Risk stratifying gastric ulcers: development and validation of a scoring system.

Objective: Debate is ongoing regarding the need for universal endoscopic follow-up to ensure gastric ulcer healing. We aimed to assess the value of follow-up oesophago-gastro-duodenoscopies (OGDs) for gastric ulcer healing and stratify patients according to risk of malignancy by developing a risk score. Design/method: All patients in National Health Service (NHS) Lothian with an index OGD and a diagnosis of gastric ulcer between 1 January 2014 and 31 December 2018 were identified. Data were analysed with logistic regression to identify factors significantly associated with a diagnosis of cancer; a risk score was derived and externally validated. Results: 778 patients were identified and 60.3% (469/778) of patients had a follow-up OGD. 8.6% (66/778) of patients were diagnosed with cancer. No cases of cancer were found on follow-up OGD of a benign appearing ulcer with negative biopsies. Macroscopic suspicion of malignancy was present at index OGD in 100% (3/3) of those diagnosed with cancer on subsequent OGDs. Older age (p=0.014), increased ulcer size (p<0.001) and non-antral location (p=0.030) were significantly associated with malignancy. A risk score (area under the curve (AUC) 0.868, p<0.001, minimum score=0, maximum score=6) was derived from these variables. 78.0% of patients with malignant ulcers scored ≥3, only 15.8% with benign ulcers scored ≥3 (negative predictive value (NPV) 97.4%). External validation yielded an AUC of 0.862 (p<0.001) and NPV of 98.6%; 84.0% of those with malignant ulcers scored ≥3. Conclusion: Ulcers with a combination of macroscopically benign appearances, at least six negative biopsies and a low risk score do not necessarily need endoscopic follow-up.

Optical-Based Biosensors and Their Portable Healthcare Devices for Detecting and Monitoring Biomarkers in Body Fluids.

The detection and monitoring of biomarkers in body fluids has been used to improve human healthcare activities for decades. In recent years, researchers have focused their attention on applying the point-of-care (POC) strategies into biomarker detection. The evolution of mobile technologies has allowed researchers to develop numerous portable medical devices that aim to deliver comparable results to clinical measurements. Among these, optical-based detection methods have been considered as one of the common and efficient ways to detect and monitor the presence of biomarkers in bodily fluids, and emerging aggregation-induced emission luminogens (AIEgens) with their distinct features are merging with portable medical devices. In this review, the detection methodologies that use optical measurements in the POC systems for the detection and monitoring of biomarkers in bodily fluids are compared, including colorimetry, fluorescence and chemiluminescence measurements. The current portable technologies, with or without the use of smartphones in device development, that are combined with optical biosensors for the detection and monitoring of biomarkers in body fluids, are also investigated. The review also discusses novel AIEgens used in the portable systems for the detection and monitoring of biomarkers in body fluid. Finally, the potential of future developments and the use of optical detection-based portable devices in healthcare activities are explored.

Wear analysis of explanted conventional metal back polyethylene glenoid liners.

INTRODUCTION: Glenoid component wear and loosening is the Achilles heel of total shoulder replacement. Analysis of failed, revised implants might give an insight into the causes of component failure. Volumetric assessment of conventional total shoulder replacement glenoid liner wear rate and scanning electron microscopy was accomplished in this study for the purpose. Coherence scanning interferometry (white light scanner) 3D images were acquired. This method requires no physical contact, ionising radiation or extensive surface preparation. METHODS: Twenty-four Nottingham total shoulder replacement system metal - back glenoid liners were explanted from revision shoulder arthroplasty cases. A Phase Vision Quartz DBE 800 scanner was used to scan the explanted polyethylene liners. The images of worn liners were registered to the reference image. Differences in wear and wear rate were quantified and central and non-central wear groups were distinguished. The Central wear group had a polyethylene wear rate of 115 ±â€¯55mm3/year (mean ±â€¯SD). The non-central group showed a wear rate of 112 ±â€¯42 mm3/year (mean ±â€¯SD), which was not significantly different from the central wear group (p = 0.426) Polyethylene liners showing edge wear from unstable shoulder replacements showed a wear rate of 545 mm3/year. Scanning electron microscopy images showed that the polyethylene was wearing in laminar flakes which indicated fatigue wear. CONCLUSION: The volumetric wear rate was found to be more than twice as fast as in the case of total hip replacement with the acetabular liner made of the same type of polyethylene. Use of coherence scanning interferometry is proposed for wear analysis.

