rocks. Mg, Ni, Fe, and Mn are enriched in the coarse-sieved fraction of Bagnold sands, corroborated by visible/near-infrared spectra that suggest enrichment of olivine. Collectively, patterns in major element chemistry and volatile release data indicate two distinctive volatile reservoirs in Martian soils: (1) amorphous components in the sand-sized fraction (represented by Bagnold) that are Si-enriched, hydroxylated alteration products and/or H2O- or OH-bearing impact or volcanic glasses and (2) amorphous components in the fine fraction (<40 µm; represented by Rocknest and other bright soils) that are Fe, S, and Cl enriched with low Si and adsorbed and structural H2O.

Protocol for the Femoroacetabular Impingement Trial (FAIT): a multi-centre randomised controlled trial comparing surgical and non-surgical management of femoroacetabular impingement.

AIMS: Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head-neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis. METHODS: FAIT is a multicentre superiority parallel two-arm randomised controlled trial comparing physiotherapy and activity modification with arthroscopic surgery for the treatment of symptomatic FAI. Patients aged 18 to 60 with clinical and radiological evidence of FAI are eligible. Principal exclusion criteria include previous surgery to the index hip, established osteoarthritis (Kellgren-Lawrence ≥ 2), hip dysplasia (centre-edge angle < 20°), and completion of a physiotherapy programme targeting FAI within the previous 12 months. Recruitment will take place over 24 months and 120 patients will be randomised in a 1:1 ratio and followed up for three years. The two primary outcome measures are change in hip outcome score eight months post-randomisation (approximately six-months post-intervention initiation) and change in radiographic minimum joint space width 38 months post-randomisation. ClinicalTrials.gov: NCT01893034. Cite this article: Bone Joint Res 2014;3:321-7.

Protocol for the United Kingdom Rotator Cuff Study (UKUFF): a randomised controlled trial of open and arthroscopic rotator cuff repair.

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery. Cite this article: Bone Joint Res 2014;3:155-60.

Genetic influences in the progression of tears of the rotator cuff.

The aim of this study was to investigate genetic influences on the development and progression of tears of the rotator cuff. From a group of siblings of patients with a tear of the rotator cuff and of controls studied five years earlier, we determined the prevalence of tears of the rotator cuff with and without associated symptoms using ultrasound and the Oxford Shoulder Score. In the five years since the previous assessment, three of 62 (4.8%) of the sibling group and one of the 68 (1.5%) controls had undergone shoulder surgery. These subjects were excluded from the follow-up. Full-thickness tears were found in 39 of 62 (62.9%) siblings and in 15 of 68 (22.1%) controls (p = 0.0001). The relative risk of full-thickness tears in siblings as opposed to controls was 2.85 (95% confidence interval (CI) 1.75 to 4.64), compared to 2.42 (95% CI 1.77 to 3.31) five years earlier. Full-thickness tears associated with pain were found in 30 of 39 (76.9%) tears in the siblings and in eight of 15 (53.3%) tears in the controls (p = 0.045). The relative risk of pain associated with a full-thickness tear in the siblings as opposed to the controls was 1.44 (95% CI 2.04 to 8.28) (p = 0.045). In the siblings group ten of 62 (16.1%) had progressed in terms of tear size or development compared to one of 68 (1.5%) in the control group which had increased in size. Full-thickness rotator cuff tears in siblings are significantly more likely to progress over a period of five years than in a control population. This implies that genetic factors have a role, not only in the development but also in the progression of full-thickness tears of the rotator cuff.

Quantum level structures at a Fermi resonance with angular momentum: classical periodic orbits, catastrophe maps and quantum monodromy.

The Xiao-Kellman catastrophe map, for the classification of classical periodic orbits of the standard 2:1 Fermi resonance Hamiltonian is extended to species with finite vibrational angular momentum. The influence of the classical periodic orbit structure on different organizations of the quantum mechanical eigenvalues, in the four regions of the map, is strikingly demonstrated. The quantum eigenvalue lattices in angular momentum and energy space show dislocations attributable to a topological effect, termed quantum monodromy. Analogues with quantum monodromy in quasi-linear molecules and LiCN/LiNC isomerisation are demonstrated.

Playground safety in South Western Sydney.

