Improving the 'Golden Patient' Initiative at a British Major Trauma Centre: A Single-Centre Study.

Introduction Delays in theatre start times are expensive and associated with poor outcomes. To reduce these delays, a Golden Patient (GP) protocol was used at one of Britain's major trauma centres, the Queen Elizabeth University Hospital, Glasgow. We sought to clarify how often Golden Patients (GPs) were stepped down from being first on the day's trauma list and to identify significant contributing factors.  Methods We collected data over an eight-week period, with 80 GPs collated in total. If stepped down, we recorded their age, gender, injury, location, and day of planned surgery. Univariate analyses were then performed to test for statistical significance. We also followed stepped-down patients, noting how long until they received their operation. Results The incidence of GPs stepped down from being first on the list was 11.25%. This did not vary with age, gender, or type of injury, but was significantly associated with patients being at home the night before their planned operation (p=0.0114) and cases occurring on Fridays (p=0.0139). Of those stepped-down GPs who remained for operative management, all received their operation within one day. Conclusion This study, the first of its kind since the COVID-19 pandemic, shows low rates of GP step down, comparable to previous audits of GP initiatives in similar centres. When delays did occur, GPs received timely operative management once underlying issues were resolved. This study suggests that planned GPs should be admitted the night before their operation. Whilst the GP system serves trauma patients well, we identified areas for improvement in the efficiency of our own service applicable to other busy major trauma centres.

Bismuth Ferrite-Silver Nanowire Flexible Nanocomposites for Room-Temperature Nitrogen Dioxide Sensing.

Nitrogen dioxide (NO2) is a major pollutant, causing acid rain, photochemical smog, and respiratory damage. The annual safe limit is 50 parts per billion (ppb), while concentrations exceeding 1 part per million (ppm) can result in respiratory ailments. Conventionally, n-type metal oxide semiconductors operating at elevated temperatures have been utilized for NO2 detection. Recently, p-type semiconductors with their hole accumulation layer, rapid recovery post-gas exposure, and good humidity tolerance are being investigated as potential NO2 sensors, once again working at elevated temperatures. In this work, a room-temperature (27 ± 2 °C) NO2 sensor is demonstrated by using a nanocomposite based on p-type bismuth ferrite (BFO) nanoparticles and silver nanowires (Ag NWs). This nanocomposite is capable of sensing a NO2 gas concentration of up to 0.2 ppm. The BFO nanoparticles are synthesized via a sol-gel route followed by sintering at 500 °C to form the crystalline phase. Nanocomposites are obtained by formulating a dispersion of the BFO nanoparticles and Ag NWs, followed by direct writing on both flexible and rigid substrates. The Ag NWs act as the conducting pathway, reducing the overall electrical resistance and thus enabling room-temperature operation. X-ray diffraction, scanning electron microscopy, and surface area studies provide phase information and surface morphology, and the porous nature of the film helps in room-temperature gas adsorption. The current-voltage and gas-sensing behavior are studied to obtain the optimized molar ratio (4:1 BFO/Ag NWs) for the sensor. The sensor deposited on poly(ethylene terephthalate) (PET) also works under a bent condition, indicating good flexibility. Rapid NO2 sensing was achieved in a BFO-Ag/PET device with response/recovery times of 7/8.5 s and 12/15 s in straight and bent geometries, respectively. Additionally, a good sensitivity of 30 to 60% was achieved for the BFO-Ag/PET device across 100 to 1000 ppb of NO2. The development of a nanocomposite combining an active sensing element (BFO) and a charge-transport element (Ag NWs) opens up a multitude of other application areas.

Lesser prevalence of polyps/WNT-dysregulation and concomitant upregulation of gamma-catenin/MYC point to alternate pathways in colorectal cancer in India.