Genome-wide association study of working memory brain activation.

In a population-based genome-wide association (GWA) study of n-back working memory task-related brain activation, we extracted the average percent BOLD signal change (2-back minus 0-back) from 46 regions-of-interest (ROIs) in functional MRI scans from 863 healthy twins and siblings. ROIs were obtained by creating spheres around group random effects analysis local maxima, and by thresholding a voxel-based heritability map of working memory brain activation at 50%. Quality control for test-retest reliability and heritability of ROI measures yielded 20 reliable (r>0.7) and heritable (h2>20%) ROIs. For GWA analysis, the cohort was divided into a discovery (n=679) and replication (n=97) sample. No variants survived the stringent multiple-testing-corrected genome-wide significance threshold (p<4.5×10-9), or were replicated (p<0.0016), but several genes were identified that are worthy of further investigation. A search of 529,379 genomic markers resulted in discovery of 31 independent single nucleotide polymorphisms (SNPs) associated with BOLD signal change at a discovery level of p<1×10-5. Two SNPs (rs7917410 and rs7672408) were associated at a significance level of p<1×10-7. Only one, most strongly affecting BOLD signal change in the left supramarginal gyrus (R2=5.5%), had multiple SNPs associated at p<1×10-5 in linkage disequilibrium with it, all located in and around the BANK1 gene. BANK1 encodes a B-cell-specific scaffold protein and has been shown to negatively regulate CD40-mediated AKT activation. AKT is part of the dopamine-signaling pathway, suggesting a mechanism for the involvement of BANK1 in the BOLD response to working memory. Variants identified here may be relevant to (the susceptibility to) common disorders affecting brain function.

A rare case of floating clavicle and a novel technique for stabilizing the sternoclavicular joint.

We present the first ever case report of a floating clavicle with a unique combination of a posterior sternoclavicular joint dislocation and an associated grade III acromioclavicular joint dislocation. We treated this injury surgically by stabilizing both ends of clavicle using a polyester surgical mesh device (LockDown™; Mandaco 569 Limited, Redditch, UK; previously called the Nottingham Surgilig).

Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study.

BACKGROUND: Health Economists in Denmark have reported poor outcomes and low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). In this setting it is important to evaluate outcomes following this commonly performed operation to justify undertaking it on our patients. The purpose of the study was to evaluate the effectiveness of ASAD for patients with SAIS and correlate clinical outcome with rate of return to work. METHODS: Prospective cohort study and retrospective review of data from the Nottingham Shoulder database. Inclusion criteria: Patients diagnosed clinically with SAIS by an experienced shoulder surgeon, who have failed conservative treatment (physiotherapy and sub-acromial injection), undergoing ASAD. Pre-operative and 6-month post-operative Oxford Shoulder Score (OSS) and Constant Score (CS) were compared. The rates of return to pre-operative work and hobbies were also analysed. Statistical analysis was carried out using the Wilcoxon signed rank test. RESULTS: 73 patients with OSS (51 also with CS documentation) were included. The improvement in median OSS between pre-operative (24) and 6-month follow-up (39) was +15 (Z = -6.726, p < 0.0001, T = 6, r = 0.55). The difference in median CS between pre-operative (39) and 6-month follow-up (67) was +28 (Z = -5.435, p < 0.0001,T = 6, r = 0.59). Improvement in median pain score was +5 (7,12, p < 0.0001) median ADL was +5.5 (10.5,16, p < 0.0001) median ROM was +13 (18,31, p < 0.0001) and median strength was +4 (3,7, p < 0.0001). 76% returned to their pre-operative level of work (mean time = 11.5 weeks post surgery). 79% returned to pre-operative hobbies at a mean of 11.8 weeks after surgery. CONCLUSION: There is a significant improvement in both subjective and objective outcome 6 months after ASAD in patients with SAIS who have had previous failed conservative treatment. The rate of return to work was good for these patients in contrast to that reported for Danish patients. ASAD is a successful method of treatment for patients with SAIS who have had an initial trial of failed conservative treatment.

Myositis ossificans of the humeral insertion of pectoralis major.

We report on a rare case of myositis ossificans of the humeral insertion of pectoralis major muscle following a single episode of trauma which, to our knowledge, has not previously been documented.

Protocol for the ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial: a pragmatic multi-centre randomised controlled trial of surgical versus non-surgical treatment for proximal fracture of the humerus in adults.

