Sugar or salt ("SOS"): A protocol for a UK multicentre randomised trial of mannitol and hypertonic saline in severe traumatic brain injury and intracranial hypertension.

Hyperosmolar solutions are widely used to treat raised intracranial pressure following severe traumatic brain injury. Although mannitol has historically been the most frequently administered, hypertonic saline solutions are increasingly being used. However, definitive evidence regarding their comparative effectiveness is lacking. The Sugar or Salt Trial is a UK randomised, allocation concealed open label multicentre pragmatic trial designed to determine the clinical and cost-effectiveness of hypertonic saline compared with mannitol in the management of patients with severe traumatic brain injury. Patients requiring intensive care unit admission and intracranial pressure monitoring post-traumatic brain injury will be allocated at random to receive equi-osmolar boluses of either mannitol or hypertonic saline following failure of routine first-line measures to control intracranial pressure. The primary outcome for the study will be the Extended Glasgow Outcome Scale assessed at six months after randomisation. Results will inform current clinical practice in the routine use of hyperosmolar therapy as well as assess the impact of potential side effects. Pre-planned longer term clinical and cost effectiveness analyses will further inform the use of these treatments.

Live video footage from scene to aid helicopter emergency medical service dispatch: a feasibility study.

BACKGROUND: Obtaining accurate information from a 112 caller is key to correct tasking of Helicopter Emergency Medical Services (HEMS). Being able to view the incident scene via video from a mobile phone may assist HEMS dispatch by providing more accurate information such as mechanism of injury and/or injuries sustained. The objective of this study is to describe the acceptability and feasibility of using live video footage from the mobile phone of a 112 caller as an HEMS dispatch aid. METHODS: Live footage is obtained via the 112 caller's mobile phone camera through the secure GoodSAM app's Instant-on-scene™ platform. Video footage is streamed directly to the dispatcher, and not stored. During the feasibility trial period, dispatchers noted the purpose for which they used the footage and rated ease of use and any technical- and operational issues they encountered. A subjective assessment of caller acceptance to use video was conducted. RESULTS: Video footage from scene was attempted for 21 emergency calls. The leading reasons listed by the dispatchers to use live footage were to directly assess the patient (18/21) and to obtain information about the mechanism of injury and the scene (11/21). HEMS dispatchers rated the ease of use with a 4.95 on a 5-point scale (range 4-5). All callers gave permission to stream from their telephone camera. Video footage from scene was successfully obtained in 19 calls, and was used by the dispatcher as an aid to send (5) or stand down (14) a Helicopter Emergency Medical Services team. CONCLUSION: Live video footage from a 112 caller can be used to provide dispatchers with more information from the scene of an incident and the clinical condition of the patient(s). The use of mobile phone video was readily accepted by the 112 caller and the technology robust. Further research is warranted to assess the impact video from scene could have on HEMS dispatching.

Mammary analogue secretory carcinoma of the salivary glands: a diagnostic dilemma.

Mammary analogue secretory carcinoma (MASC) is a recently identified salivary gland neoplasm that can mimic other salivary gland tumours such as acinic cell carcinoma and cystadenocarcinoma. It is distinguished from these by differences in immunohistochemical profile and the identification of an ETV6-NTRK3 translocation (12;15)(p13;q25), which is also found in secretory carcinomas of the breast. Previous publications have suggested that MASC tumours have similar biological behaviour to acinic cell carcinoma. We report two cases of MASC that affected the upper lip, and showed an infiltrative and locally aggressive growth pattern that required several operations to ensure clearance of microscopic tumour cells.

The effect of deprivation on the incidence of mandibular fractures in a British city.