Colorectal cancer (CRC) is known to follow adenoma carcinoma sequence (ACS) in majority of the tumors and the driver variants and associated pathways are well delineated. However, most of the published data are from the west and information in other ethnicities is sparse. We therefore comprehensively evaluated the CRC tumors from Indian ethnicity for the prevalence of ACS. In this cohort study, clinical data of 100,497 patients who attended hospital between 2013 and 2018 were accessed. Tumors from patients (n = 130) with CRC who were treated primarily by surgery were included. DNA and RNA were isolated to assess variants (direct sequencing) and WNT-pathway dysregulation in genes related to ACS. Global gene expression was generated and analyzed on microarrays (Affymetrix; N = 10) and next generation sequencing platforms (Illumina; N = 25). Gene expression at mRNA (qRT-PCR) and protein level (IHC) of JUP/CTNNB1/MYC were assessed. Correlation between expression of JUP and MYC was evaluated by Karl Pearson's correlation coefficient. The prevalence of polyps was 16.75%, while 18.26% variants in APC/CTNNB1, 20.00% in KRAS, and 18.33% WNT dysregulation were noted. Interestingly, 29/60 (48.33%) tumors showed only MYC upregulation with normal APC/CTNNB1 expression. Global gene expression and validation in an independent tumor cohort confirmed concomitant upregulation of JUP (gamma-catenin) & MYC (r = 0.71; p = 0.001) at mRNA and protein in sizeable number of tumors (45/96; 46.88%). Our study provides evidence for limited prevalence of ACS in the Indian ethnicity. Preventive colonoscopies for early identification and management of CRC may not be an effective strategy in this ethnicity.

Indocyanine green guided sentinel lymph node biopsy may have a high sensitivity for early (T1/T2) colon cancer: A prospective study in Indian patients.

Objectives: Indocyanine green (ICG) dye guided near infrared fluorescence (NIR) imaging is a promising tool for mapping lymphatics. The aim of this study was to evaluate the role of ICG guided SLN biopsy in Indian colon cancer patients. Material and Methods: Forty-eight patients of clinically staged T1-T3 node negative colon cancer underwent laparoscopic/open resection. Patients received colonoscopic peritumoral submucosal ICG injections for laparoscopic (n= 32) and subserosal injections for open resections (n= 16) followed by the detection of SLN using NIR camera. SLNs underwent conventional hematoxylin and eosin (H & E) staging with additional serial sectioning and immunohistochemistry for pancytokeratin antibody (ultra-staging). Detection rate and upstaging rate were the primary end points. Results: Forty-eight patients were recruited. An average of 2.08 ± 1.27 SLNs were identified in 45 patients at a mean time of 8.2 ± 3.68 minutes with a detection rate of 93.75%. Mean age and mean BMI were 59.7 ± 12.54 years and 24.8 ± 4.09 kg/m2 , respectively. Eighteen patients had node positive disease, and SLN was false negative in four of these patients resulting in a sensitivity of 77.77% with a trend towards higher sensitivity for T1-T2 tumours (90% vs. 62.5%, p= 0.068). Upstaging rate was 10%. Negative predictive value (NPV) and accuracy of the procedure were 87.09% and 91.11%, respectively. Conclusion: ICG guided SLN biopsy can identify metastatic lymph nodes in colon cancer patients that can be missed on H & E staging with relatively higher sensitivity for early (T1/T2) tumours.

Cement-in-cement versus uncemented modular stem revision for Vancouver B2 periprosthetic fractures.

Background: To compare outcomes of revision to a long uncemented stem with cement-in-cement revision for Vancouver B2 periprosthetic fracture (PPF). Methods: Patients undergoing surgery for a Vancouver B2 PPF in a cemented stem from 2008 to 2018 were identified using our prospectively collated database. Results: We identified 43 uncemented and 29 cement-in-cement revisions. Cement-in-cement revision had a shorter operative time, reduction in certain complications, no increased rate of non-union, lower degree of stem subsidence and no difference in re-revision rate. Conclusion: With appropriate patient selection, both cement-in-cement and long uncemented stem revision represent appropriate treatment options for Vancouver B2 fractures.

Driving reaction time following periacetabular osteotomy.