BACKGROUND: Proximal humeral fractures, which occur mainly in older adults, account for approximately 4 to 5% of all fractures. Approximately 40% of these fractures are displaced fractures involving the surgical neck. Management of this group of fractures is often challenging and the outcome is frequently unsatisfactory. In particular it is not clear whether surgery gives better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform this decision. METHODS/DESIGN: We aim to undertake a pragmatic UK-based multi-centre randomised controlled trial evaluating the effectiveness and cost-effectiveness of surgical versus standard non-surgical treatment for adults with an acute closed displaced fracture of the proximal humerus with involvement of the surgical neck. The choice of surgical intervention is left to the surgeon, who must use techniques that they are fully experienced with. This will avoid 'learning curve' problems. We will promote good standards of non-surgical care, similarly insisting on care-provider competence, and emphasize the need for comparable provision of rehabilitation for both groups of patients.We aim to recruit 250 patients from a minimum of 18 NHS trauma centres throughout the UK. These patients will be followed-up for 2 years. The primary outcome is the Oxford Shoulder Score, which will be collected via questionnaires completed by the trial participants at 6, 12 and 24 months. This is a 12-item condition-specific questionnaire providing a total score based on the person's subjective assessment of pain and activities of daily living impairment. We will also collect data for other outcomes, including general health measures and complications, and for an economic evaluation. Additionally, we plan a systematic collection of reasons for non-inclusion of eligible patients who were not recruited into the trial, and their baseline characteristics, treatment preferences and intended treatment. DISCUSSION: This article presents the protocol for a multi-centre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50850043.

Thinking activates EMG in scalp electrical recordings.

OBJECTIVE: Fast electrical rhythms in the gamma range (30-100Hz) in scalp (but not intracranial) recordings are predominantly due to electromyographic (EMG) activity. We hypothesized that increased EMG activity would be augmented by mental tasks in proportion to task difficulty and the requirement of these tasks for motor or visuo-motor output. METHODS: EEG was recorded in 98 subjects whilst performing cognitive tasks and analysed to generate power spectra. In four other subjects, neuromuscular blockade was achieved pharmacologically providing EMG-free spectra of EEG at rest and during mental tasks. RESULTS: In comparison to the paralysed condition, power of scalp electrical recordings in the gamma range varied in distribution, being maximal adjacent to cranial or cervical musculature. There were non-significant changes in mean gamma range activity due to mental tasks in paralysed subjects. In normal subjects, increases in scalp electrical activity were observed during tasks, without relationship to task difficulty, but with tasks involving limb- or eye-movement having higher power. CONCLUSIONS: Electrical rhythms in the gamma frequency range recorded from the scalp are inducible by mental activity and are largely due to EMG un-related to cognitive effort. EMG varies with requirements for somatic or ocular movement more than task difficulty. SIGNIFICANCE: Severe restrictions exist on utilizing scalp recordings for high frequency EEG.

Improvements in survival of the uncemented Nottingham Total Shoulder prosthesis: a prospective comparative study.

BACKGROUND: The uncemented Nottingham Total Shoulder Replacement prosthesis system (Nottingham TSR) was developed from the previous BioModular shoulder prosthesis taking into consideration the causes of the initial implant's failure. We investigated the impact of changes in the design of Nottingham TSR prosthesis on its survivorship rate. METHODS: Survivorship analyses of three types of uncemented total shoulder arthroplasty prostheses (BioModular, initial Nottingham TSR and current Nottingham TSR systems with 11, 8 and 4 year survivorship data respectively) were compared. All these prostheses were implanted for the treatment of disabling pain in the shoulder due to primary and secondary osteoarthritis or rheumatoid arthritis. Each type of the prosthesis studied was implanted in consecutive group of patients--90 patients with BioModular system, 103 with the initial Nottingham TSR and 34 patients with the current Nottingham TSR system. The comparison of the annual cumulative survivorship values in the compatible time range between the three groups was done according to the paired t test. RESULTS: The 8-year and 11-year survivorship rates for the initially used modified BioModular uncemented prosthesis were relatively low (75.6% and 71.7% respectively) comparing to the reported survivorship of the conventional cemented implants. The 8-year survivorship for the uncemented Nottingham TSR prosthesis was significantly higher (81.8%), but still not in the desired range of above 90%, that is found in other cemented designs. Glenoid component loosening was the main factor of prosthesis failure in both prostheses and mainly occurred in the first 4 postoperative years. The 4-year survivorship of the currently re-designed Nottingham TSR prosthesis, with hydroxylapatite coating of the glenoid baseplate, was significantly higher, 93.1% as compared to 85.1% of the previous Nottingham TSR. CONCLUSION: The initial Nottingham shoulder prosthesis showed significantly higher survivorship than the BioModular uncemented prosthesis, but lower than expected. Subsequently re-designed Nottingham TSR system presented a high short term survivorship rate that encourages its ongoing use.

