Assessment of the equivalence of a generic to a branded femoral stem.

AIMS: The aim of this study was to compare the design of the generic OptiStem XTR femoral stem with the established Exeter femoral stem. MATERIALS AND METHODS: We obtained five boxed, as manufactured, implants of both designs at random (ten in total). Two examiners were blinded to the implant design and independently measured the mass, volume, trunnion surface topography, trunnion roughness, trunnion cone angle, Caput-Collum-Diaphyseal (CCD) angle, femoral offset, stem length, neck length, and the width and roughness of the polished stem shaft using peer-reviewed methods. We then compared the stems using these parameters. RESULTS: We found that the OptiStems were lighter (p < 0.001), had a rougher trunnion surface (p < 0.001) with a greater spacing and depth of the machined threads (p < 0.001), had greater trunnion cone angles (p = 0.007), and a smaller radius at the top of the trunnion (p = 0.007). There was no difference in stem volume (p = 0.643), CCD angle (p = 0.788), offset (p = 0.993), neck length (p = 0.344), stem length (p = 0.808), shaft width (p = 0.058 to 0.720) or roughness of the polished surface (p = 0.536). CONCLUSION: This preliminary investigation found that whilst there were similarities between the two designs, the generic OptiStem is different to the branded Exeter design. Cite this article: Bone Joint J 2017;99-B:310-16.

Perfoation of the gallbladder: 'bait' for the unsuspecting laparoscopic surgeon.

INTRODUCTION Cholecystectomy is one of the most common elective procedures carried out by general surgeons. Most patients present with typical biliary anatomy and simple gallstone disease. Intraoperative and postoperative courses are frequently predictable and uncomplicated. Nevertheless, a small but significant number of patients experience complicated disease with rare presentations and complex biliary anatomy. Unfortunately, consensus on appropriate care for such patients is lacking. CASE HISTORY We describe three patients who presented with complex manifestations of gallbladder perforation: acute perforation of the gallbladder; a spontaneous cholecystocutaneous fistula; a cholecystoduodenal fistula. The initial presentation, preoperative investigations, and selected surgical strategy for each case are described. CONCLUSIONS The case studies described here illustrate the need for a low index of suspicion for gallbladder perforation. Caution should be exercised in preoperative and intraoperative phases in this patient population.

The Waterlow score for risk assessment in surgical patients.

INTRODUCTION: Perioperative scoring systems aim to predict outcome following surgery and are used in preoperative counselling to guide management and to facilitate internal or external audit. The Waterlow score is used prospectively in many UK hospitals to stratify the risk of decubitus ulcer development. The primary aim of this study was to assess the potential value of this existing scoring system in the prediction of mortality and morbidity in a general surgical and vascular cohort. METHODS: A total of 101 consecutive moderate to high risk emergency and elective surgical patients were identified through a single institution database. The preoperative Waterlow score and outcome data pertaining to that admission were collected. The discriminatory power of the Waterlow score was compared against that of the American Society of Anesthesiologists (ASA) grade and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM). RESULTS: The inpatient mortality rate was 17% and the 30-day morbidity rate was 29%. A statistically significant association was demonstrated between the preoperative Waterlow score and inpatient mortality (p<0.0001) and 30-day morbidity (p=0.0002). Using a threshold Waterlow score of 20 to dichotomise risk, accuracies of 0.84 and 0.76 for prediction of mortality and morbidity were demonstrated. In comparison with P-POSSUM, the preoperative Waterlow score performed well on receiver operating characteristic analysis. With respect to mortality, the area under the curve was 0.81 (0.80-0.85) and for morbidity it was 0.72 (0.69-0.76). The ASA grade achieved a similar level of discrimination. CONCLUSIONS: The Waterlow score is collected routinely by nursing staff in many hospitals and might therefore be an attractive means of predicting postoperative morbidity and mortality. It might also function to stratify perioperative risk for comparison of surgical outcome data. A prospective study comparing these risk prediction scores is required to support these findings.

Management of jejunal pouch dysfunction following total gastrectomy and Roux-en-Y reconstruction for gastric cancer: a case report.

INTRODUCTION: Total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction is a well recognised procedure for patients undergoing curative resections for gastric malignancy. The formation of a jejunal pouch is thought by some to create a reservoir that, when compared with straight oesophagojejunal anastomosis, reduces the incidence of post-operative dumping. CASE HISTORY: A patient presented two years after a total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction for a T3N2M0 adenocarcinoma of the stomach, with postprandial vomiting and dysphagia resulting in massive weight loss and malnutrition. Recurrent cancer and stricturing was ruled out by gastroscopy and computed tomography, and distal obstruction was ruled out by an oral contrast study. The diagnosis of a functional jejunal pouch disorder was made by exclusion. Balloon dilatation of the pouch and the oesophagojejunal anastomosis found little symptomatic improvement. The patient's deteriorating nutritional status prompted us to urgently perform revisional surgery. A re-laparotomy and pouch-jejunal bypass procedure was performed. Post-operatively, the patient made a full symptomatic recovery and began gaining weight. CONCLUSIONS: A pouch-enteric bypass is a suitable treatment option for patients with functional jejunal pouch dysmotility following a total gastrectomy and jejunal pouch formation in the absence of distal obstruction and recurrent disease.