INTRODUCTION: Periacetabular osteotomy (PAO) is increasingly being used to treat young adults with symptomatic hip dysplasia. Currently there is a lack of evidence to guide return to driving after this procedure. This study aimed to identify the length of time required after a Periacetabular Osteotomy procedure before a patient can safely return to driving. METHODS: All patients undergoing PAO were assessed for suitability for the study. Inclusion criteria were: currently driving with a valid licence; and being able to attend follow-up assessment. Baseline driving reaction time was assessed using a driving simulator preoperatively. The simulation was repeated 5 times for each patient and reaction times recorded (Thinking time, Action time and Total reaction time for braking at 30 mph). The driving simulation was repeated using the same methods at 6 weeks and 12 weeks postoperatively. Pre- and postoperative times were compared. RESULTS: 26 patients were included (24 females, 2 males) with a mean age of 32 (range 19-50) years. The mean preoperative times were: Thinking time 0.48, Action time 0.21, Total time 0.69 seconds. At 6 weeks postoperatively, mean Action time increased to 0.26 seconds (p = 0.012) and mean Total time increased to 0.78 seconds (p = 0.013). By 12 weeks post procedure, there was no significant difference in reaction times compared to baseline (mean Thinking time 0.47 seconds, Action time 0.23, Total time 0.72; p > 0.05). CONCLUSIONS: Most patients may not be safe to drive at 6 weeks following PAO procedures but should be safe to drive at 12 weeks postoperatively. Individual patient factors should also be taken into consideration.

Musculoskeletal sarcoidosis: A single center experience over 15 years.

BACKGROUND: Musculoskeletal (MSK) sarcoidosis presents with a variety of clinical phenotypes. Four subtypes of MSK sarcoidosis have been identified to date: Lofgren syndrome, chronic sarcoid arthritis, osseous sarcoidosis, sarcoid myopathy. Each subtype has been reported with varying incidence mainly due to lack of universal classification criteria. METHODS: We performed a retrospective chart review of patients with MSK sarcoidosis at a single academic center between January 2000 and December 2014. Descriptive statistics were used to describe the proportion of patients with sarcoidosis who had the 4 MSK syndromes of interest, demographic characteristics and therapeutic agents used. RESULTS: A cohort of 58 patients with MSK manifestations were identified among 1016 patients with sarcoidosis. Frequency of subtypes include: Lofgren syndrome 46.6%, osseous sarcoidosis 25.9%, chronic sarcoid arthritis 24.1% and sarcoid myopathy 6.9%. The cohort was predominantly female (43/58 patients, 74%) and Caucasian (48/58 patients, 82.8%). Mean age was 47.2 years. One patient had overlap of osseous sarcoidosis and chronic sarcoid arthritis, another patient initially had Lofgren syndrome and later developed chronic sarcoid arthritis. Sarcoid myopathy patients presented with myalgia more often than muscle weakness. CONCLUSION: We identified a large cohort of MSK sarcoidosis and determined the prevalence of all 4 subtypes. In patients who do develop MSK manifestations of sarcoidosis, they are commonly a part of the initial presentation of sarcoidosis. There is an unmet need to establish standardized classification criteria for the 4 MSK sarcoidosis syndromes.

Obesity is associated with higher complication rates in revision total hip arthroplasty.

We examined differences in complication rates between obese and non-obese patients undergoing revision total hip arthroplasty. Sixty-five patients with a BMI ≥30 kg/m2 and 54 patients with a BMI of <30 kg/m2 were identified. Obese patients were 2.5 times more likely to suffer a complication than non-obese (38.4% cf 14.8%, p = 0.02). Obese patients were more likely to experience dislocation, leg length discrepancy, fracture, implant loosening, infection and pulmonary embolus. The obese group had a significantly higher revision rate (12.3% cf 1.8%, p = 0.039). Obese patients should be counselled pre-operatively on their elevated risk.

Microwave-assisted synthesis of novel 5-substituted benzylidene amino-2-butyl benzofuran-3-yl-4-methoxyphenyl methanones as antileishmanial and antioxidant agents.

A series of 5-substitutedbenzylideneamino-2-butylbenzofuran-3-yl-4-methoxyphenyl methanones is synthesized and evaluated for antileishmanial and antioxidant activities. Compounds 4f (IC50 = 52.0 ±â€¯0.09 µg/ml), 4h (IC50 = 56.0 ±â€¯0.71 µg/ml) and 4l (IC50 = 59.3 ±â€¯0.55 µg/ml) were shown significant antileishmanial when compared with standard sodium stibogluconate (IC50 = 490.0 ±â€¯1.5 µg/ml). Antioxidant study revealed that compounds 4i (IC50 = 2.44 ±â€¯0.47 µg/ml) and 4l (IC50 = 3.69 ±â€¯0.44 µg/ml) have shown potent comparable activity when compared with standard ascorbic acid (IC50 = 3.31 ±â€¯0.34 µg/ml). Molecular docking study was carried out which replicating results of biological activity in case of initial hits 4f and 4h suggesting that these compounds have a potential to become lead molecules in drug discovery process. In silico ADME study was performed for predicting pharmacokinetic profile of the synthesised antileishmanial agents and expressed good oral drug like behaviour.