AIM: To examine the relationship between social and material deprivation and mandibular fractures. METHOD: Three hundred and forty three consecutive patients who underwent mandibular fracture fixation were selected for the study. After exclusions, 290 were divided into age groups and ranked according to their Index of Multiple Deprivation (IMD) score. Rankings were determined using postcodes, and divided into quintiles for statistical analysis. RESULTS: Ages ranged from 7 to 82 with 146 (50%) patients aged between 20 and 29. Males accounted for 85% of cases. The most common site of fracture was the angle (n = 195) and assault was shown to be the most common mechanism of injury (63.3%). A strong relationship was demonstrated between fractures of the mandible and worsening deprivation, with the most striking relationship seen with fractures sustained as a consequence of assault. Females were less likely than males to sustain a fracture of the mandible as a consequence of assault; however, when assault was the mechanism of injury they were also likely to be from a deprived background. CONCLUSION: This study has demonstrated that a strong relationship exists between deprivation and the incidence of mandibular fractures in our catchment area. Fractures that resulted from interpersonal violence were shown to have a particularly strong correlation with deprivation.

Caudwell Xtreme Everest: An Overview.

The Caudwell Xtreme Everest (CXE) expedition in the spring of 2007 systematically studied 222 healthy volunteers as they ascended from sea level to Everest Base Camp (5300 m). A subgroup of climbing investigators ascended higher on Everest and obtained physiological measurements up to an altitude of 8400 m. The aim of the study was to explore inter-individual variation in response to environmental hypobaric hypoxia in order to understand better the pathophysiology of critically ill patients and other patients in whom hypoxaemia and cellular hypoxia are prevalent. This paper describes the aims, study characteristics, organization and management of the CXE expedition.

A practitioner's guide for exploring water quality patterns using principal components analysis and Procrustes.

To design sustainable water quality monitoring programs, practitioners must choose meaningful variables, justify the temporal and spatial extent of measurements, and demonstrate that program objectives are successfully achieved after implementation. Consequently, data must be analyzed across several variables and often from multiple sites and seasons. Multivariate techniques such as ordination are common throughout the water quality literature, but methods vary widely and could benefit from greater standardization. We have found little clear guidance and open source code for efficiently conducting ordination to explore water quality patterns. Practitioners unfamiliar with techniques such as principal components analysis (PCA) are faced with a steep learning curve to summarize expansive data sets in periodic reports and manuscripts. Here, we present a seven-step framework for conducting PCA and associated tests. The last step is dedicated to conducting Procrustes analysis, a valuable but rarely used test within the water quality field that describes the degree of concordance between separate multivariate data matrices and provides residual values for similar points across each matrix. We illustrate the utility of these tools using three increasingly complex water quality case studies in US parklands. The case studies demonstrate how PCA and Procrustes analysis answer common applied monitoring questions such as (1) do data from separate monitoring locations describe similar water quality regimes, and (2) what time periods exhibit the greatest water quality regime variability? We provide data sets and annotated R code for recreating case study results and as a base for crafting new code for similar monitoring applications.

Focal atrophy of the masticatory muscles caused by pure trigeminal motor neuropathy: case report.

Pure trigeminal motor neuropathy is rare and characterised by weakness of the mandibular motor branch with no signs of involvement of the trigeminal sensory or other cranial nerve. Its aetiology is unclear but it has been hypothesised that a viral infection may be a cause. Magnetic resonance imaging is useful in its diagnosis and typically shows loss of volume of the affected masticatory muscles and infiltration of fat. We describe the case of a 29-year-old woman who presented with a 12-year history of progressive facial asymmetry, which was later shown on imaging to be caused by unilateral atrophy of the masseter with compensatory contralateral hypertrophy.

LAT gel, a powerful tool underused in the repair of paediatric lacerations.

Paediatric lacerations presenting to emergency departments are a common cause of referral to surgical specialties in the UK. LAT gel (lidocaine, adrenaline, and tetracaine) is a safe and effective topical anaesthetic that can aid with the closure of uncomplicated lacerations, particularly in the paediatric trauma setting. The benefits to both the patient and management in terms of the avoidance of a general anaesthetic and the freeing up of hospital resources (e.g. beds, staffing, emergency theatre) make it an invaluable tool in the arsenal of the emergency department. The authors describe a reliable method of anaesthetizing lacerations with LAT gel and question its underuse within the emergency departments in the South West region of the UK.

Neurotrauma - a multidisciplinary disease.

