Provision of revision knee arthroplasty services across Scotland: A national audit.

BACKGROUND: There is increasing evidence that both low surgeon and centre case volumes are associated with poorer outcomes following Revision Knee Arthroplasty (rTKA). Given the unique challenges faced in Scotland relating to funding and geography, understanding details on the complexity of cases is required to guide development of future rTKA services. METHODS: Utilising the Scottish Collaborative Orthopaedic Trainee Research Network (SCOTnet) a retrospective review of all Scottish 2019 rTKA cases was undertaken. Regional leads co-ordinated local data collection using individual case note review. The number of cases performed by regions, hospitals and individual surgeons were identified. Patient demographics and case complexity (Revision Knee Complexity Classification [RKCC]) were also collected. Results were compared against current standards. RESULTS: 17 units performed rTKA, delivered by 77 surgeons. A total of 506 cases were included. The mean age was 69 years (46% male). Revision for infection accounted for 147/506 (29%) cases. Extensor compromise was present in 35/506 (7%) and 11/506 (2%) required soft tissue reconstruction. According to the RKCC - 214/503 (43%) were classified as R1 (Less complex cases), 228/503 (45%) R2 (complex cases), and 61/503 (12%) R3 (most complex / salvage cases). 5/17 (29%) units met current national guidelines for case volume/year, with only 11/77 (14%) surgeons meeting recommended individual case volumes. 37/77 (48%) surgeons performed ≤ 2 cases per year. CONCLUSIONS: Most individual centre volumes could be increased by re-organising services or locations providing rTKA within a region. This should provide better access to Multidisciplinary Team (MDT) involvement. We recorded a significant number of very low volume surgeons (≤2 year) that is contradictory to current evidence-based practice.

Does early surgery improve outcomes for periprosthetic fractures of the hip and knee? A systematic review and meta-analysis.

INTRODUCTION: Previous evidence has established that early surgery is beneficial to improve outcomes for individuals with native hip fractures in the elderly population. Patients who sustain a periprosthetic fracture have been demonstrated to have similar demographics and outcomes as those with native fractures around the hip and knee. We therefore set out to determine if there is a similar difference in perioperative outcomes between early and delayed surgery for periprosthetic fractures of the hip and knee through a systematic review and meta-analysis. METHODS: Literature search outputs were screened for studies meeting the inclusion criteria. The groups of early surgery and delayed surgery were defined by study authors. The primary outcome measure was 30 day mortality. Where there was sufficient study homogeneity, a random-effects meta-analysis was performed. Individual study risk of bias was assessed using the ROBINS-I criteria, with the GRADE criteria used for independent outcome evaluation. The review protocol was registered on PROSPERO prior to commencement (Registration number CRD42019149360). RESULTS: The inclusion criteria was met in 11 studies (n = 3006). Mean time to surgery from admission for reporting studies was 64 h. 59.6% patients underwent early surgery as defined by the study authors. We identified a significantly lower risk of 30 day mortality for those with early surgery versus delayed surgery (RR 0.21; 95% CI 0.05, 0.90; p = 0.04, n = 2022). There were also significantly better outcomes for early versus delayed surgery regarding: medical complications, length of stay, transfusion risk, and reoperation. The quality of evidence for all the individual outcomes was low or very low. CONCLUSIONS: There is evidence that delaying surgery in those with periprosthetic fractures of the hip and knee has a deleterious impact on mortality and other important patient outcomes. There are, however, notable limitations to the existing available literature, with further appropriately designed large-scale studies required to confirm these findings.

Quantitative determination of neuronal size and density using flow cytometry.