Delays in diagnosis are associated with poorer outcomes in adult hip dysplasia.

Background and Aims Developmental dysplasia of the hip is a common cause of osteoarthritis. Periacetabular osteotomy can restore femoral head coverage; however, it is reserved for patients with minimal articular degeneration. We examined the relationship between delays in diagnosis and outcomes. Methods We identified patients presenting to a hip specialist with a new diagnosis of hip dysplasia. The time taken between patients presenting to their general practitioner and attending the young adult hip clinic was established. Patients were stratified into Early, Moderate and Late Referral groups. Hip and SF-12 questionnaires were completed. Radiographs were graded according to the Tönnis classification system and the outcome following hip specialist review documented. Results Fifty-one patients were identified. Mean time from attending a general practitioner to review at the young adult hip clinic was 40.4 months. Lower hip and SF-12 scores, and higher radiological osteoarthritis grades were found in the Moderate and Late Referral groups. A higher proportion of the Moderate and Late Referral group underwent total hip arthroplasty rather than periacetabular osteotomy. Conclusion Delays in referring a patient to a hip specialist are associated with poorer outcomes. We propose pelvic radiographs are requested early by general practitioners to allow prompt diagnosis and referral to a hip specialist.

Antileishmanial potential of fused 5-(pyrazin-2-yl)-4H-1,2,4-triazole-3-thiols: Synthesis, biological evaluations and computational studies.

A series of newer 1,2,4-triazole-3-thiol derivatives 5(a-m) and 6(a-i) containing a triazole fused with pyrazine moiety of pharmacological significance have been synthesized. All the synthesized compounds were screened for their in vitro antileishmanial and antioxidant activities. Compounds 5f (IC50=79.0µM) and 6f (IC50=79.0µM) were shown significant antileishmanial activity when compared with standard sodium stibogluconate (IC50=490.0µM). Compounds 5b (IC50=13.96µM) and 6b (IC50=13.96µM) showed significant antioxidant activity. After performing molecular docking study and analyzing overall binding modes it was found that the synthesized compounds had potential to inhibit L. donovani pteridine reductase 1 enzyme. In silico ADME and metabolic site prediction studies were also held out to set an effective lead candidate for the future antileishmanial and antibacterial drug discovery initiatives.

Locoregional Therapy With Curative Intent Versus Primary Liver Transplant for Hepatocellular Carcinoma: Systematic Review and Meta-Analysis.

BACKGROUND: Locoregional therapy with curative intent (CLRT) followed by salvage liver transplantation (SLT) in case of hepatocellular carcinoma (HCC) recurrence is an alternative to primary liver transplantation (LT) in selected patients with HCC. METHODS: We performed a systematic review and meta-analysis of studies comparing the survival of patients treated with CLRT versus LT, stratified by the stage of liver disease, extent of cancer, and whether SLT was offered or not. RESULTS: We included 48 studies involving 9835 patients (5736 patients with CLRT and 4119 patients with primary LT). Five-year overall survival (OS) and disease-free survival (DFS) was worse for all categories of CLRT combined, than for primary LT (odds ratio [OR] for OS, 0.59; 95% confidence interval [CI], 0.48-0.71; P < 0.01). However, 5-year OS for CLRT and primary LT was not significantly different among patients with (i) Child-A cirrhosis and (ii) single HCC lesion, although DFS was worse. When SLT was offered after CLRT, intention-to-treat analysis showed no significant difference in 5-year OS (OR, 1.0; 95% CI, 0.6-1.7) between CLRT-SLT and primary LT, though noninferiority could not be shown. Only 32.5% patients with HCC recurrence after CLRT actually received SLT, as the rest were not medically eligible. Thus, the DFS was worse with CLRT-SLT (OR, 0.31; 95% CI, 0.2-0.6) compared with LT. CONCLUSIONS: CLRT-SLT may be offered as first-line therapy to patients with HCC and well-compensated cirrhosis instead of primary LT because it may lead to better utilization of donor liver. However, a large proportion of patients with HCC recurrence after CLRT may not be candidates for SLT.