Traumatic brain injury is one of the most important diseases of our time, both in terms of morbidity, mortality and economic loss. Public health policy is key to reducing its incidence. Integrated multidisciplinary clinical care is vital to minimise its morbidity and mortality.

Surgical management of acute subdural haematomas: current practice patterns in the United Kingdom and the Republic of Ireland.

INTRODUCTION: Uncertainty remains as to the role of decompressive craniectomy (DC) for primary evacuation of acute subdural haematomas (ASDH). In 2011, a collaborative group was formed in the UK with the aim of answering the following question: "What is the clinical- and cost-effectiveness of decompressive craniectomy, in comparison with craniotomy for adult patients undergoing primary evacuation of an ASDH?" The proposed RESCUE-ASDH trial (Randomised Evaluation of Surgery with Craniectomy for patients Undergoing Evacuation of Acute Subdural Haematoma) is a multicentre, pragmatic, parallel group randomised trial of DC versus craniotomy for adult head-injured patients with an ASDH. In this study, we used an online questionnaire to assess the current practice patterns in the management of ASDH in the UK and the Republic of Ireland, and to gauge neurosurgical opinion regarding the proposed RESCUE-ASDH trial. MATERIALS AND METHODS: A questionnaire survey of full members of the Society of British Neurological Surgeons and members of the British Neurosurgical Trainees Association was undertaken between the beginning of May and the end of July 2012. RESULTS: The online questionnaire was answered by 95 neurosurgeons representing 31 of the 32 neurosurgical units managing adult head-injured patients in the UK and the Republic of Ireland. Forty-five percent of the respondents use primary DC in at least 25% of patients with ASDH. In addition, of the 22 neurosurgical units with at least two Consultant respondents, only three units (14%) showed intradepartmental agreement regarding the proportion of their patients receiving a primary DC for ASDH. CONCLUSION: The survey results demonstrate that there is significant uncertainty as to the optimal surgical technique for primary evacuation of ASDH. The fact that the majority of the respondents are willing to become collaborators in the planned RESCUE-ASDH trial highlights the relevance of this important subject to the neurosurgical community in the UK and Ireland.

Does Early Decompressive Craniectomy Improve Outcome? Experience from an Active UK Recruiter Centre.

Introduction. The results of the recent DECRA study suggest that although craniectomy decreases ICP and ICU length of stay, it is also associated with worst outcomes. Our experience, illustrated by these two striking cases, supports that early decompressive craniectomy may significantly improve the outcome in selected patients. Case Reports. The first patient, a 20-year-old man who suffered severe brain contusion and subarachnoid haemorrhage after a fall downstairs, with refractory ICP of 35 mmHg, despite maximal medical therapy, eventually underwent decompressive craniectomy. After 18 days in intensive care, he was discharged for rehabilitation. The second patient, a 23-year-old man was found at the scene of a road accident with a GCS of 3 and fixed, dilated pupils who underwent extensive unilateral decompressive craniectomy for refractory intracranial hypertension. After three weeks of cooling, paralysis, and neuroprotection, he eventually left ICU for rehabilitation. Outcomes. Four months after leaving ICU, the first patient abseiled 40 m down the main building of St. Mary's Hospital to raise money for the Trauma Unit. He has returned to part-time work. The second patient, was decannulated less than a month later and made a full cognitive recovery. A year later, with a titanium skull prosthesis, he is back to part-time work and to playing football. Conclusions. Despite the conclusions of the DECRA study, our experience of the use of early decompressive craniectomy has been associated with outstanding outcomes. We are currently actively recruiting patients into the RESCUEicp trial and have high hopes that it will clarify the role of the decompressive craniectomy in traumatic brain injury and whether it effectively improves outcomes.

Medical emergencies in dental practice.

Serious medical emergencies are fortunately a rare occurrence in the dental practice environment; however, if an emergency situation is encountered a delay in treatment may result in potentially avoidable consequences. The risk of mortality or serious morbidity can be reduced by ensuring that basic emergency equipment and medications are in place, and that the dental team is appropriately trained in basic life support measures. This article aims to provide an overview of the basic emergency medications and equipment that should be present in dental practices, and to discuss specific responses to some of the more common adverse medical events that can present while providing dental treatment.

