17 years' experience of surgical management of thoracic outlet syndrome at a district general hospital.

INTRODUCTION: Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular structures passing through the thoracic inlet. It is categorised into three subtypes: neurogenic TOS (NTOS), venous TOS (VTOS) and arterial TOS (ATOS). This study evaluates the outcomes of patients who underwent first rib resection (FRR) for TOS during a period of 17 years at a single district general hospital. METHODS: Retrospective review of patient notes of individuals treated with FRR from August 2004 to August 2021. RESULTS: A total of 62 FRRs were performed on 51 individual patients. Indications for FRR included 42 NTOS (68%), 6 VTOS (10%) and 14 ATOS (23%). Thirty-four patients (64%) were female and the mean age at time of surgery was 39 years (range 27 to 64 years). Eleven patients (21%) underwent bilateral FRR and seven cases of cervical ribs were observed. The mean time from initial symptoms to diagnosis was 18 months (range 2 to 60 months). Overall, outcomes after surgery were positive across all subtypes of TOS. Based on Derkash's classification, 52 patients (84%) reported excellent/good, 8 (13%) reported fair and 2 (3%) reported poor resolution of symptoms at 6 month follow-up. Complications included four (9%) pneumothorax, two (4%) wound infections, two (4%) haematoma, one (2%) haemothorax, three (5%) phrenic nerve complications and one (2%) brachial neuropraxia. CONCLUSIONS: FRR for TOS can be performed safely and effectively in a district general hospital environment with excellent patient clinical outcomes.

Effective equations governing an active poroelastic medium.

In this work, we consider the spatial homogenization of a coupled transport and fluid-structure interaction model, to the end of deriving a system of effective equations describing the flow, elastic deformation and transport in an active poroelastic medium. The 'active' nature of the material results from a morphoelastic response to a chemical stimulant, in which the growth time scale is strongly separated from other elastic time scales. The resulting effective model is broadly relevant to the study of biological tissue growth, geophysical flows (e.g. swelling in coals and clays) and a wide range of industrial applications (e.g. absorbant hygiene products). The key contribution of this work is the derivation of a system of homogenized partial differential equations describing macroscale growth, coupled to transport of solute, that explicitly incorporates details of the structure and dynamics of the microscopic system, and, moreover, admits finite growth and deformation at the pore scale. The resulting macroscale model comprises a Biot-type system, augmented with additional terms pertaining to growth, coupled to an advection-reaction-diffusion equation. The resultant system of effective equations is then compared with other recent models under a selection of appropriate simplifying asymptotic limits.

The development of change blindness: children's attentional priorities whilst viewing naturalistic scenes.

Change blindness describes the surprising difficulty of detecting large changes in visual scenes when changes occur during a visual disruption. In order to study the developmental course of this phenomenon, a modified version of the flicker paradigm, based on Rensink, O'Regan & Clark (1997), was given to three groups of children aged 6-12 years and to a group of adults. This paradigm tested the ability to detect single colour, presence/absence and location changes of both high and low semantic importance in a complex scene. Semantically important changes were detected more quickly and accurately than less semantically important changes, by all age groups, indicating that children had the same attentional priorities as adults. Older children achieved more efficient and accurate detection of changes than younger children and reached almost adult level at 10-12 years old. These improvements parallel age-related developments in attention and visual perception.

The Health Assessment Questionnaire Disability Index is a valid measure of physical function in gout.

OBJECTIVE: There are no disability instruments that have specifically been validated for gout. The aim of this study was to determine the construct validity of the Health Assessment Questionnaire Disability Index (HAQ-DI) in gout and the internal validity using Rasch analysis. METHODS: An observational cohort study of two groups of clinic patients with gout (n=20, n=53), in which clinical and functional measures were correlated with HAQ-DI scores. Rasch analysis was used to determine the internal validity of summated scores as a measure of physical disability. RESULTS: The HAQ-DI items fitted a Rasch measurement model, confirming internal validity of the scale, although there was evidence of disordered thresholds and rescoring items as a 3-option response rather than a 4-option response improved model fit and resolved the disordered thresholds. HAQ-DI scores showed a bimodal distribution and evidence of floor effects. Clinical indices correlated highly with HAQ-DI scores in gout patients, particularly other measures of physical function. A strong relationship between days of sick leave and HAQ-DI was observed in gout patients (r2=0.44, p<0.001). CONCLUSIONS: It is concluded that HAQ-DI has good construct and internal validity in gout but a modified scoring approach better fits a Rasch model.

Tophaceous joint disease strongly predicts hand function in patients with gout.