Noise production in ceramic-on-ceramic total hip arthroplasty is associated with lower patient satisfaction and hip scores.

BACKGROUND: Ceramic-on-ceramic total hip arthroplasties (THA) are commonly implanted. We investigated the incidence of noise in ceramic-on-ceramic and determined any association with patient satisfaction and hip scores. METHODS: We recruited 140 THA. Questionnaires were completed to assess the incidence and frequency of noise, and satisfaction level. Hip and SF-12 scores were recorded. RESULTS: Forty-two patients (30%) were aware of noise production. Patients with noise production had lower satisfaction, mean hip and SF-12 scores than those with silent hips. CONCLUSION: Given the high incidence of noise in ceramic-on-ceramic THA, patients should be counselled on this risk pre-operatively.

Use of the trochanteric flip osteotomy to facilitate internal fixation of a femoral head fracture.

We report the case of a 42-year-old male who suffered a fracture-dislocation of the femoral head. After a closed reduction of the hip, this proceeded to an open reduction with internal fixation of the fractured femoral head, in addition to labral repair and micro-fracture of an articular cartilage defect. After considering the risks to the femoral head blood supply, the trochanteric flip osteotomy was used. This provided ample and safe exposure. At 14 months follow-up, the patient-reported outcome measures are favourable: modified Harris Hip Score (81/100), the non-arthritic hip score (92.5/100) and SF-12 (41/48).

Surgical dislocation of the hip for excision of benign tumours.

AIM: Surgical dislocation of hip is used to treat a variety of hip conditions. We report our experience of the approach in excision of benign tumours of the hip. METHODS: This is a review of the cases presenting with benign tumours to a tertiary care complex hip clinic. Data was collected prospectively. All patients were radiologically investigated before surgery for anatomical detail. Surgical dislocation was carried out by the senior surgeon in all cases. Non-Arthritic Young Hip Scores were done preoperatively and at 12 months. All patients are under annual follow-up. RESULTS: There were 9 cases of benign tumours in this series including Pigmented Villonodular Synovitis (2), synovial chondromatosis (2), fibrous dysplasia (2), osteochondroma (2) and chondroblastoma (1). No recurrences, trochanteric nonunion or avascular necrosis have been seen up to a minimum of 18 months follow-up. Non-arthritic Young Hip scores improved from a mean of 45 to 89 at 12 months. CONCLUSION: Surgical dislocation of the hip is a useful approach for removal of benign tumours of the hip joint.

Psychosocial aspects of hip disease in the young adult.

The psychosocial impact of hip disease on the young adult has not been elucidated. This study aimed to identify the functional and psychosocial characteristics of a cohort of young patients (age less than 40 years) presenting to our tertiary care complex hip clinic. A postal questionnaire comprising of a Visual Analogue Scale (VAS) for Pain, the Oswestry Disability Index (ODI) and the Hospital Anxiety and Depression Scale (HADS) was posted to 63 patients. Forty-nine (n = 49) patients (79%) responded to the questionnaire. Mean age was 20 years (range 16-38) with a gender ratio of 2:1 (female: male). More than half of our patients had moderate to severe pain based on the VAS and at least moderate disability on the ODI. HADS showed that 32% and 49% of patients were classified as having borderline to abnormal levels of depression and anxiety respectively. Multiple regression showed ODI scores to be a significant predictor of anxiety and depression. Comparison with asymptomatic controls shows that these patients have significantly worse ODI and HADS scores compared to normal population. This study quantifies the degree of functional and psychosocial compromise present in young patients with hip problems.

A positive hip arthrogram may predict lower function in patients with primary hip arthroplasty.

