Reoperative surgery for bilateral multinodular goitre in the era of total thyroidectomy.

BACKGROUND: Total thyroidectomy, rather than bilateral subtotal thyroidectomy, is now accepted as the preferred management for bilateral benign multinodular goitre (BMNG) in order to reduce the need for reoperative surgery. The aim of this study was to examine whether this approach has had an impact on presentation for bilateral reoperative thyroid surgery. METHODS: This was a retrospective cohort study. The study group comprised patients presenting with recurrent BMNG who underwent bilateral reoperative thyroid surgery following previous bilateral subtotal or partial thyroidectomy. They were compared with patients undergoing unilateral reoperative thyroid surgery following previous lobectomy, and those undergoing primary total thyroidectomy for BMNG. RESULTS: Between 1 January 1987 and 31 December 2009, 12 354 consecutive thyroid procedures were undertaken. Among those with BMNG, primary total thyroidectomy was undertaken in 3298 patients, unilateral reoperative thyroidectomy in 337 and bilateral reoperative thyroidectomy in 191. Presentations of patients with recurrent BMNG declined gradually over the study period following the change in policy from subtotal to total thyroidectomy; only five patients (representing less than 0.5 per cent of all thyroid surgery) underwent bilateral reoperative surgery for BMNG in the last year of the study. Four of these patients had their initial operation before 1987 and in another unit, whereas the remaining patient initially had surgery overseas. CONCLUSION: The introduction of a policy of initial total thyroidectomy for bilateral BMNG has essentially eliminated the need for bilateral reoperative surgery for recurrent goitre.

A 25-year dynamic ecological analysis of psychiatric hospital admissions and prison committals: Penrose's hypothesis updated.

AIMS: There is renewed interest in the inverse association between psychiatric hospital and prison places, with reciprocal time trends shown in more than one country. We hypothesised that the numbers of admissions to psychiatric hospitals and committals to prisons in Ireland would also correlate inversely over time (i.e. dynamic measures of admission and committal rather than static, cross-sectional numbers of places). METHOD: Publicly available activity statistics for psychiatric hospitals and prisons in Ireland were collated from 1986 to 2010. RESULTS: There was a reciprocal association between psychiatric admissions and prison committals (Pearson r=-0.788, p<0.001), an increase of 91 prison committals for every 100 psychiatric hospital admissions foregone. CONCLUSION: Penrose's hypothesis applies to admissions to psychiatric hospitals and prisons in Ireland over time (dynamic measures), just as it does to the numbers of places in psychiatric hospitals and prisons in Ireland and elsewhere (static, cross-sectional measures). Although no causal connection can be definitively established yet, mentally disordered prisoners are usually known to community mental health services. Psychiatric services for prisons and the community should be linked to ensure that the needs of those currently accessing care through prisons can also be met in the community.

When pathological and radiological correlation is achieved, excision of fibroadenoma with lobular neoplasia on core biopsy is not warranted.

BACKGROUND: The diagnosis and management of lobular neoplasia (LN) including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) remains controversial. Current management options after a core needle biopsy (CNB) with lobular neoplasia (LN) incorporating both ALH and LCIS include excision biopsy or careful clinical and radiologic follow up. METHODS: A retrospective analysis of the surgical database at Cork University Hospital was performed to identify all core needle biopsies from January 1st 2010 to 31st December 2013 with a diagnosis of FA who subsequently underwent surgical excision biopsy. All cases with associated LN including ALH and classical LCIS were selected. We excluded cases with coexistent ductal carcinoma in situ (DCIS), invasive carcinoma, LN associated with necrosis, pleomorphic lobular carcinoma in situ (PLCIS) or lesions which would require excision in their own right (papilloma, radial scar, atypical ductal hyperplasia (ADH) or flat epithelial atypia (FEA)). Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded. RESULTS: 2878 consecutive CNB with a diagnosis of FA were identified. 25 cases had a diagnosis of concomitant ALH or classical LCIS. Our study cohort consisted of 21 women with a mean age 53 years (age range 41-70 years). The core biopsy diagnosis was of LCIS and FA in 16 cases and ALH and FA in 5 cases. On excision biopsy, a FA was confirmed in all 21 cases. In addition to the FA, residual LCIS was present in 14 cases with residual ALH in 2 cases. One of the twenty-one cases (4.8%) was upgraded to invasive ductal carcinoma on excision.

