An audit of consent for allograft use in elective orthopaedic surgery.

Introduction Patients receiving musculoskeletal allografts may be at risk of postoperative infection. The General Medical Council guidelines on consent highlight the importance of providing patients with the information they want or need on any proposed investigation or treatment, including any potential adverse outcomes. With the increased cost of defending medicolegal claims, it is paramount that adequate, clear informed patient consent be documented. Methods We retrospectively examined the patterns of informed consent for allograft bone use during elective orthopaedic procedures in a large unit with an onsite bone bank. The initial audit included patients operated over the course of 1 year. Following a feedback session, a re-audit was performed to identify improvements in practice. Results The case mix of both studies was very similar. Revision hip arthroplasty surgery constituted the major subgroup requiring allograft (48%), followed by foot and ankle surgery (16.3%) and revision knee arthroplasty surgery (11.4%) .On the initial audit, 17/45 cases (38%) had either adequate preoperative documentation of the outpatient discussion or an appropriately completed consent form on the planned use of allograft. On the re-audit, 44/78 cases (56%) had adequate pre-operative documentation. There was little correlation between how frequently a surgeon used allograft and the adequacy of consent (Correlation coefficient -0.12). Conclusions Although the risk of disease transmission with allograft may be variable, informed consent for allograft should be a routine part of preoperative discussions in elective orthopaedic surgery. Regular audit and feedback sessions may further improve consent documentation, alongside the targeting of high volume/low compliance surgeons.

Structure and dynamics of 1-ethyl-3-methylimidazolium acetate via molecular dynamics and neutron diffraction.

The liquid state structure of the ionic liquid, 1-ethyl-3-methylimidazolium acetate ([C(2)mim][OAc]), an excellent nonderivitizing solvent for cellulosic biomass, has been investigated at 323 K by molecular dynamics (MD) simulation and by neutron diffraction using the SANDALS diffractometer at ISIS to provide experimental differential neutron scattering cross sections from H/D isotopically substituted materials. Ion-ion radial distribution functions both calculated from MD and derived from the empirical potential structure refinement (EPSR) model to the experimental data show the alternating shell structure of anions around the cation, as anticipated. Spatial probability distributions reveal the main anion-to-cation features as in-plane interactions of anions with the three imidazolium ring hydrogens and cation-cation planar stacking above/below the imidazolium rings. Interestingly, the presence of the polarized hydrogen-bond acceptor (HBA) anion (acetate) leads to an increase in anion-anion tail-tail structuring within each anion shell, an indicator of the onset of hydrophobic regions within the anion regions of the liquid. MD simulations show the importance of scaling of the effective ionic charges in the basic simulation approach to accurately reproduce both the observed experimental neutron scattering cross sections and ion self-diffusion coefficients.

Ion association in [bmim][PF6]/naphthalene mixtures: an experimental and computational study.

Mixtures of room temperature ionic liquids (IL) with neutral organic molecules provide a valuable testing ground to investigate the interplay of the ionic and molecular-dipolar state in dense Coulomb systems at near ambient conditions. In the present study, the viscosity eta and the ionic conductivity sigma of 1-n-butyl-3-methylimidazolium hexafluorophosphate ([bmim][PF6])/naphthalene mixtures at T = 80 degrees C have been measured at 10 stoichiometries spanning the composition range from pure naphthalene to pure [bmim][PF6]. The viscosity grows nearly monotonically with increasing IL mole fraction ( x), whereas the conductivity per ion displays a clear peak at x approximately 15%. The origin of this maximum has been investigated using molecular dynamics simulations based on a classical force field. Snapshots of the simulated samples show that the conductivity maximum is due to the gradual transition in the IL component from an ionic state at high x to a dipolar fluid made of neutral ion pairs at low x. At concentrations x < 0.20 the ion pairs condense into molecular-thin filaments bound by dipolar forces and extending in between nanometric droplets of IL. These results are confirmed and complemented by the computation of dynamic and transport properties in [bmim][PF6]/naphthalene mixtures at low IL concentration.

The use of contrast-enhanced ultrasound in the characterisation of focal liver lesions.