OBJECTIVES: The functional impact of gout is poorly understood. The aim of this study was to determine predictors of hand function in gout. METHODS: Twenty unselected patients with gout were recruited from rheumatology clinics. No patient had an acute gout flare at assessment. Participants were assessed for clinical characteristics of gout, including the site and number of tophi. Hand function was assessed by the Sollerman hand function test. Fingertip to palm (FTP) distance measurement, grip strength and the Disability Assessment of Shoulder and Hand (DASH) questionnaire scores were also recorded. Data were analysed by simple and multiple linear regression models. RESULTS: The median Sollerman score was 75.5 (range 31-80). The median hand FTP distance was 2.91 (0.88-6.69) cm, grip strength was 31 (4-71) kg, and DASH score was 28.77 (0-76.47). Of the clinical characteristics measured, the number of joints of the hand with overlying tophi (hand tophus joint count) was the strongest single predictor of the Sollerman score (r2 = 0.59), and also predicted the other measures of hand mobility and function. A multiple regression model including hand tophus joint count, sex, number of gout flares in the preceding 6 months, gout disease duration and hand tender joint count was a better predictor of the Sollerman score than hand tophus joint count alone (r2 = 0.81, F(4,14) = 3.94, P = 0.024). CONCLUSIONS: Measures of chronic and poorly controlled disease predict hand function in patients with gout. In particular, tophaceous joint disease has a major impact on functional capacity in gout.

Losartan, an angiotensin type 1 receptor antagonist, improves endothelial function in non-insulin-dependent diabetes.

OBJECTIVES: The present study examined the effect on forearm endothelial function of an angiotensin II type 1 receptor antagonist, losartan, in subjects with non-insulin-dependent diabetes mellitus (NIDDM). BACKGROUND: Angiotensin-converting enzyme (ACE) inhibition with enalapril improves acetylcholine (ACh)-dependent endothelial function in patients with NIDDM. This could be mediated through angiotensin II and the type 1 receptor or could be due to inhibition of kininase II and a bradykinin preserving effect. It is therefore relevant to determine whether a type 1 receptor antagonist improves endothelial function. METHODS: The influence of losartan (50 mg daily for four weeks) on endothelium-dependent and independent vasodilator function was determined in 9 NIDDM subjects using a double-blinded placebo-controlled crossover protocol. Forearm blood flow was measured using strain-gauge plethysmography. RESULTS: Losartan significantly decreased infused arm vascular resistance in response to three incremental doses of intrabrachial acetylcholine (p < 0.05, ANOVA). The forearm blood flow ratio (flow in infused to noninfused arm) was also increased (p < 0.01). Responses to sodium nitroprusside and monomethyl arginine were not significantly changed. CONCLUSIONS: Losartan administration at 50 mg per day improved endothelium-dependent dilation of resistance vessels in patients with NIDDM. That is, blockade of the angiotensin II type 1 receptors improves endothelial function in NIDDM. At least some of the similarly beneficial effect of ACE inhibition is probably mediated also through the angiotensin II-type 1 receptor pathway. The use of a type 1 receptor antagonist seems a reasonable alternative to an ACE inhibitor to maintain endothelial function in NIDDM subjects.

Combined aerobic and resistance exercise training improves functional capacity and strength in CHF.

This study examined the effect of a novel circuit weight training (CWT) program on cardiorespiratory fitness, muscular strength, and body composition in 13 patients with chronic heart failure (CHF), using a prospective randomized crossover protocol. Peak exercise oxygen uptake (VO(2 peak)) increased after the 8-wk CWT program (19. 5 +/- 1.2 vs. 22.0 +/- 1.5 ml. kg(-1). min(-1), P < 0.01), as did exercise test duration (15.2 +/- 0.9 vs. 18.0 +/- 1.1 min, P < 0. 001). Submaximal exercise heart rate was lower after training at 60 and 80 W (121 +/- 3 vs. 134 +/- 5 beats/min, P < 0.01) as was rate pressure product, whereas ventilatory threshold increased, from 52 +/- 3 to 58 +/- 3% of VO(2 peak) (P < 0.05). CWT also increased maximal isotonic voluntary contractile strength for seven different muscle groups, from 392 to 462 kg (P = 0.001). CWT, an exercise prescription specifically targeting peripheral abnormalities in CHF, improves functional capacity and muscular strength in these patients.

A survey of denture hygiene in patients attending Cardiff Dental Hospital.