Using genetics to control cattle parasites-the Rockhampton experience.

Ever since their accidental introduction, cattle ticks, gastrointestinal nematodes and buffalo flies have been major parasites of cattle in northern Australia. Enormous effort and resources have been directed at chemical control of these parasites but the problem persists in undiminished form. The principal control measure remains the use of breeds that have some degree of parasite resistance. No breed is completely resistant and all are at times adversely affected by parasites. Complete resistance is the ultimate solution but has been generally ignored as a commercial reality. Studies at Rockhampton have demonstrated that completely resistant lines can be developed by genetic means within a commercially acceptable timeframe from even the most parasite-susceptible breeds. Genetic changes in tick and worm resistance over 15 years in response to selection for increased tick resistance in the Belmont Adaptaur (Bos taurus) line are reported. Costs and benefits of achieving increased tick resistance are examined and the applicability of the results to other breeds is discussed. Breed differences in resistance to buffalo flies and their effects on live weight are also reported and the possibility of selecting for increased buffalo fly resistance is explored.

Calving rates in a tropical beef herd after treatment with a synthetic progestagen, norgestomet, or a prostaglandin analogue, cloprostenol.

Maiden heifers and lactating cows of known ovarian status and of several breeds were treated with a synthetic prostaglandin, cloprostenol, or a synthetic progestagen, norgestomet, at the start of an artificial insemination (AI) program. Animals in the cloprostenol treatment received 2 injections 10 days apart. Over the next 26 days those animals that showed oestrous behaviour were inseminated. Synchronisation rates and calving rates to insemination over the first 7 days were calculated. Those in the norgestomet treatment received an implant of norgestomet plus an injection of norgestomet and oestradiol valerate. The implant was removed 10 days later and the animals were given an injection of pregnant mare serum gonadotrophin (PMSG). They were inseminated at 48 h (maiden heifers) or 56 h (lactating cows) after implant removal. Calving rates to fixed-time insemination were recorded. After completion of the AI program the animals in both treatments were joined with bulls. Overall calving rates (AI plus bulls) were calculated. By day 7 of the program, 82% of the maiden heifers and 76% of the lactating cows in the cloprostenol treatment had been detected in oestrus. By day 21 the respective figures were 99% and 81%. Norgestomet treatment had an immediate and a prolonged effect on ovarian activity in those females classified as having inactive ovaries at the start of the AI program. Calving rates of those females to fixed-time AI and overall were similar to those of the females with active ovaries in both treatments. Their calving rates to fixed-time insemination, and overall calving rates for the lactating females, were significantly higher than the corresponding values of their contemporaries treated with cloprostenol and inseminated on observed oestrus over 7 days. For those females classified as having active ovaries at the start of the AI program, calving rates to first insemination and overall were similar for both treatments. Overall calving rates of lactating cows of each breed were, with one exception, higher in the norgestomet treatment than in the cloprostenol treatment. Although norgestomet treatment was more expensive than cloprostenol treatment, the advantage in calf crop resulted in an overall monetary advantage to the norgestomet treatment.

Fractures of the neck of the talus and the Blair fusion: a review of the literature and case report.