BACKGROUND: Recent anthropomorphic disturbances are occurring at an increasing rate leading to organisms facing a variety of challenges. This change is testing the information processing capacity (IPC) of all animals. Brain function is widely accepted to be influenced by a variety of factors, including relative size, number of neurons and neuronal densities. Therefore, in order to understand what drives an animals IPC, a methodological approach to analyze these factors must be established. NEW METHOD: Here we created a protocol that allowed for high-throughput, non-biased quantification of neuronal density and size across six regions of the brain. We used the Isotropic Fractionator method in combination with flow cytometry to identify neuronal and non-neuronal cells in the brains of adult rats. COMPARISON WITH EXISTING METHODS: The results obtained were comparable to those identified using stereological counting methods. RESULTS: By employing this new method, the number of nuclei in a specific brain region can be compared between replicate animals within an experiment. By calibrating the forward scatter channel of the flow cytometer with size standard beads, neuronal and non-neuronal nuclear sizes can be estimated simultaneously with nuclei enumeration. These techniques for nuclear counting and size estimation are technically and biologically reproducible. CONCLUSION: Use of flow cytometry provides a methodological approach that allows for consistency in research, so that information on brain morphology, and subsequent function, will become comparable across taxa.

Early versus delayed surgery for paediatric supracondylar humeral fractures in the absence of vascular compromise: a systematic review and meta-analysis.

AIMS: We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis. MATERIALS AND METHODS: A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently. RESULTS: A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes: Iatrogenic nerve injury, pin site infection, and re-operation. The quality of evidence for all the individual outcomes was low or very low. CONCLUSIONS: There is no evidence that delaying supracondylar fracture surgery negatively influences outcomes in the absence of vascular compromise. There are, however, notable limitations to the existing available literature.

Search for retrogressive reactions accompanying demineralization in native and air-oxidized coals.

This solid state 13C NMR study confirms, for coals, and extends, for air-oxidized coals, the claim that the Bishop and Ward strong aqueous-acid coal demineralization procedure [M. Bishop, D.L. Ward, Fuel 37 (1958) 191.] does not lead to the formation of detectable levels of cross-links in the organic matrix of these materials. The study was prompted by the demonstration that polymerization accompanies strong acid demineralization in lignin, and the recognition that the chemical environment created in air-oxidized coals contains introduced reactive functionality similar to that in the lignin. In particular, both contain oxidized benzylic carbon functionality that can undergo acid-catalyzed polymerization reactions. For two coals of differing rank, no acid-induced cross-link formation has been observed in the pristine or air-oxidized coals, within the 5 parts per thousand (ppt) sensitivity of the NMR technique used in this study.

c-erbB3 and c-erbB4 expression is a feature of the endocrine responsive phenotype in clinical breast cancer.

We examined c-erbB3 and c-erbB4 mRNA expression in 47 primary breast cancer samples by simultaneous RT-PCR and have investigated correlations between these parameters and the expression of both ER and EGFR mRNA and protein as measured by RT-PCR and ICA and with Ki67 immunostaining. A direct association was found between c-erbB3 and c-erbB4 mRNA and ER marker status measured by either RT-PCR (c-erbB3 P = 0.0003; c-erbB4 P = 0.02) or ICA (c-erbB-3 P = 0.002; c-erbB4 P = 0.01). Inverse associations were seen between c-erbB3 and c-erbB4 mRNA marker status and EGFR membrane protein (c-erbB3: P = 0.003; cerbB4: P = 0.003) and mRNA (c-erbB4: P = 0.009) status. These associations were reinforced by Spearman Rank Correlation Tests. A significant relationship was seen between Ki67 and c-erbB4 mRNA status and level. Measurements of c-erbB3 protein levels in tumour samples removed from a further 89 patients of known response to endocrine therapy: (i) confirmed the relationship between c-erbB3 and ER and (ii) identified that patients whose ER positive tumours expressed high levels of c-erbB3 were most likely to benefit from endocrine measures. A non-significant trend was recorded between c-erbB3 levels and Ki67 immunostaining. These results clearly demonstrate that increased c-erbB3 and c-erbB4 expression appears to be associated with the prognostically-favourable ER phenotype.

Gilbert's syndrome and Ramadan: exacerbation of unconjugated hyperbilirubinemia by religious fasting.

Gilbert's syndrome is a benign, often familial condition characterized by recurrent but asymptomatic jaundice. We report two cases of recurrent jaundice due to unconjugated hyperbilirubinemia in Muslim subjects during the fast of Ramadan. As the diagnosis of Gilbert's syndrome was not suspected, both patients were extensively investigated before the relationship to fasting was recognized and the correct diagnosis made. We conclude that the possible exacerbation of Gilbert's by fasting should be borne in mind in the evaluation of Muslim patients with jaundice.