Renal disease and chronic renal failure in dental practice.

Patients with renal diseases are increasingly common in dental practice. This is due to advances in medicine, and the increasing life expectancy of western populations. Chronic renal failure is a serious condition that general dental practitioners may see in their practice. This article discusses the functions of the kidney, and the causes and medical management of chronic renal failure, as well as considerations in the dental management of these patients. Common complications such as infection and bleeding are discussed. General recommendations are made, based on current evidence with respect to prescribing of medications.

Epilepsy in dental practice.

Epilepsy is a neurological condition characterised by seizure activity. It has an approximate incidence of 1%. General dental practitioners will encounter these patients in practice. This article discusses the types of epilepsy, the medical management and considerations in dental management of epileptic patients. General recommendations are made, based on current evidence, with respect to prescribing of medications. The management of an epileptic seizure is discussed. Status epilepticus is a rare but serious complication of epileptic seizures. An easy-to-follow algorithm is provided to assist the practitioner in managing seizures.

Increased and decreased activity elicits specific morphological adaptations of the neuromuscular junction.

The objective of this investigation was to compare the effects of decreased vs. increased activity on the neuromuscular system. Twenty-four young adult (7 weeks old) Sprague-Dawley rats were randomly assigned to three treatment groups (N=8/group). Increased activity was achieved by treadmill running for up to 1 h/day. Decreased activity was induced by muscle unloading via the hindlimb suspension model. Control animals engaged in normal weight bearing and ambulatory activity. At the end of the 10 week intervention period, animals were killed and soleus muscles were removed, quickly frozen, and examined using cytofluorescent (neuromuscular junctions) and histochemical (myofibers) procedures. Pre-synaptic morphology was quantified by measuring nerve terminal branching, and post-synaptic assessment was conducted by staining acetylcholine receptors at the endplate. Myofiber profiles of solei were compiled by determining fiber size (cross-sectional area) and fiber type composition. Results show that exercise training significantly (P

Factors preventing gun acquisition and carrying among incarcerated adolescent males.

CONTEXT: Despite the wide availability of guns in the United States, not all delinquent adolescents own guns and not all adolescent gun owners carry them at all times. Research about the factors that prevent high-risk youth from acquiring and carrying guns is limited. OBJECTIVE: To determine, from the perspective of incarcerated adolescent males, factors that prevent acquiring or carrying guns, either on a temporary or permanent basis. DESIGN AND SETTING: In-depth, semistructured interviews were conducted with randomly selected incarcerated adolescent males at a residential juvenile justice facility from January to May 1998. Transcribed interviews were examined for recurrent themes. PARTICIPANTS: Forty-five incarcerated adolescent males. MAIN OUTCOME MEASURES: Reported factors limiting gun acquisition and carrying. RESULTS: Seventy-one percent of the sample had either owned or carried a gun out of their home. We identified 6 recurring themes that, at least on occasion, prevented or delayed delinquent youth from acquiring or carrying guns. The most commonly cited factors were fear of being arrested and incarcerated and lack of perceived need for a gun. Other themes included not wanting to hurt oneself or others, respect for the opinions of others, inability to find a source for a desired gun, and lack of money to acquire a desired gun. CONCLUSIONS: We identified 6 factors that limited gun acquisition and carrying among a sample of incarcerated male adolescents. Knowledge of these factors should inform intervention efforts to reduce youth gun acquisition and carrying.

The role of a conserved inter-transmembrane domain interface in regulating alpha(2a)-adrenergic receptor conformational stability and cell-surface turnover.