Historically, fractures of the neck of the talus have been serious injuries with sometimes devastating results. Several mechanisms have been reviewed to explain the types of injuries most commonly seen. Hawkin's classification of the types of talar neck fractures has been explained and used as a guideline in a review of treatment and results of talar neck fractures. Hawkin's group I fractures generally require only immobilization and are frequently without serious sequelae. Hawkin's group II fractures are more serious injuries, which may frequently be treated with closed reduction. Open reduction is occasionally necessary. Hawkin's group III fractures have the most potentially devastating results. These generally require open reduction with internal fixation or occasionally primary salvage procedures. Secondary salvage procedures are also sometimes necessary. Avascular necrosis of the talar body is reviewed in detail, including correlation with the type of fracture as well as diagnostic techniques and treatment. Other complications, including soft-tissue damage, osteomyelitis, malunion, and posttraumatic arthrosis, are discussed. The Blair tibiotalar arthrodiesis is reviewed in detail, with the consideration that it may be used as a primary or secondary salvage procedure with good results. Finally, a case in which the Blair fusion was used successfully is reported with 1-year follow-up.

Using UHF proximity loggers to quantify male-female interactions: a scoping study of estrous activity in cattle.

Reproductive efficiency is an important determinant of profitable cattle breeding systems and the success of assisted reproductive techniques (ART) in wildlife conservation programs. Methods of estrous detection used in intensive beef and dairy cattle systems lack accuracy and remain the single biggest issue for improvement of reproductive rates and such methods are not practical for either large-scale extensive beef cattle enterprises or free-living mammalian species. Recent developments in UHF (ultra high frequency) proximity logger telemetry devices have been used to provide a continuous pair-wise measure of associations between individual animals for both livestock and wildlife. The objective of this study was to explore the potential of using UHF telemetry to identify the reproductive cycle phenotype in terms of intensity and duration of estrus. The study was conducted using Belmont Red (interbred Africander Brahman Hereford-Shorthorn) cattle grazing irrigated pasture on Belmont Research Station, northeastern Australia. The cow-bull associations from three groups of cows each with one bull were recorded over a 7-week breeding season and the stage of estrus was identified using ultrasonography. Telemetry data from bull and cows, collected over 4 8-day logger deployments, were log transformed and analyzed by ANOVA. Both the number and duration of bull-cow affiliations were significantly (P<0.001) greater in estrous cows compared to anestrus cows. These results support the development of the UHF technology as a hands-off and noninvasive means of gathering socio-sexual information on both wildlife and livestock for reproductive management.

Focal femoral condyle resurfacing.

Focal femoral inlay resurfacing has been developed for the treatment of full-thickness chondral defects of the knee. This technique involves implanting a defect-sized metallic or ceramic cap that is anchored to the subchondral bone through a screw or pin. The use of these experimental caps has been advocated in middle-aged patients who have failed non-operative methods or biological repair techniques and are deemed unsuitable for conventional arthroplasty because of their age. This paper outlines the implant design, surgical technique and biomechanical principles underlying their use. Outcomes following implantation in both animal and human studies are also reviewed.

Neck narrowing in resurfacing hip arthroplasty: a vascular insult?

INTRODUCTION: Recent reports show increased failure rates in hip resurfacings that display >10 % neck narrowing. The etiology of neck narrowing remains unknown. METHODS: We assessed 80 hip resurfacings at mean 3.5 years follow-up. RESULTS: The overall rate of significant narrowing was 11.25 %. Neck narrowing occurred in 4 % of patients using an anterolateral approach and 23.3 % using a posterior approach (P = 0.019). Logistic regression showed that both surgical approach and cup inclination angle were the most important risk factors for the development of narrowing. The odds of the presence of narrowing increased for every degree increase in cup abduction angle (P = 0.021). There was no significant association with age, sex, pre-operative diagnosis, pre- and post-operative SF-36 scores, neck shaft angle, femoral or acetabular component sizes. CONCLUSION: We postulate that neck narrowing is a result of damage to the medial circumflex femoral vessel when resurfacing through a posterior approach.

A preliminary study of Salmonella, verocytotoxigenic Escherichia coli/Escherichia coli O157 and Campylobacter on four mixed farms.

