Survivorship and functional outcome of a cemented acetabular component with bulk roof autograft for severe acetabular dysplasia: 12- to 23-year follow-up.

AIMS: Primary aim was to determine survival of a cemented acetabular component with bulk roof autograft with a minimum of 12 years follow-up. The secondary aim was to determine the clinical outcome. METHODS: A cohort of 62 consecutive patients (74 hips) undergoing cemented total hip arthroplasty with acetabular bulk roof autograft for acetabular dysplasia were retrospectively identified. The group consisted of 57 female patients (67 hips) and 5 male patients (7 hips) with a mean age at operation of 45 years. No patient was lost to follow-up, however 9 patients died had during the study period. The Oxford Hip Score (OHS), Forgotten Joint Score (FJS), EuroQol 5-Dimensional Score (EQ-5D), Short Form (SF-12) physical score and patient satisfaction were used to assess clinical outcome for patients with a surviving prosthesis. RESULTS: The median follow-up was 16.6 (13.4-19.1) years. 6 revisions were performed during the follow-up period, all of which were due to aseptic loosening of the acetabular component. The all-cause Kaplan Meier survival rate for the acetabular component was 99% at 10 years, 95% at 15 years and 83% at 20 years. Neither age, gender, femoral osteotomy or polyethylene (UHMW vs. cross-linked) were significant predictors of aseptic revision of the acetabular component. There were no case of graft resorption and all grafts were radiologically incorporated. 45 patients were available for functional assessment at a mean follow-up of 18.2 years. The mean OHS was 37.8, FJS was 55.7, EQ5D was 0.73, and SF-12 physical component was 43.2. No patient was dissatisfied, with 2 patients reporting a neutral satisfaction, 7 stating they were satisfied and the remaining 36 were very satisfied. CONCLUSIONS: A cemented acetabular component with bulk roof autograft for dysplasia offers excellent survival with good to excellent functional outcome with high patient satisfaction in the medium- to long-term.

Metagenomic analysis of nepoviruses: diversity, evolution and identification of a genome region in members of subgroup A that appears to be important for host range.

Data mining and metagenomic analysis of 277 open reading frame sequences of bipartite RNA viruses of the genus Nepovirus, family Secoviridae, were performed, documenting how challenging it can be to unequivocally assign a virus to a particular species, especially those in subgroups A and C, based on some of the currently adopted taxonomic demarcation criteria. This work suggests a possible need for their amendment to accommodate pangenome information. In addition, we revealed a host-dependent structure of arabis mosaic virus (ArMV) populations at a cladistic level and confirmed a phylogeographic structure of grapevine fanleaf virus (GFLV) populations. We also identified new putative recombination events in members of subgroups A, B and C. The evolutionary specificity of some capsid regions of ArMV and GFLV that were described previously and biologically validated as determinants of nematode transmission was circumscribed in silico. Furthermore, a C-terminal segment of the RNA-dependent RNA polymerase of members of subgroup A was predicted to be a putative host range determinant based on statistically supported higher π (substitutions per site) values for GFLV and ArMV isolates infecting Vitis spp. compared with non-Vitis-infecting ArMV isolates. This study illustrates how sequence information obtained via high-throughput sequencing can increase our understanding of mechanisms that modulate virus diversity and evolution and create new opportunities for advancing studies on the biology of economically important plant viruses.

Identification, molecular characterization and prevalence of a novel cytorhabdovirus infecting zucchini crops in Greece.

A new cytorhabdovirus was identified in zucchini (Cucurbita pepo) in Greece with the aid of high-throughput sequencing technology. The negative-sense, single-stranded genomic RNA of the new virus was determined and includes seven open reading frames in the order 3'-N-P-P3-P4-M-G-L-5' in the antigenomic orientation. Typical rhabdovirus-like particles were observed in infected leaf material. Comparative sequence analysis and phylogenetic reconstructions suggested that the described virus is a new member of the genus Cytorhabdovirus, and it was tentatively named cucurbit cytorhabdovirus 1 (CuCV1). To our knowledge CuCV1 is the first cytorhabdovirus infecting cucurbits in nature. Our surveys indicated that it occurs in a percentage of 36.7 % in zucchini crops in Greece.

Leading article: how can I optimise my role as a leader within the surgical team?

Leadership is uncommonly taught formally at any level in surgical training, and is not often evaluated formally either within assessment programmes or during appraisal. Good leadership skills in oral and maxillofacial surgery (OMFS) include professionalism, technical competence, motivation, innovation, ability to communicate, resilience, and effective teaching. They also include the recognition of when and how to "follow" when appropriate. Such skills can be developed through experience, observation, and education using a framework that can include mentoring, coaching, and feedback. This review provides some guidance in how to improve leadership skills in OMFS, which we hope will to improve the quality of training and care of patients.