Hospital mortality under surgical care.

INTRODUCTION: The 'hospital standardised mortality ratio' (HSMR) has been used in England since 1999 to measure NHS hospital performance. Large variations in reported HSMR between English hospitals have recently led to heavy criticism of their use as a surrogate measure of hospital performance. This paper aims to review the mortality data for a consultant general surgeon contributed by his NHS trust over a 3-year period as part of the trust's HSMR calculation and evaluate the accuracy of coding the diagnoses and covariates for case mix adjustment. SUBJECTS AND METHODS: The Dr Foster Intelligence database was interrogated to extract the NHS trust's HSMR benchmark data on inpatient mortality for the surgeon from 1 April 2006 to 31 March 2009 and compared to the hospital notes. RESULTS: 30 patients were identified of whom 12 had no evidence of being managed by the surgeon. This represents a potential 40% inaccuracy rate in designating consultant responsibility. The remaining 18 patients could be separated into 'operative' (11 patients) and 'non-operative' (7 patients) groups. Only 27% in the operative group and 43% of the non-operative mortality group respectively had a Charlson co-morbidity index recorded despite 94% of the cases having significant co-morbidities CONCLUSIONS: Highlighting crude and inaccurate clinician-specific mortality data when only 1-5% of deaths under surgical care may be associated with avoidable adverse events seems potentially irresponsible.

Quantification of the difference between 3D CT and plain radiograph for measurement of the position of medial unicompartmental knee replacements.

The aim of this study was to quantify the differences in measurements obtained from 3D Computed Tomography and plain radiograph, for the positioning of the tibial component of the Oxford unicompartmental knee replacement. Post-operative 3D Computed Tomography data and plain radiographs (long antero-posterior (AP) and short lateral) were obtained for 28 knees of patients who had undergone medial unicompartmental knee replacement. Parameters of the orientation/positioning of the tibial component: Varus/valgus, posterior tibial slope and rotation were measured with both modalities. Bland-Altman plots were used to calculate the 1.96 standard deviation limits of agreement (LOA) between imaging modalities. Intra class correlation was used to assess inter-method and inter-rater reliability (>0.81 = very good reliability). Radiographs were less reliable in all parameters, when compared with 3D CT (intra class correlation coefficients: tibial rotation 0.94 vs 0.96, varus/valgus 0.76 vs 0.94, and posterior tibial slope 0.82 vs 0.92). The LOA were -4.9° to 3.4° for varus/valgus (bias -0.7°, one third >3° different); -4.9° to 0.1° for posterior tibial slope (bias -2.4°, one third >3° different); and -20.6° to 16.1° for rotation (bias -2.2°, one third >10° different). There was some disagreement between measurement by 3D Computed Tomography and plain radiograph for all three parameters of tibial component orientation, especially tibial rotation. This will be particularly relevant to research into the relationship between the accuracy of implant positioning/orientation and patient satisfaction/implant survival rates. This method offers a more reliable standard for the reporting of knee arthroplasty.

A case of obscure gastrointestinal bleeding in a teenager.

In this report, we discuss a case of obscure gastrointestinal bleeding (OGIB) in an 18-year-old man, where oesophagogastroduodenoscopy (OGD) and colonoscopy proved inconclusive in determining a source of bleeding. On day 14 of admission, a laparoscopy was performed, identifying a mass 2 feet from the ileocaecal junction. This was thought initially to be a Meckel's diverticulum and the patient underwent a laparotomy and a small bowel resection. Surprisingly, the histology revealed a benign gastrointestinal stromal tumour (GIST) of the ileum, rare in such a young person. Given the diagnostic delay, we propose a simple algorithm for the diagnostic management of a teenager presenting with a significant ongoing gastrointestinal bleed.

The lipopolysaccharide of moraxella catarrhalis structural relationships and antigenic properties.

Moraxella catarrhalis has recently been shown to be both widespread and pathogenic, in contrast to previous reports. Several factors have been suggested as virulence factors, lipopolysaccharide (LPS) being one. Recent studies have shown the LPS to be without the O-chain, i.e. the polysaccharide part, and to have specific structural features corresponding to each of the three serogroups, A, B and C. The structures resemble in many respects those present in other Gram-negative nonenteric bacteria, with a galabiosyl element as a prominent common denominator. The presence of such common structures suggests that the LPS of these bacteria might be a part of a mechanism of survival for bacteria colonizing the human host.