The aims of this study were to investigate the incidence of Salmonella, verocytotoxigenic Escherichia coli (VTEC)/Escherichia coli O157 and Campylobacter on four mixed farms and to characterize the isolates in terms of a range of virulence factors. Eighty-nine composite (five different samples from the same animal species combined) faecal [cattle (24), pigs (14), sheep (4), poultry (4), horses (7), deer (4), dogs (9), rodents (2) and wild birds (20)] samples, 16 composite soil samples plus 35 individual water samples were screened using culture-based, immunomagnetic separation and molecular methods. Salmonella was detected in bovine faeces, cattle and poultry house water. Salmonella serotypes/phage types included Dublin, Kiel and Typhimurium DT193, and most isolates were spvC, invA and rck positive. The pefA and rck genes were found exclusively in the non-Typhimurium strains, while Salmonella Dublin and Salmonella Kiel strains carried Salmonella genomic island I marker(s). VTEC/E. coli O157 were found in deer and dog faeces only. The E. coli O157 isolate was an enteroinvasive E. coli, while the VTEC isolate was untypable but carried the vt1, eaeA, hlyA, tir and eptD genes. This article reports the first confirmed carriage of E. coli O157 in Irish deer. Campylobacter species were not detected over the course of this study. It was concluded that [1] Salmonella, VTEC and Campylobacter have low (<5%) prevalence or are absent on the farms in this study; [2] water was an important source of bacterial pathogens; [3] both dogs and deer may act as a source of pathogenic E. coli and [4] key virulence and resistance determinants are widespread in farm Salmonella strains. This study highlights the need to control water as a source of pathogens and suggests that the domestic pets and deer should be considered in any farm risk assessment.

Management of follicular thyroid carcinoma should be individualised based on degree of capsular and vascular invasion.

INTRODUCTION: Follicular thyroid carcinoma (FTC) includes a spectrum of neoplasms with varying propensity for metastasis. The aim of this study is to describe outcomes for FTC following multimodality treatment, with particular reference to the degree of capsular and vascular invasion and to recommend a rational management approach based on these characteristics. METHODS: Patients with histologically confirmed FTC were identified from a prospectively maintained database. Details of intervention and long-term outcomes were obtained. Outcomes were compared between patients with minimally invasive follicular carcinoma (MI FTC) without vascular invasion (Group 1); angioinvasive MI FTC (Group 2); and those with widely invasive FTC (Group 3). RESULTS: Between May 1983 and December 2008, 124 patients with FTC were identified. The overall disease-free survival rate was 85% at a median of 40 months follow-up. Disease-free survival was 97%, 81% and 46%, respectively, in Groups 1, 2 and 3, and significantly different between groups (p<0.001). Thirteen patients in this series developed distant metastases including 2 in Group 1 and 6 in Group 2. Only patients <45 years of age with MI FTC and no vascular invasion had 100% disease-free survival. After multivariate linear regression, age (p=0.03) and the presence of vascular invasion (p=0.03) were the most powerful predictors of distant metastasis. CONCLUSIONS: Survival is improved in those with minimally invasive compared with widely invasive FTC. In patients <45 years with MI FTC without vascular invasion, hemithyroidectomy may be adequate treatment. All other patients with FTC should undergo total thyroidectomy and radioactive iodine ablation.

Uterine leiomyosarcomas are characterized by high p16, p53 and MIB1 expression in comparison with usual leiomyomas, leiomyoma variants and smooth muscle tumours of uncertain malignant potential.