Patients attending the Cardiff Dental Hospital were interviewed by staff and students in the Department of Prosthetic Dentistry and a multidisciplinary teaching clinic. Information on denture hygiene was collected using a questionnaire. This questionnaire consisted of nineteen questions on the methods and materials used for denture hygiene, along with details pertinent to the patients and their dentures. One thousand patients were interviewed. The results showed that patients were less critical of standards of denture hygiene than clinicians. Only 46% of patients believed their dentures stained. This suggests high patient apathy regarding denture hygiene, that should be addressed in health education programs.

Assessment of a recently introduced fluoroelastomeric soft lining material.

The clinical usefulness of soft denture-lining materials is well established. This laboratory-based comparative study of a heat-processed silicone (Molloplast-B) and a recently introduced fluoroelastomeric soft lining material (Novus) evaluated absorption behaviour in distilled water; the softness of the materials at different thicknesses, both dry and after immersion in water; and their compatibility with denture cleansers. A significant absorption of water, greater than 5% by weight, was displayed by Novus after 4 months' immersion. The softness of different thicknesses of Novus (up to 1.35 mm) increased significantly upon immersion over the same period when compared to Molloplast-B, which showed no change. Some surface degradation of Novus was evident upon exposure to denture cleansers that was not apparent with Molloplast-B.

Adsorption of glycosaminoglycans to commercially pure titanium.

Aqueous solutions of the glycosaminoglycans (GAG), chondroitin-4-sulphate (C4S), chondroitin-6-sulphate (C6S), heparan sulphate (HS) and hyaluronan (HY) were reacted with 5 g samples of both native and calcium-treated titanium powder (99.5% pure) for 0-48 h in 10 ml volume at 37 degrees C. Residual GAG was detected in the supernatant following recovery of the TiO2-GAG complex by centrifugation (5000 g for 1 min) as hexuronic acid using the carbazole tetraborate method of Bitter and Muir. No adsorption on to native TiO2 was evident. In contrast, prior treatment of TiO2 with calcium produced a significant adsorption of C4S to a maximum of 60 micrograms of GAG per gram Ti. Only trace amounts of C6S, HS and hyaluronan interacted in the same way. Further evidence of interaction was obtained following the liberation of bound GAG from the TiO2-Ca-GAG complex with EDTA and identification using cellulose acetate electrophoresis. These findings suggest that calcium ions are required for adsorption of GAG to TiO2 which is mediated through the anionic determinants of the GAG surface and that the special configuration of C4S, the predominant chondroitin sulphate isomer found in alveolar bone, is important in the adsorption process. The implication of these findings in relation to the interaction between bone and titanium implants is discussed.

Education. What school nurses want.

Drawing on her experiences as a tutor, June Collis focuses on the educational needs of school nurses in a period of development and change in the NHS. Noting practitioners' own perceptions of their changing needs, she highlights the need for more research into school nurse practice.

Varieties of object constancy.

Three experiments are described in which two pictures of isolated man-made objects were presented in succession. The subjects' task was to decide, as rapidly as possible, whether the two pictured objects had the same name. With a stimulus-onset asynchrony (SOA) of above 200 msec two types of facilitation were observed: (1) the response latency was reduced if the pictures showed the same object, even though seen from different viewpoints (object benefit); (2) decision time was reduced further if the pictures showed the same object from the same angle of view (viewpoint benefit). These facilitation effects were not affected by projecting the pictures to different retinal locations. Significant benefits of both types were also obtained when the projected images differed in size. However, in these circumstances there was a small but significant performance decrement in matching two similar views of a single object, but not if the views were different. Conversely, the object benefit, but not the viewpoint benefit, was reduced when the SOA was only 100 msec. The data suggest the existence of (at least) two different visual codes, one non-retinotopic but viewer-centred, the other object-centred.

Toward some principles of school nursing.

An examination of the school nursing role based on four principles covering provision of health care, the nurse as a source of knowledge, the school as a health promoting community, and a team approach which acknowledges parents as partners is presented.

The rib gap anomaly in partial or mosaic trisomy 8.

Gaps in the first ribs were observed in two children, one with partial and the other with mosaic trisomy for chromosome 8. The sign may be considered in conjunction with other features as a relative indication for chromosomal studies.

Total disc replacement: a modified posterior lumbar interbody fusion. Report of 750 cases.

Total disc replacement is a modification of posterior lumbar interbody fusion. A study of 750 patients treated by total disc replacement with allogeneic bone shows that the operation is complicated but uniquely effective. Successful results have occurred in over 90% of the cases.

Massive lignocaine overdose during cardiopulmonary bypass. Successful treatment with cardiac pacing.

A case of accidental massive overdose of lignocaine while a patient was on cardiopulmonary bypass is described. The benefits of cardiopulmonary bypass and cardiac pacing in the management of the patient are discussed.