Morbidity associated with operative management of bladder stones in spinal cord-injured patients.

STUDY DESIGN: Retrospective cohort study of spinal cord-injured (SCI) patients undergoing bladder stone removal operations between 1999 and 2013. OBJECTIVES: To determine the morbidity associated with different operative management of bladder stones in SCI patients. SETTING: National Spinal Injuries Unit, Stoke Mandeville Hospital, UK. METHODS: Data on age, sex, level and Frankel classification of spinal cord injury, method of bladder drainage, method of bladder stone removal, complications and length of stay were collected from patient records. Complication was defined as bladder perforation, sepsis or persistent haematuria. Predictors of complications and length of stay were determined using univariate and multivariate regression analyses. RESULTS: Overall, 112 consecutive bladder stone removal operations were performed, one open cystolithotomy and 111 transurethral procedures utilising simple washout, stone punch or electrohydraulic lithotripsy (EHL). Of these procedures, 17% (19/112) had complications; 0/11 (0%) following washout, 5/44 (11%) after stone punch, 3/12 (25%) following EHL and 10/26 (38%) after combined procedures using stone punch and EHL. In a multivariate model, patients with a cervical-level injury and those undergoing a combined procedure were significantly more likely to have a complication (P=0.032 and P=0.046). Length of stay was longer following a complication, the mean was 4.18 days compared with 1.37 days without a complication (P<0.001). Controlling complications and age, use of a combined procedure was associated with significantly longer stay than use of stone punch alone. CONCLUSION: This study provides important outcome data that should guide operative procedure choice and inform patients about possible risks during consent. It sets a benchmark that other centres can evaluate their outcomes against.

Obtaining patient feedback in an outpatient lithotripsy service is facilitated by use of a touch-screen tablet (iPad™) survey.

There is now a requirement for every doctor in the UK to obtain patient feedback for revalidation. This can be an onerous and time-consuming task. The objective of this study was to evaluate a novel electronic patient feedback method in an outpatient lithotripsy service setting. Between September 2013 and January 2014, 100 patients attending an outpatient lithotripsy service in Oxford were asked to complete a selection of pre-approved NHS questions about the service they had received. Questions were presented on a tablet device (iPad™) and answered using the touch screen. Departmental staff were unaware of the questions in the survey. Patients were asked to complete the survey by an independent research nurse. Questions were created online in a free-to-use web-based survey application and presented on the tablet device in a user-friendly format via an application. Data were uploaded via wifi™ to the online system. Data were viewed, automatically analysed and displayed graphically. The age range of the patients surveyed was 20-80 years of age. All 100 patients completed the survey without difficulty. All patients answered every question. Data could be automatically viewed, analysed and presented graphically. This method of collecting patient feedback proved to be rapid and efficient. The feedback highlighted a high patient satisfaction with the lithotripsy service. A touch screen tablet device is an efficient and effective method of collecting truly objective patient feedback. This method of patient feedback could be employed in other clinical environments to collect data for revalidation purposes.

Label-free quantitative proteomics reveals differentially regulated proteins influencing urolithiasis.

Urinary proteins have been implicated as inhibitors of kidney stone formation (urolithiasis). As a proximal fluid, prefiltered by the kidneys, urine is an attractive biofluid for proteomic analysis in urologic conditions. However, it is necessary to correct for variations in urinary concentration. In our study, individual urine samples were normalized for this variation by using a total protein to creatinine ratio. Pooled urine samples were compared in two independent experiments. Differences between the urinary proteome of stone formers and nonstone-forming controls were characterized and quantified using label-free nano-ultraperformance liquid chromatography high/low collision energy switching analysis. There were 1063 proteins identified, of which 367 were unique to the stone former groups, 408 proteins were unique to the control pools, and 288 proteins were identified for comparative quantification. Proteins found to be unique in stone-formers were involved in carbohydrate metabolism pathways and associated with disease states. Thirty-four proteins demonstrated a consistent >twofold change between stone formers and controls. For ceruloplasmin, one of the proteins was shown to be more than twofold up-regulated in the stone-former pools, this observation was validated in individuals by enzyme-linked immunosorbent assay. Moreover, in vitro crystallization assays demonstrated ceruloplasmin had a dose-dependent increase on calcium oxalate crystal formation. Taken together, these results may suggest a functional role for ceruloplasmin in urolithiasis.

Understanding waiting lists as the matching of surgical capacity to demand: are we wasting enough surgical time?