PURPOSE: To determine the potential application of contrast-enhanced ultrasound in the characterisation of focal liver lesions encountered in radiological practice at a district general hospital. MATERIALS & METHODS: Retrospective analysis of 68 sequential patients undergoing contrast-enhanced ultrasound (CEUS) of liver. All patients were referred for CEUS following identification of 1 or more focal liver lesions on conventional ultrasound or CT imaging. After baseline US examination (Acuson), a bolus of 1.0-2.4 ml of SonoVue (Bracco, UK) was administered intravenously. CEUS images were obtained during arterial, portal venous and delayed phases. Patients were followed up for a mean period of 6 months. The CEUS diagnosis was compared to that indicated by other imaging modalities, histopathology, and clinical follow up. RESULTS: CEUS correctly identified malignant liver lesions in 19 patients, with the final diagnosis confirmed by histopathology in 5 cases and clinico-radiological follow up in 14 cases. 47 patients were correctly identified with benign liver lesions on CEUS imaging, with all these cases confirmed on clinico-radiological follow up. In the detection of malignancy, the sensitivity was 95.0% and the specificity was 97.9%. CONCLUSIONS: In our experience to date, contrast-enhanced ultrasound imaging is highly accurate in characterising malignant and benign focal liver lesions. It therefore has significant potential for utilisation in most general radiology departments.

Magnetic resonance (MR) imaging of lumbar spine: use of a shortened protocol for initial investigation of degenerative disease.

PURPOSE: To assess the potential use of shortened protocol MRI of lumbar spine in the investigation of degenerative disc disease in Northern Ireland. MATERIALS & METHODS: Prospective study of 35 patients having MR imaging of lumbar spine performed during a 12-month period by one consultant radiologist. T1-weighted and T2-weighted sagittal images of lumbar spine were obtained in all cases, as well as T2-weighted axial images. The detection of degenerative disc disease by sagittal T2-weighted imaging alone was compared with the diagnostic information obtained by combined use of axial T2 and sagittal T1 and T2 images. RESULTS: In comparison with the full protocol, the shortened protocol had 100% sensitivity and 100% specificity in detecting loss of disc hydration and loss of disc height. In the detection of disc prolapse, the sensitivity was 87% and the specificity was 91% using the shortened protocol. The sensitivity was 35% for detection of thecal sac indentation, and 33% for nerve root encroachment. Therefore, the shortened protocol had high sensitivity and specificity in the detection of disc degeneration and prolapse, but was less sensitive in the detection of nerve root or thecal sac encroachment.

CT-guided fine-needle aspiration of lung nodules: effect on outcome of using coaxial technique and immediate cytological evaluation.

PURPOSE: To evaluate the risk of pneumothorax during CT-guided fine-needle aspiration (FNA) of lung nodules with single needle and coaxial needle techniques and to assess the effect on diagnostic accuracy of immediate cytological examination of lung FNA samples. MATERIALS AND METHODS: This prospective study analysed 53 patients undergoing transthoracic FNA biopsy of lung. 36 cases were performed by a radiologist using a coaxial technique, with 17 cases performed by a radiologist using a direct single-needle method. Effect of technique on occurrence of pneumothorax was recorded. FNA samples from all the patients in the study were examined immediately on-site by a cytologist or MLSO to determine whether sufficient aspirate had been obtained. Provisional diagnosis at immediate examination was compared to final diagnosis following full pathological evaluation. RESULTS: Coaxial and non-coaxial groups were comparable for age and gender. Number of pleural passes was significantly lower in coaxial group (P < 0.01). Pneumothorax occurred in six (17%) of the 36 patients biopsied by coaxial technique, compared to four (24%) of the 17 patients by non-coaxial method (P = 0.55). Chest tube placement was required in four patients (11%) in the coaxial group, and two patients (12%) in the non-coaxial group (P = 0.85). A provisional cytological diagnosis was recorded for 74% of the patients in the study. 83% of the provisional reports were accurate on comparison with full pathology report. Specimen size was sufficient in 81% of cases. CONCLUSIONS: The use of coaxial technique for CT-guided lung FNA biopsy reduced the number of pleural passes but did not significantly reduce the occurrence of pneumothorax. Immediate cytological examination of FNA specimens provided an accurate provisional diagnosis in the majority of cases, and should be routinely employed.

The use of local accident and emergency injury surveillance to monitor the impact of a lay safety community programme.

To study prospectively the injury patterns in under 14 year olds presenting to casualty. To use this information to assess the impact of a local Community Childhood Accident Prevention Project (CCAPP) Prospective injury surveillance was collected on all attendees under 14 years of age. Casualty attendance for the members of the Safety Club and matched controls were analysed. Of the 4,267 attendees there was the expected male predominance. 2,261 (53%) of injuries occurred at home, 574 (13.5%) on the road, 553 (13%) at school with 202 (4.7%) during sports. Priority areas noted were high falls > 1 metre, road accidents, burns and poisonings. Those participating in the program demonstrated significantly (p-value < 0.05) reduced admission rates and head injury rates when compared to non-participants. The above database allows us to analyse injury patterns and to assess the success of an EU-sponsored local injury prevention campaign in areas of high social deprivation.