BACKGROUND: A local anesthetic hip arthrogram is a simple test mainly used as an adjunct to define the origin of hip pain. Temporary pain relief (a positive response) following an injection may lead to a surgeon recommending hip surgery. However, it is unclear whether relief of pain corresponds to better postoperative pain relief or function. QUESTIONS/PURPOSES: We therefore compared the function in patients with a positive response to a local anesthetic hip arthrogram who underwent primary THA and patients with typical osteoarthritis presentation who underwent primary THA without a preoperative arthrogram. METHODS: We retrospectively reviewed 22 patients who had a positive response to a local anesthetic hip arthrogram who subsequently underwent primary hip arthroplasty and a control group of 74 patients who had typical osteoarthritis hip pain and subsequent primary hip arthroplasty without having a previous arthrogram. All patients completed the Oxford Hip Score, WOMAC™ function short form, and the SF-12 preoperatively and at regular clinical followups. The minimum followups were 28 months (mean, 42 months; range, 28-72 months) for the study group and 33 months (mean, 52 months; range, 33-73 months) for the control group. RESULTS: Patients in the arthrogram group had lower mean functional scores: 30 versus 39 for the Oxford Hip Score, 39 versus 46 for the WOMAC™, and 36 versus 42 for the physical component of the SF-12. CONCLUSIONS: Preoperative use of a local anesthetic hip arthrogram remains an important tool to differentiate spinal disorders or confirm the hip as the cause of pain. However, patients who have a preoperative hip arthrogram to clarify symptoms may report a lower function score and pain relief than patients who do not.

A novel technique for femoral canal occlusion during cement pressurization in proximal femoral arthroplasty.

We describe a novel technique for occluding the femoral canal distal to the isthmus during proximal femoral arthroplasty. Synthetic bone models were reamed and sectioned to simulate loss of the proximal femur. Two experimental conditions were used. The first used no restrictor to act as a control. The second used calcium sulphate pellets impacted in distal femoral canal. A 100 × 12 mm Limb Preservation System stem (DePuy, Leeds, UK) was used in all experiments. We recorded cement pressure, leakage of cement, and penetration of cement into the femoral condyles. The calcium sulphate pellets prevented cement leakage, enabled higher cementing pressures, and prevented penetration of the cement into the femoral condyles. We would recommend this technique in cases where loss of proximal femoral bone loss requires the use of a cemented proximal femoral replacement.

Improving the accuracy of acetabular cup implantation using a bulls-eye spirit level.

Acetabular introducers have a built-in inclination of 45 degrees to the handle shaft. With patients in the lateral position, surgeons aim to align the introducer shaft vertical to the floor to implant the acetabulum at 45 degrees. We aimed to determine if a bulls-eye spirit level attached to an introducer improved the accuracy of implantation. A small circular bulls-eye spirit level was attached to the handle of an acetabular introducer. A saw bone hemipelvis was fixed to a horizontal, flat surface. A cement substitute was placed in the acetabulum and subjects were asked to implant a polyethylene cup, aiming to obtain an angle of inclination of 45 degrees. Two attempts were made with the spirit level masked and two with it unmasked. The distance of the air bubble from the spirit level's center was recorded by a single assessor. The angle of inclination of the acetabular component was then calculated. Subjects included both orthopedic consultants and trainees. Twenty-five subjects completed the study. Accuracy of acetabular implantation when using the unmasked spirit level improved significantly in all grades of surgeon. With the spirit level masked, 12 out of 50 attempts were accurate at 45 degrees inclination; 11 out of 50 attempts were "open," with greater than 45 degrees of inclination, and 27 were "closed," with less than 45 degrees. With the spirit level visible, all subjects achieved an inclination angle of exactly 45 degrees. A simple device attached to the handle of an acetabular introducer can significantly improve the accuracy of implantation of a cemented cup into a saw bone pelvis in the lateral position.

Fracture of an Exeter 'cement in cement' revision stem: a case report.

The 'cement in cement' technique for revision hip arthroplasty has become popular in recent years, particularly in relation to polished taper stems. Since 2006 a short Exeter stem with 44 mm offset has been available specifically for this purpose. We report a fracture of such a stem in the absence of trauma 5 years after the revision procedure. The patient had a BMI of 27.8 and the proximal cement mantle gave good support to the stem. The fracture initiated and propagated from the introducer hole on the shoulder of the prosthesis. Macroscopically there was no defect in this area. This may be an unusual case of fatigue failure.