Scalp electrical recording during paralysis: quantitative evidence that EEG frequencies above 20 Hz are contaminated by EMG.

OBJECTIVE: To identify the possible contribution of electromyogram (EMG) to scalp electroencephalogram (EEG) rhythms at rest and induced or evoked by cognitive tasks. METHODS: Scalp EEG recordings were made on two subjects in presence and absence of complete neuromuscular blockade, sparing the dominant arm. The subjects undertook cognitive tasks in both states to allow direct comparison of electrical recordings. RESULTS: EEG rhythms in the paralysed state differed significantly compared with the unparalysed state, with 10- to 200-fold differences in the power of frequencies above 20 Hz during paralysis. CONCLUSIONS: Most of the scalp EEG recording above 20 Hz is of EMG origin. Previous studies measuring gamma EEG need to be re-evaluated. SIGNIFICANCE: This has a significant impact on measurements of gamma rhythms from the scalp EEG in unparalysed humans. It is to be hoped that signal separation methods will be able to rectify this situation.

Functional outcome of surgical treatment of symptomatic nonunion and malunion of midshaft clavicle fractures.

Disability caused by nonunited or malunited fracture of the midshaft clavicle is a rare condition that is expressed by local pain or neurovascular impairment. This condition is usually treated by reduction of the fracture and stable fixation with augmentation by autogenous bone graft. We evaluated the functional outcome in 13 patients who were treated by this method. The mean postsurgical follow-up was 41 months. In all patients, satisfactory osseous union was achieved. Only 46% of the patients returned to their previous professional and recreational activities. There was also evidence that the current Constant scores of the affected shoulders remained significantly lower than those of the normal contralateral side. Ten patients reported various degrees of pain, and only three patients were pain-free. We show that, although solid union after realignment of symptomatic nonunion or malunion of midshaft clavicle fractures is predictable, the patients can remain functionally impaired.

Preseizure increased gamma electroencephalographic activity has no effect on extracellular potassium or calcium.

Extracellular ion concentrations change during seizures in seizure models. [K(+)](o) increases and [Ca(2+)](o) decreases, resulting from population discharges, enhanced neuronal excitability, though not obviously before seizure onset. In acute pharmacological epilepsy models, there are striking increases in preictal high-frequency (gamma) electroencephalographic (EEG) activity. It is not known whether enhanced gamma EEG results in ionic changes, because gamma and ions have not been measured simultaneously. In this study, unanesthetized, paralyzed rats were given intravenous injections of kainic acid or picrotoxin to induce EEG discharges. Changes in EEG, [K(+)](o), and [Ca(2+)](o) in cortex and hippocampus were recorded. Kainic acid caused small [K(+)](o) fluctuations, without a temporal relationship of these with increased gamma EEG or with onset of discharges. Gamma EEG increases after picrotoxin also failed to affect [K(+)](o) and [Ca(2+)](o). Picrotoxin-induced electrical discharges led to [K(+)](o) rises of >9 mM and [Ca(2+)](o) falls of 0.1-0.2 mM. Kainic acid-induced discharges generated only moderate (2-3 mM) rises in [K(+)](o) and no changes in [Ca(2+)](o). In both models, there were large potassium rises (15-80 mM) and calcium falls (>0.5 mM), suggesting spreading depressions. Small [K(+)](o) fluctuations after kainic acid are consistent with disruption in potassium homeostasis, possibly because of depolarization of astrocytes. To reveal possible latent [K(+)](o) or [Ca(2+)](o) changes, we injected fluorocitrate intracortically to impair astrocytic function, before administering picrotoxin. Even fluorocitrate did not cause gamma-related ion changes but did cause low-magnitude, transient, potassium increases and slower potassium homeostasis during discharges, minor changes consistent with involvement of both astrocytes and neurons in [K(+)](o) regulation. (c) 2007 Wiley-Liss, Inc.