If surgical 'capacity' always matched or exceeded 'demand' then there should be no waiting lists for surgery. However, understanding what is meant by 'demand', 'capacity' and 'matched' requires some mathematical concepts that we outline in this paper. 'Time' is the relevant measure: 'demand' for a surgical team is best understood as the total min required for the surgery booked from outpatient clinics every week; and 'capacity' is the weekly operating time available. We explain how the variation in demand (not just the mean demand) influences the analysis of optimum capacity. However, any capacity chosen in this way is associated with only a likelihood (that is, a probability rather than certainty) of absorbing the prevailing demand. A capacity that suitably absorbs the demand most of the time (for example, > 80% of weeks) will inevitably also involve considerable waste (that is, many weeks in which there is spare, unused capacity). Conversely, a level of capacity chosen to minimise wasted time will inevitably cause an increase in size of the waiting list. Thus the question of how to balance demand and capacity is intimately related to the question of how to balance utilisation and waste. These mathematical considerations enable us to consider objectively how to manage the waiting list. They also enable us critically to analyse the extent to which philosophies adopted by the National Health Service (such as 'Lean' or 'Six Sigma') will be successful in matching surgical capacity to demand.

Tuberculous peritonitis and tuberculous endometritis diagnosed in the same patient by high clinical suspicion and a minimally invasive approach.

Tuberculous peritonitis and tuberculous endometritis are extremely rare entities in the Western world. In this article, we discuss a rare case of a 40-year-old Nigerian female presenting with abdominal pain, distension and secondary amenorrhea, and show that a high clinical suspicion combined with minimally invasive procedures can help physicians make the diagnosis, avoid extensive surgery, and rapidly initiate appropriate therapy.

Bladder management and risk of bladder stone formation in spinal cord injured patients.

PURPOSE: We determined by statistical analysis whether method of management is associated with risk of bladder stone formation in spinal cord injured patients. MATERIALS AND METHODS: A retrospective cohort study was performed of 457 patients admitted to Stoke Mandeville Hospital Spinal Injuries Center between 1985 and 1990 with more than 6 months of followup. Analysis included Cox regression and Poisson regression. RESULTS: Relative to those patients treated with intermittent self-catheterization, the hazard ratio was 10.5 (p <0.0005, 95% confidence interval 4.0-27.5) for patients with suprapubic catheters and it was 12.8 (p <0.0005, 95% confidence interval 5.1-31.9) for those with indwelling urethral catheters. The absolute annual risk of stone formation in patients with a catheter was 4% compared with 0.2% for those on intermittent self-catheterization. However, having formed a stone, the risk of forming a subsequent stone quadrupled to 16% per year. Bladder stones were no more likely to form in patients with suprapubic catheters compared to those with indwelling urethral catheters (hazard ratio 1.2, p = 0.6). CONCLUSIONS: In spinal cord injured patients long-term catheterization is associated with a substantial increased risk of bladder stone formation. This increased risk occurs independently of age, sex and injury level. Degree of injury (complete or incomplete) was considered in the model. Catheter type (suprapubic or urethral) did not change this risk significantly if at all.

Sphincterotomy and the treatment of detrusor-sphincter dyssynergia: current status, future prospects.

STUDY DESIGN: Literature review of current treatment options for detrusor-sphincter dyssynergia (DSD) in spinal cord injury. OBJECTIVES: To review the outcomes and complications associated with external sphincterotomy and to summarise the results and complications of alternative treatment options for detrusor-sphincter dyssynergia in spinal cord injury. In addition, we propose a potential alternative future drug treatment for external sphincter dyssynergia based upon recent research on the neuropharmacology of the external urethral sphincter. SETTING: The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK. METHODS: Medline search from 1966 to 2002 using the words 'external sphincterotomy', 'detrusor-sphincter dyssynergia' and 'neurogenic bladder combined with surgery'. RESULTS: While external sphincterotomy is an effective treatment for DSD, a significant number of men following this procedure continue to have high intrarenal pressures, recurrent urinary infection or troublesome autonomic dysreflexia and a worryingly high proportion demonstrate persistently raised leak point pressures, putting them at subsequent risk of renal damage. Alternative treatments for external sphincter dyssynergia include urethral stents and balloon dilatation, both of which are effective. However, over the long term stents can undergo encrustation and there remains a definite risk of stent migration necessitating stent removal or replacement. Balloon dilatation of the external sphincter is associated with a risk of subsequent stricture formation. Intraurethral Botulinum A toxin seems to be effective though there have been no large randomised studies comparing it against placebo. However, it is not a durable treatment option and it has not found a common place in the treatment of DSD. There is now a considerable amount of experimental data from both animal and human studies to suggest that nitric oxide (NO) is an important physiological inhibitory neurotransmitter in the urethral sphincter, mediating relaxation of the external urethral sphincter. The potential role of sphincter NO augmentation for treatment of DSD is discussed. CONCLUSION: External sphincterotomy remains the mainstay of treatment for urodynamically significant detrusor-sphincter dyssynergia, but in recent years a number of effective, alternative treatment options have become available. While at present there is no effective systemic drug treatment, recent research into external sphincter neuropharmacology suggests that systemic or topical augmentation of external sphincter NO may provide an effective method for lowering sphincter pressure.