Negative symptoms in schizophrenia: considerations for clinical trials. Working group on negative symptoms in schizophrenia.

There is little agreement about the methodology of clinical trials of antipsychotic drugs in patients with negative symptoms. A literature review revealed wide variation in experimental design, rating scales and study duration. This reflects differing views as to the definition and response to treatment of negative symptoms. Some degree of standardization would improve comparability of studies and aid the development of new compounds. Patients included in such studies should have displayed negative symptoms for at least 6 months. Depressive symptoms, positive schizophrenic symptoms and extrapyramidal signs may all influence or be confused with negative symptoms and may respond to treatment; they should be at a low level at baseline and should be measured during the study period. Studies should last at least 8 weeks. Several scales are available for measuring negative symptoms and are reviewed; a global impression score should be used additionally.

Systemic paraphenylenediamine (PPD) poisoning: a case report and review.

A case of suicidal poisoning with paraphenylenediamine (PPD) is reported. The patient presented with typical features of severe oropharyngeal oedema and rhabdomyolysis. He suffered sudden cardiac death within 4 hours of admission despite full supportive treatment. The diagnosis was only established after his death. Systemic poisoning with paraphenylenediamine (PPD) is rare in western countries, and therefore a high degree of awareness and circumstantial evidence is required to make an early diagnosis. The classical and other less commonly reported features of this poisoning are discussed. There is no specific antidote available but some guidelines for management of such a case are reviewed.

Career opportunities in oncology.

Oncology nursing offers nurses a wide range of opportunities. Nurses need a wide range of skills in order to care for patients who may have acute oncological illnesses or require palliative care. The nature of the nurse/patient relationship can be intense. Nurses generally find this enhances job satisfaction. The pressures exerted on nurses working in oncology can be immense. Oncology nursing is rewarding but very demanding and therefore the nurse has to be resourceful. Early career planning is advisable to take advantage of the opportunities that are currently available.

Severe orthostatic hypotension in carcinoma of the pancreas.

Autonomic dysfunction has been described in patients with advanced forms of cancer. We report a case of severe orthostatic hypotension in a patient with carcinoma of the pancreas in whom there was no clinical evidence of autonomic failure to account for the severity of the hypotension. Despite normal circulating levels of nor-adrenalin and an appropriate rise in the erect position, the vascular system appeared unresponsive. We suggest that in this patient the orthostatic hypotension was due to a paraneoplastic complication of the pancreatic tumour.

Predicting the daily prothrombin time response to warfarin.

Our objective was to evaluate the effectiveness of a computer program to predict daily prothrombin time (PT) response to warfarin therapy using prospectively collected data. The program's predictive performance (precision) and accuracy (bias) were evaluated using fraction mean absolute error and fraction mean error, respectively. We analyzed data from 40 patients using from zero to nine PT feedbacks. The fraction mean absolute error varied from 0.058 to 0.13. The program utilized a pharmacokinetic/pharmacodynamic Bayesian forecasting system to predict prothrombin response.

Identification of transferrin as the main binding site for protactinium in rat blood serum.

The distribution of 233Pa in rat serum at periods between 5 and 50 min after i.v. injection of a solution of protactinium chloride was studied by gel chromatography. Sequential analysis of sera on Sephacryl S-300 and DEAE-Sephadex showed that 233Pa was associated only with the transferrin fraction of the serum proteins. This finding was confirmed by iso-electric focusing electrophoresis. In the cytosol fractions prepared from the liver and kidneys of the 233Pa injected rats the nuclide was also shown to be protein bound.

Non-A, non-B hepatitis in West London.