OBJECTIVE: Recognition of the cost of injuries sustained in playgrounds has led to the development of Australian/New Zealand Standards for playground safety. This study assesses compliance of public playgrounds in South Western Sydney with the current Standards. METHODS: Playgrounds in South Western Sydney were randomly audited for compliance with Australian/New Zealand Standards for playground equipment pertaining to fall height, type of undersurface material, adequacy of maintenance of undersurface materials and adequacy of the safe fall zone. Comparisons were made with an audit of playgrounds in New South Wales undertaken in 1995 by Kidsafe. RESULTS: Of the 257 pieces of equipment from 87 playgrounds audited, only three (3.4%) playgrounds and 65 (25.3%) pieces of equipment complied with all criteria assessed. Compared with the 1995 study, there has been a significant improvement in equipment complying with height standards (84.4% vs 72.2%, P < 0.0001) and appropriate undersurface material (66.8% vs 45.4%, P < 0.0001). Pinebark is now the most common appropriate undersurface material used but is poorly maintained, particularly in high-traffic areas. Of 131 pieces of equipment with an appropriate undersurface material, only 38 (29%) had an adequate safe fall zone. CONCLUSIONS: Improvements in playground safety have occurred; however, very few playgrounds meet the Australian/New Zealand Standards. Compliance with Standards pertaining to maintenance of undersurface materials and safe fall zone is poor. Mechanisms need to be developed to support councils in the upgrading and maintenance of existing playgrounds.

Barriers to immunization: attitudes of general practitioners to varicella, the disease and its vaccine.

OBJECTIVES: To investigate the attitudes of general practitioners (GPs) to varicella disease and varicella vaccine. METHODS: A cross-sectional questionnaire was mailed to GPs in Fairfield (located in the south-western suburbs of Sydney, NSW, Australia) to identify attitudes about varicella vaccine, previous experience with varicella disease and the likelihood of prescribing varicella vaccine. RESULTS: Of 239 questionnaires issued, 160 were returned (67%). The majority (72%) of respondents agreed that varicella vaccine should become part of the immunization schedule. However 12% of GPs did not support vaccination for varicella as they considered it to be a benign self-limiting disease. Respondents who had experience with varicella complications were significantly more likely to recommend universal vaccination (OR 3.36; 95% confidence interval (CI) 1.38-8.19) whereas those respondents who were concerned about side effects of the vaccine were less likely to recommend universal vaccination (OR 0.31; CI 0.15-0.63). CONCLUSIONS: The majority of GPs are receptive to varicella vaccination becoming part of the immunization schedule. Experience with varicella complications is associated with recommending universal varicella vaccination. General practitioners in this cohort do not consider varicella to be a benign disease, but they are concerned about possible unknown side effects of the vaccine. Public health measures for introducing universal vaccination need to address these concerns.

Serum leptin and leptin binding activity in children and adolescents with hypothalamic dysfunction.

Marked disturbance in eating behaviour and obesity are common sequelae of hypothalamic damage. To investigate whether these were associated with dysfunctional leptin central feedback, we evaluated serum leptin and leptin binding activity in 37 patients (age 3.5-21 yr) with tumour or trauma involving the hypothalamic-pituitary axis compared with 138 healthy children (age 5.0-18.2 yr). Patients were subdivided by BMI <2 SDS or > or = 2 SDS and healthy children and children with simple obesity of comparable age and pubertal status served as controls. Patients had higher BMI (mean 1.9 vs 0.2 SDS; p <0.001), a greater proportion had BMI > or = 2 SDS (54% vs 8%; p <0.001) and higher serum leptin (mean 2.1 vs 0.04 SDS; p <0.001) than healthy children. Serum leptin (mean 1.1 vs -0.1 SDS; p = 0.004) and values adjusted for BMI (median 0.42 vs 0.23 microg/l:kg/m2; p = 0.02) were higher in patients with BMI <2 SDS. However, serum leptin adjusted for BMI was similar in patients with BMI > or = 2 SDS compared to corresponding controls (1.08 vs 0.95; p = 0.6). Log serum leptin correlated with BMI SDS in all subject groups but the relationship in patients with BMI <2 SDS was of higher magnitude (r = 0.65, slope = 0.29, p =0.05 for difference between slopes) than in healthy controls (r = 0.42, slope = 0.19). Serum leptin binding activity (median 7.5 vs 9.3%; p = 0.02) and values adjusted for BMI (median 0.28 vs 0.48 % x m2/kg; p <0.001) were lower in patients than in healthy children. The markedly elevated leptin levels with increasing BMI in non-obese patients with hypothalamic-pituitary damage are suggestive of an unrestrained pattern of leptin secretion. This along with low leptin binding activity and hence higher free leptin levels would be consistent with central leptin insensitivity.

Evidence for recent climate change on Mars from the identification of youthful near-surface ground ice.

Ground ice in the crust and soil may be one of the largest reservoirs of water on Mars. Near-surface ground ice is predicted to be stable at latitudes higher than 40 degrees (ref. 4), where a number of geomorphologic features indicative of viscous creep and hence ground ice have been observed. Mid-latitude soils have also been implicated as a water-ice reservoir, the capacity of which is predicted to vary on a 100,000-year timescale owing to orbitally driven variations in climate. It is uncertain, however, whether near-surface ground ice currently exists at these latitudes, and how it is changing with time. Here we report observational evidence for a mid-latitude reservoir of near-surface water ice occupying the pore space of soils. The thickness of the ice-occupied soil reservoir (1-10 m) and its distribution in the 30 degrees to 60 degrees latitude bands indicate a reservoir of (1.5-6.0) x 104 km3, equivalent to a global layer of water 10-40 cm thick. We infer that the reservoir was created during the last phase of high orbital obliquity less than 100,000 years ago, and is now being diminished.