AIMS: It has been suggested that p16 is overexpressed in uterine leiomyosarcomas in comparison with leiomyomas. In this study, p16 immunohistochemical expression was assessed in a variety of uterine smooth muscle tumours, including usual leiomyomas, leiomyoma variants, smooth muscle tumours of uncertain malignant potential (STUMPs) and leiomyosarcomas. The aim was to ascertain whether there are differences in p16 expression between these groups and whether p16 is of potential value in the assessment of problematic uterine smooth muscle neoplasms. p16 expression was also compared with that of p53 and MIB1. METHODS AND RESULTS: Cases of usual leiomyoma (n = 10), leiomyoma variants (n = 27), STUMP (n = 4) and leiomyosarcoma (n = 22) were subject to p16, p53 and MIB1 immunohistochemistry. For p16, cases were evaluated with respect to both staining distribution and intensity. There was a statistically significant difference in p16 distribution (P < 0.001) and intensity (P = 0.001) between leiomyosarcomas and the other groups. There was no difference in p16 expression between usual leiomyomas, leiomyoma variants and STUMPs. There were also statistically significant differences in p53 (P = 0.014) and MIB1 (P < 0.001) immunoreactivity between leiomyosarcomas and the other groups. CONCLUSIONS: p16 is overexpressed in uterine leiomyosarcomas compared with leiomyomas, benign leiomyoma variants and STUMPs, suggesting that p16 may be implicated in the pathogenesis of malignant uterine smooth muscle neoplasms. p16, in combination with p53 and MIB1, may be of value as an adjunct to morphological examination in the assessment of problematic uterine smooth muscle tumours, although further large-scale studies with follow-up are necessary to confirm this.

High-grade ovarian serous carcinoma exhibits significantly higher p16 expression than low-grade serous carcinoma and serous borderline tumour.

AIMS: A dualistic pathway of ovarian serous carcinogenesis is now well established whereby high-grade serous carcinoma and low-grade serous carcinoma represent two distinct tumour types with a different underlying pathogenesis. The aim of this study was to compare expression of p16 INK4A (p16) in these two tumour types. We also included cases of serous borderline tumour, since these are considered to represent a precursor lesion of low-grade serous carcinoma. METHODS AND RESULTS: Cases of serous borderline tumour (n = 18), low-grade ovarian serous carcinoma (n = 22) and high-grade ovarian serous carcinoma (n = 24) were stained with a monoclonal antibody against p16. Cases were scored both with respect to intensity of immunoreactivity (weak, 1+; moderate, 2+; or strong, 3+) and distribution (0, negative or occasional positive cells; 1+, < 10% cells positive; 2+, 10-25% cells positive; 3+, 26-50% cells positive; 4+, 51-75% cells positive; or 5+, 76-100% cells positive). An immunohistochemical composite score was also calculated (0-15) by multiplying the intensity and distribution scores. There was a statistically significant difference in p16 immunoreactivity with respect to intensity, distribution and composite score between high-grade serous carcinoma and each of the other two groups, with the high-grade neoplasms exhibiting stronger and more diffuse positivity. Most high-grade serous carcinomas exhibited positivity of close to 100% of tumour cells. There was no significant difference in p16 expression between the borderline tumours and low-grade serous carcinomas. CONCLUSIONS: The increased expression of p16 in high-grade serous carcinoma compared with low-grade serous carcinoma and serous borderline tumour is in keeping with a different underlying pathogenesis. p16 may be implicated in the development of high-grade serous neoplasia within the ovary and elsewhere within the female genital tract.

Therapeutic drug monitoring of digoxin: help or hindrance?

A major role of therapeutic drug monitoring services is to advise on the dose of a drug which would be required to bring the concentration in the blood to within specific 'therapeutic' limits. Monitoring digoxin usage constitutes a substantial part of the work load. We have examined the potential variability in recommendations for digoxin dosages based on a series of serum digoxin measurements in each of 80 out-patients. In over a third of cases a dose, which seemed to be optimal on the basis of the first assay result, would have produced concentrations outside the conventional therapeutic range when the measurement was repeated. This was despite careful supervision of medication and the timing of the blood sample in relation to its administration. In routine practice the apparent variability in dose requirements would be far greater. Objectives of therapeutic drug monitoring services remain the same, the way forward would seem to lie in their taking on a heavy commitment to counsel and supervise patients before repeated blood sampling. However, effort and resources might be better channelled into producing simple prescribing aids relating the risk of cardiotoxicity directly to the size of the maintenance dose and the individual's renal function.