Acute and convalescent sera from 368 patients drawn from a 3-year survey of viral hepatitis in West London were tested for radioimmunoassay for evidence of recent infection with hepatitis A or B and, if neither was found, antibody to Epstein-Barr (EB) virus and cytomegalovirus. In 215 patients (58%) there was evidence of hepatitis A, in 98 (27%) hepatitis B, and in 5 both A and B. 2 patients with evidence of recent EB virus infection were excluded, leaving 48 (13%) attributed to non-A, non-B hepatitis. This illness was milder than hepatitis B as judged by duration of jaundice and peak serum bilirubin alanine-aminotransferase levels. The ratio of men to women was 1.4 to 1, but there was an excess of women in their twenties, most of whom were single. Only one had received blood, and none was a drug addict.

Nitric acid vapor line parameters measured by CO laser transmittance.

Transmittance curves on pure nitric acid vapor have been determined at CO laser frequencies of 1661.8833 cm(-1), 1693.9957 cm(-1), and 1711.6199 cm(-1). Voigt profile analyses for the first and third frequencies give, respectively, alpha = (2.02 +/- 0.72) x 10(-4) Torr(-1) cm(-1), Delta = (1.63 +/- 0.33) x 10(-3) cm(-1) , E(nu(o)) = (0.668 +/- 0.302) X 10(-2) Torr(-1) cm(-1); alpha = (8.95 +/- 0.27) x 10(-4) Torr(-1) cm(-1), Delta = (1.64 +/- 0.33) x 10(-3) cm(-1), E(nu(o)) = 0.327 +/- 0.140 Torr(-1) cm(-1). Here alpha is the broadening parameter, Delta the frequency offset, and E(nu(0)) the extinction coefficient at line center in the Doppler region. Application of the Galatry profile gives the same results as well as a self-diffusion coefficient consistent with the value 0.057 cm(2)/sec from kinetic theory. Finally, the foreign gas broadening parameter with respect to nitrogen is determined as B = 0.997 +/- 0.245 at 1661.8833 cm(-1) and B = 5.91 +/- 0.78 at 1711.6199 cm(-1) .

A three-year survey of viral hepatitis in West London.

During a total population survey of viral hepatitis in the London Boroughs of Hounslow, Richmond and Ealing, 784 patients were seen in three years from 1 March 1972 to 28 February 1975. A diagnosis of viral hepatitis was accepted in 489. The annual incidence was 24 per 100 000. 455 of the patients were tested for the hepatitis B surface antigen (HBsAg) by a radioimmunoassay technique and 93 (20%) of these were positive. The majority of the patients with type B hepatitis were in their third or fourth decades. None was under the age of 16. The male to female ratio among patients with hepatitis B was 2 to 1 in those under the age of 30 and 5 to 1 in those aged 30 and over. The seasonal distribution of viral hepatitis showed a peak in the spring, solely from an increased incidence of non-B hepatitis, and a second, smaller peak in the autumn. There was no appreciable clustering of patients except for one local outbreak in a housing estate during the first year affecting mainly children going to the same primary school, and their parents. Patients with hepatitis B had a longer pre-icteric illness (p less than 0.05), greater duration of jaundice (p less than 0.001) and higher peak levels of serum bilirubin (p less than 0.0005) and serum alanine amino transferase (A1T) (p less than 0.03) than patients with non-B hepatitis. The finding of the surface antigen was also associated with a higher frequency of skin rash (p less than 0.0005) and a greater duration of arthralgia (p less than 0.03). Among the HBsAg negative patients the incidence of arthralgia increased with age (p less than 0.0005). Abdominal pain (p less than 0.005) and vomiting (p less than 0.005) were more common in the young. The injection experience of patients with hepatitis B showed a high proportion of 'non-therapeutic' exposure such as drug addiction. Significantly more HBsAg positive men were single than in the local community (p less than 0.001) or among the HBsAg negative men (p less than 0.01). There was no significant difference between the proportions of single women among the antigen positive and negative patients. Many of the HBsAg positive single men were either known to be or strongly suspected of being homosexual. The ad subtype of the HBsAg was found more often in males (p less than 0.01), particularly over the age of 30. All eight drug addicts tested for subtype were ay, as were two non-addicted female consorts. The association between addiction and ay subtype was highly significant in the males (p less than 0.001). The ad subtype was found in all 11 of the admitted homosexual HBsAg positive men and in all but one of the 17 strongly suspected of being homosexual.