Monoclonal antibodies to the epitope alpha-Gal-(1-4)-beta-Gal-(1- of Moraxella catarrhalis LPS react with a similar epitope in type IV pili of Neisseria meningitidis.

Murine monoclonal antibodies (MAbs) against the A, B and C LPS serotypes of M. catarrhalis were generated and their binding specificity was examined in an enzyme-linked immunosorbent assay (ELISA). Two broadly cross-reactive monoclonal antibodies (MCA1 and MCC2) against the outer core region of LPS were further characterized. A panel of synthetic glycoproteins and glycolipids was used to determine the binding specificity of the MAbs. MCA1 and MCC2 bound specifically to alpha-Gal-(1-4)-beta-Gal of galabiose and globotriose glycoconjugates. The reactivity of the MAbs with galabiose was higher than that with globotriose. The MAbs could recognize the alpha-Gal-(1-4)-beta-Gal epitope only when it was in a terminal position. MCA1 was further shown to react with a similar epitope in the glycosylated type IV pili of N. meningitidis, which has been shown to contain a 1-4 linked digalactose at the terminal part of the saccharide present in the pili. MCA1 could efficiently recognize this epitope indicating that it was exposed on the surface of the pili.

Human immunoglobulin isotype and IgG subclass response to different antigens of Moraxella catarrhalis.

Enzyme immunoassays were tested for the determination of antibodies of different isotypes and IgG subclasses to Moraxella catarrhalis in human sera. An assay based on an outer membrane protein preparation (OMP) as antigen was compared to assays using whole bacterial cells and a purified lipopolysaccharide preparation. There was a good correlation between the results obtained with the OMP preparation and the whole-cell antigen. In paired sera, optimal sensitivity was obtained by using the OMP preparation as coating antigen and testing for a rise in IgG3 antibodies. However, patients with high levels of antibodies in acute serum had no or only an insignificant antibody response during infection.

Cholesterol granuloma of the breast presenting as an intracystic papilloma.

Cholesterol granuloma of the breast is a rare benign condition. It is often clinically and radiologically indistinguishable from breast carcinoma. A case of cholesterol granuloma which manifested as an intracystic papilloma on ultrasound is described. This unusual ultrasonographic appearance has not previously been reported.

The structures of oligosaccharides isolated from the lipopolysaccharide of Moraxella catarrhalis serotype B, strain CCUG 3292.

The oligosaccharides from the lipopolysaccharides of Moraxella catarrhalis serotype B, strain CCUG 3292, were isolated after mild acid hydrolysis and separated by high-performance anion-exchange chromatography. The structures of the oligosaccharides were established by fast atom bombardment mass spectrometry and nuclear magnetic resonance spectroscopy. It is concluded that the oligosaccharides comprise a mixture of mainly a nona- and a deca-saccharide. [formula: see text] Smaller amounts of undeca-saccharides and of truncated forms, namely, hexa-, hepta-, and octa-saccharides, were also detected.

Interaction of the C-polysaccharide of Streptococcus pneumoniae with the receptor asialo-GM1.

C-polysaccharide (PnC) is the major surface component of pneumococci containing phosphoryl choline residues. In order to investigate the possibility that PnC can bind to glycolipid receptors present on epithelial cells we extracted carbohydrate material from a nonencapsulated strain of pneumococci. The components of the extract were separated by gel permeation chromatography. An ELISA was used for detection of fractions binding to the pneumococcal glycolipid receptor asialo GM1. These fractions were pooled and analysed by nuclear magnetic resonance spectroscopy (NMR). The 1H NMR spectrum showed good agreement with a reference spectrum of pure PnC showing that this substance was the major component. Binding of the purified PnC to asialo-GM1 was unaffected by protease K treatment. Immunoblots of the purified PnC after separation by SDS-PAGE resulted in a characteristic banding pattern. PnC could be released from pneumococci by heat treatment of whole bacteria in buffer as shown by reaction with a monoclonal antibody specific for the phosphoryl choline determinant. After separation by SDS-PAGE of the components of the heat extract, immunoblots showed the presence of bands characteristic for PnC. Eluates from the characteristic bands in the gel were shown to contain material binding to asialo-GM1. This binding was not reduced upon treatment with protease K. Pneumococci deprived of choline by cultivation in a medium containing ethanolamine as the only amino alcohol source did not bind to asialo-GM1, indicating that the phosphoryl choline residue of PnC is essential for the interaction between PnC and the glycolipid receptor. These data provide evidence that PnC containing an intact phosphoryl choline residue is a ligand responsible for binding of pneumococci to the receptor asialo-GM1.