Analysis of connexin phosphorylation sites.

Most connexins, the proteins that form gap junction channels, are phosphoproteins. Connexin phosphorylation has been thought to regulate gap junctional protein trafficking, gap junction assembly, channel gating, and turnover. Connexin phosphorylation has been investigated in a variety of ways. Some connexins show mobility shifts in sodium dodecyl sulfate-polyacrylamide gel electrophoresis on phosphorylation. Kinase modulators can change the level of connexin phosphorylation and affect gap junctional communication levels. Metabolic labeling of cultured cells has allowed both phosphoamino acid identification and generation of phosphotryptic peptide maps. However, identification of the location of phosphorylated residues within the connexin sequence has required either targeted peptide synthesis, in vitro phosphorylation of known sites, and two-dimensional comigration studies or liquid chromatographic separation and N-terminal sequencing of peptides. In addition to these conventional methods, we discuss new applications of mass spectrometry to the identification of phosphorylated peptides and the specific residues phosphorylated within the connexin-derived peptide.

Evaluating photoscreeners II: MTI and fortune videorefractor.

BACKGROUND: Amblyopia is a public health problem, usually amenable to treatment if detected early. Photoscreeners are camera-based instruments which can detect risk factors for amblyopia such as squint, refractive errors and media opacities. OBJECTIVE: To evaluate two commercially available photoscreeners, namely the MTI photoscreener (Medical Technology, Iowa City, IA, USA) and the Fortune Optical VRB-100 (Fortune Optical, Padova, Italy) videophotorefractor, in a selected childhood population, having a high prevalence of amblyopia, before undertaking a full-scale trial in the general population. SUBJECTS AND METHODS: The study design was a double-masked study. One-hundred and five children aged between 12 and 44 months with either normal vision or known visual disorders were photoscreened without cycloplegia using the Fortune and the MTI photoscreeners. Each child had a full ophthalmic examination either on the day of screening or in the preceding 6 months. Risk factors were: any manifest strabismus (squint), hypermetropia >3.5 D, anisometropia > or =1 D sphere, myopia > or =2 D sphere, astigmatism > or =2 D, media opacity or fundus abnormality affecting vision. The prevalence of risk factors for amblyopia was 60%. Photoscreen images were reviewed by two independent masked observers for indicators of amblyopiogenic risk factors and compared to the full ophthalmological examination to determine sensitivity and specificity for each instrument. RESULTS: Sensitivities and specificities for the detection of risk factors for amblyopia were as follows. Fortune photoscreener: reader 1, sensitivity 60%, specificity 75%; reader 2, sensitivity 68% specificity 86%. MTI photoscreener: reader 1, sensitivity 56%, specificity 79%; reader 2, sensitivity 61%, sensitivity 86%. The results for reader 1 and 2 showed no significant differences for either instrument. CONCLUSION: Both instruments performed unsatisfactorily in a study population aged 1-4 years with a high prevalence of amblyopiogenic risk factors. Accordingly, we do not believe that either instrument can be recommended to screen for eye disorders in children between the ages of 1 and 4 years because the low prevalence of amblyopia in this population demands very high sensitivity and specificity in order to avoid inappropriate over- or under-referral.

Evaluation of photoscreener instruments in a childhood population. 1. Otago photoscreener and Dortmans videophotorefractor.

OBJECTIVE: To evaluate two photoscreeners in a childhood population. STUDY DESIGN: Double-masked study. SUBJECTS AND METHOD: One hundred and thirteen children aged between 11 and 44 months with either normal vision or known visual disorders were photoscreened without cycloplegia by the Otago and Dortmans (prototype) photoscreeners. Each child had a full ophthalmological examination either on the day of screening or in the proceeding six months. Photoscreen images were reviewed by an independent observer for indicators of amblyopiogenic risk factors, and compared to the full ophthalmological examination to determine sensitivity and specificity for each instrument. RESULTS: The Otago photoscreener returned a sensitivity of 70% and specificity of 82% for the detection of amblyopiogenic risk factors. The Dortmans photoscreener returned a sensitivity of 70% and specificity of 90%. Both photoscreeners were portable and easily operated. CONCLUSION: Children can be screened successfully for amblyopiogenic risk factors with these photoscreening systems. Further evaluation is required to determine specificity in a normal population. This would also provide information on the potential usefulness of photoscreeners in a cost effective childhood vision screening program.