Reducing methane emissions in sheep by immunization against rumen methanogens.

This work was conducted to determine if methane emissions from sheep immunized with an anti-methanogen vaccine were significantly lower than methane emissions from non-immunized sheep, to test the effectiveness of two different vaccine formulations (VF) on methane abatement, and to compare methane emissions measured using a closed-circuit respiration chamber and the sulphur-hexafluoride (SF6) tracer technique. Thirty mature wether sheep were randomly allocated to three treatment groups (n = 10). One group received an immunization of adjuvant only on days 0 and 153 (control), a second group received an immunization with a 3-methanogen mix on days 0 and 153 (VF3 + 3), and a third group received an immunization of a 7-methanogen mix on day 0 followed by a 3-methanogen mix on day 153 (VF7 + 3). Four weeks post-secondary immunization, there was a significant 7.7% reduction in methane production per kg dry matter intake in the VF7 + 3 group compared to the controls (P = 0.051). However, methane emissions from sheep immunized with VF7 + 3 were not significantly different when compared to the sheep in the control group (P = 0.883). The average IgG and IgA antibody titres in both plasma and saliva of the VF3 + 3 immunized sheep were four to nine times higher than those immunized with VF7 + 3 (P< 0.001) at both 3 and 6 weeks post-secondary immunization. Data also revealed that SF6 methane estimates were consistently higher than the respiration chamber estimates and that there was no significant correlation between the SF6 methane estimates and the respiration chamber methane estimates (R2 = 0.11).

Assessment of the bradyphrenia of parkinsonism: a novel use of delayed auditory feedback.

Sufferers from parkinsonism have difficulty shifting or developing an appropriate mental set. Delayed auditory feedback may, therefore, disrupt their speech more than that of healthy controls. This was the case when 104 subjects with idiopathic parkinsonism and 144 without were compared. Moreover, the disruptive effect was complementary, in discriminating between those with and without clinical parkinsonism, to the response in reaction time to a warning. Unlike the latter, the disruption caused by delayed auditory feedback appeared independent of mental test score results and uninfluenced by consumption of tobacco or anti-parkinsonian therapy. Neither were influenced by a rating of affect. More precise delineation of the mental disorders of parkinsonism is needed in clinical practice, set against background information on prognosis and drug responsiveness.

Quantification of the cardinal signs of parkinsonism and of associated disability in spouses of sufferers.

Work on the causation of idiopathic parkinsonism is limited by relying on gross clinical definition and lack of studies in the old. A prognostic index for parkinsonism, based on hypo/bradykinesia of gait, had considerably higher values in spouses of 20 aged suffers, who had been cohabiting for about half a century, than in 40 controls. Postural abnormality, measured by standing sway and foot separation during walking, was also greater in these spouses. Marked differences remained after correction for relevant covariates. A blinded rigidity rating was greater in the spouses of sufferers, tremor rating was not. The differences found are difficult to explain by selective mating, learned or reactive behaviour. This suggests that environmental causative influences operate in adult life.

Could seborrhoeic dermatitis be implicated in the pathogenesis of parkinsonism?

The spouses of a group of aged sufferers have been demonstrated to have multifarious differences relevant to parkinsonism from matched controls, which were difficult to explain by selective mating, learned or reactive behaviour. Could parkinsonism be transmissible? The frequency of inflammation and scaling on head or neck was greater (P = 0.05) in these spouses (19 available) than in controls (36), the best discriminating site of inflammation being scalp (P = 0.02). Both seborrhoeic dermatitis and overt, or pre-clinical, parkinsonism occurred in sufferers and spouses: to presume they are not causally related is to accept multiple entities. In favour of seborrhoeic dermatitis being causal for parkinsonism, rather than vice versa, is the involvement of a known organism, Pityrosporum ovale, in the dermatitis, and that the evidence of parkinsonism in the spouses indicated that they were only part way down the path towards the clinical condition.