Functional and structural data from G protein-coupled receptors (GPCR) predict that transmembrane-domain (TM)2 is adjacent to TM7 within the GPCR structure, and that within this interface a conserved aspartate in TM2 and a conserved asparagine in TM7 exist in close proximity. Mutation at this D79(TM2)-N422(TM7) interface in the alpha(2A)-adrenergic receptor (alpha(2A)AR) affects not only receptor activation but also cell-surface residence time and conformational stability. Mutation at TM2(D79N) reduces allosteric modulation by Na(+) and receptor activation more dramatically than affecting cell-surface receptor turnover and conformational stability, whereas mutation at TM7(N422D) creates profound conformational instability and more rapid degradation of receptor from the surface of cells despite receptor activation and allosteric modulation properties that mirror a wild-type receptor. Double mutation of TM2 and 7(D79N/N422D) reveals phenotypes for receptor activation and conformational stability intermediate between the wild-type and singly mutated alpha(2A)AR. Additionally, the structural placement of a negative charge at this TM2/TM7 interface is necessary but not sufficient for receptor structural stability, because mislocalization of the negative charge in either the D79E alpha(2A)AR (which extends the charge out one methylene group) or the D79N/N422D alpha(2A)AR (placing the charge in TM7 instead of TM2) results in conformational lability in detergent solution and more rapid cell-surface receptor clearance. These studies suggest that this interface is important in regulating receptor cell-surface residence time and conformational stability in addition to its previously recognized role in receptor activation.

Screening for iron deficiency anemia by dietary history in a high-risk population.

BACKGROUND: Iron deficiency anemia (IDA) in young children is important to identify because of its adverse effects on behavior and development. Because of costs and inconvenience associated with blood test screening and the decline in prevalence of IDA, the Institute of Medicine and the Centers for Disease Control and Prevention recommend that blood test screening for IDA be targeted to children first identified by dietary and health history. OBJECTIVE: To evaluate a parent-completed dietary and health history as the first stage of 2-stage screening for IDA. DESIGN AND METHODS: A cross-sectional study was conducted in inner-city clinics in children 9 to 30 months old having routine anemia screening as part of a scheduled visit. Parents completed a questionnaire and children had venous blood sampling for complete blood count and ferritin. Anemia was defined as Hb <11.0 g/dL. Iron deficiency (ID) was defined as ferritin <10 microg/L or mean corpuscular volume <70 fL and red cell distribution width >14.5%. Children were categorized into 1 of 4 groups: iron-sufficient, not anemic (ISNA); iron-sufficient, anemic (ISA); iron-deficient, not anemic (IDNA); and iron-deficient anemic (IDA). The questionnaire consisted of 15 dietary items in domains of infant diet, intake of solid food, intake of beverages, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children together with 14 historical items in domains of birth history, recent illness, chronic medical conditions, history of anemia, and maternal history. Analysis was performed on individual items, domains, and combinations of selected items. RESULTS: In the 282 study subjects, the prevalence of anemia (35%), IDNA (7%), and IDA (8%) did not vary significantly by age. Among individual historical and dietary questions, maternal history of anemia and drinking >2 glasses of juice per day identified the highest proportion of children with IDA: 50% sensitivity (95% confidence interval [CI]: 16,81) and 77% sensitivity (95% CI: 54,89), respectively. However, specificities for these questions were 60% (95% CI: 55,65) and 22% (95% CI: 17,27), respectively. Domains of questions with the highest sensitivity for IDA were beverage intake (91%; 95% CI: 68,99) and intake of solid food (91%; 95% CI: 68,99). However, specificities of the domains were only 14% (95% CI: 10,18) and 29% (95% CI: 24,35), respectively. The dietary items used by Boutry and Needlman were 95% (95% CI: 77, 99) sensitive but only 15% (95% CI: 11,19) specific for IDA. The recommendations of the Centers for Disease Control and Prevention for health and dietary screening were 73% (95% CI: 56,92) sensitive and 29% (95% CI: 24,35) specific for IDA. The individual questions, domains of questions, and interdomain groups of questions had similar sensitivity and specificity for anemia and ID (IDA + IDNA). CONCLUSION: In this high-risk population, neither individual nor combinations of parental answers to dietary and health questions were able to predict IDA, anemia, or ID well enough to serve as a first-stage screening test.