Radiation-induced haemorrhagic cystitis.

OBJECTIVES: In this article we review the literature concerning the frequency and management of severe haemorrhagic radiation-induced cystitis. METHODS: A Medline search was performed from 1966 to 1999 for articles in English. A total of 309 references were found. Abstracts and complete articles were reviewed. RESULTS: Severe haemorrhagic cystitis following radiotherapy remains a relatively rare event. However, the fact that it is relentlessly progressive and that treatment options are suboptimal makes it clinically important. The incidence of severe haematuria following pelvic irradiation is difficult to determine from the literature although most studies state an incidence of less than 5% which increases with time since irradiation. Methods of treatment include simple bladder irrigation, cystodiathermy, oral, parenteral and intravesical agent, hyperbaric oxygen therapy, hydrodistension, internal iliac embolisation, urinary diversion and cystectomy. No management strategy is 100% successful and a stepwise progression in treatment intensity is often required. CONCLUSION: The articles available on radiation-induced haemorrhagic cystitis are principally retrospective and involve small numbers of patients who have had several different treatment modalities. In the absence of randomised studies comparing treatments, it is impossible to set definitive rules about management but patients with this condition probably warrant early and aggressive treatment.

Augmentation of nitric oxide to treat detrusor-external sphincter dyssynergia in spinal cord injury.

Detrusor-external sphincter dyssynergia (DSD) is a common cause of bladder outlet obstruction in men with spinal cord injuries, which if left untreated leads ultimately to renal failure. External sphincterotomy is currently the main treatment for DSD. However, obstruction persists in a substantial proportion of cases after this procedure. There is no effective drug treatment for DSD. Nitric oxide is an inhibitory neurotransmitter synthesised by nitric oxide synthase. Both animal and human studies suggest that nitric oxide mediates urethral sphincter relaxation. Nitric-oxide-synthase staining neurons have been identified in very high density in the urethral sphincters of a variety of animals and in human beings. Relaxation of the urethral sphincter is abolished by inhibitors of nitric oxide synthase and enhanced by nitric oxide donors. Mice with targeted deletion of the gene, for neuronal nitric oxide have urethral sphincters that do not relax in response to electrical stimulation. We hypothesise that augmentation of external sphincter nitric oxide could be an effective pharmacological treatment for DSD. Currently available nitric oxide donors such as glyceryl trinitrate or isosorbide mononitrate could be used to deliver nitric oxide to the urethral sphincter. The variable pharmacokinetics of these drugs combined with different modes of delivery (sublingual, buccal, or oral) could be used to achieve both short-term and long-term increases in concentrations of sphincter nitric oxide, thereby resulting in either acute or chronic lowering of urethral pressure. The safety and efficacy of this potential treatment for DSD needs to be established in clinical trials of men with spinal cord injures with DSD.

Relation of nocturnal polyuria of the elderly to essential hypertension.

Nocturnal polyuria is common in the elderly. In this condition the normal circadian rhythm of urine production is reversed so that urine flow is higher at night than during the day. Elderly men with nocturnal polyuria are commonly referred for prostate surgery, which, not surprisingly, fails to relieve their symptoms. Compared with controls, patients with nocturnal polyuria have higher nocturnal sodium excretion but not higher nocturnal free-water clearance. Similar results have been obtained in children with nocturnal enuresis. Use of vasopressin analogues to induce water retention in elderly patients with nocturnal polyuria is illogical and potentially hazardous; nocturia can be more safely alleviated by diuretic therapy. Nocturnal polyuria in the elderly is associated with hypertension: this is consistent with studies in younger age groups that show that essential hypertension is associated with nocturia and with increased night/day ratios for sodium excretion. We propose that nocturnal polyuria and essential hypertension share some of the same pathophysiological determinants. Specifically, we suggest that a defect in the nitric-oxide pathway may lead to resetting of the pressure-natriuresis relation in the kidney, sodium retention, and compensatory nocturnal natriuresis. This suggestion is consistent with evidence that ageing and essential hypertension are both associated with defects in the nitric-oxide pathway. Our hypothesis has obvious therapeutic implications. More generally, studying the pathogenesis of nocturnal polyuria in the elderly may advance our understanding of the pathogenesis of essential hypertension.