Heated birthing pools as a source of Legionnaires' disease.

In June 2014 Public Health England confirmed a case of Legionnaires' disease (LD) in a neonate following birth at home in a hired birthing pool incorporating a heater and a recirculation pump which had been filled in advance of labour. The case triggered a public health investigation and a microbiological survey of an additional ten heated birthing pools hired or recently hired to the general public across England. The birthing pool used by the parent of the confirmed case was identified as the source of the neonate's infection following detection of Legionella pneumophila ST48 in both patient and environmental samples. Legionella species were detected by quantitative polymerase chain reaction but not culture in a further three pools together with other opportunistic pathogens identified by culture and matrix-assisted laser desorption ionization-time of flight (MALDI-ToF) mass spectrometry. A Patient Safety Alert from NHS England and Public Health England was issued stating that heated birthing pools filled in advance of labour should not be used for home births. This recommendation remains in place. This investigation in conjunction with other recent reports has highlighted a lack of awareness regarding the microbiological safety of heated birthing pools and their potential to be a source of LD and other opportunistic infections. Furthermore, the investigation raised important considerations with regards to microbiological sampling and testing in such incidents. Public health authorities and clinicians should consider LD in the differential diagnosis of severe respiratory infection in neonates within 14 days of a water birth.

Case of Legionnaires disease in a neonate following a home birth in a heated birthing pool, England, June 2014.

Public Health England was notified of Legionnaires' disease in a neonate following a home birth in a heated birthing pool filled from the domestic hot water supply two weeks earlier. We describe the incident, sampling results, and public health actions. It is recommended that heated birthing pools should not be used for home births. Neonates developing pneumonia within 14 days of labour or birth in any birthing pool should be tested for Legionnaires' disease.

Protection of the environment.

The International Commission on Radiological Protection's (ICRP) system to protect the living components of the environment is designed to provide a broad and practical framework across different exposure situations. The framework recognises the need to be able to demonstrate an adequate level of protection in relation to planned exposure situations, whilst also providing an ability to manage existing and emergency situations in an appropriate way. In all three exposure situations, the release of radionuclides into the natural environment leads to exposures of non-human biota (wildlife), as well as having the potential for exposures of the public. How the key principles of the ICRP system of radiological protection apply in each of these exposure situations will be discussed. Using examples, we will demonstrate how the overall approach provides a mechanism for industry to assess and demonstrate compliance with the environmental protection objectives of relevant (national) legislation, and to meet stakeholder expectations that radiological protection of the environment is taken into consideration in accordance with international best practice. However, several challenges remain, and these will be discussed in the context of the need for additional guidance on the protection of the environment.

Zinc from foliar-applied nanoparticle fertiliser is translocated to wheat grain: A 65Zn radiolabelled translocation study comparing conventional and novel foliar fertilisers.

Foliar zinc (Zn) fertilisers can be used to supplement or replace soil applications of Zn in situations where soil properties may decrease the plant bioavailability of Zn. However, conventional foliar Zn formulations such as zinc sulfate can cause leaf damage due to the rapid release of high amounts of Zn2+ into leaf tissue which can be locally phytotoxic. Zinc oxide nanoparticles (ZnO-NPs) offer an alternative approach by providing a more sustained release of Zn into leaf tissue, and potentially avoiding the need for multiple applications. We compared the efficacy of ZnO-NPs and microparticles (ZnO-MPs) to that of conventional formulations (ZnCl2 and ZnEDTA) in wheat. This is the first study to use 65Zn radiolabelled formulations and gamma spectrometry to determine the translocation of Zn to the grains and subsequent efficiency of foliar-applied ZnO-NP fertilisers. We found that ZnEDTA was the most efficient fertiliser in terms of the proportion of applied Zn translocated to wheat grain. We also investigated the effect of Zn application rate on fertiliser efficiency. For all forms of Zn, when plants were treated with Zn at 750 mg/L or 75 mg/L, there were no significant differences in the concentration of applied Zn translocated to the grain. This suggests that current Zn application rates could be decreased while still maintaining the nutritional quality of grain. Finally, using photo-stimulated luminescence (PSL) autoradiography and synchrotron-based X-ray fluorescence microscopy (XFM) we showed that the grain distribution of foliar-applied Zn mirrors that of Zn derived from root uptake.

Diabetic patients are almost twice as likely to experience complications from arthroscopic rotator cuff repair.

AIMS: Large population-based studies have demonstrated increased prevalence of rotator cuff disease amongst diabetics. Recent studies have suggested comparable clinical outcomes from rotator cuff repair despite suggestions of increased complication rates amongst diabetics. However, there is a relative paucity of studies considering the effect of diabetes upon complication rate. We aim to report and quantify the effect of diabetes on complication rates following arthroscopic rotator cuff repair. MATERIALS AND METHODS: A retrospective review of a consecutive series of patients undergoing arthroscopic rotator cuff repair between January 2011 and December 2014 was performed. Diabetic status and complication data defined as infection, frozen shoulder, re-tear or re-operation were collected and interrogated. RESULTS: A total of 462 patients were included at median follow-up of 5.6 years. Diabetics were significantly more likely to experience frozen shoulder (15.8% vs. 4.4%, p = 0.001), re-tear (26.3% vs. 15.6%, p = 0.042) or at least one complication following surgery (35.1% vs. 22.7%, p = 0.041) compared to non-diabetics. These equated to odds ratios of 4.03, 1.94 and 1.84, respectively. CONCLUSIONS: Diabetic patients are almost twice as likely to experience complications following arthroscopic rotator cuff repair, including double the risk of repair failure and more than four times the risk of frozen shoulder.

Continuing acromioclavicular joint pain after excision arthroplasty: is further surgery effective?

BACKGROUND: Little published evidence exists on the incidence of continuing acromioclavicular joint pain with no published outcomes for revision surgery. This study aimed to establish the incidence and outcomes of revision acromioclavicular joint excision surgery. MATERIALS AND METHODS: A consecutive retrospective cohort of patients undergoing revision arthroscopic or open acromioclavicular joint excision was identified. Patients were identified from a prospectively collected database. Inclusion criteria were revision acromioclavicular joint excisions over a 14-year period between 2001 and 2015. Exclusion criteria were previous surgery for acromioclavicular joint instability or shoulder arthroplasty. Outcome measures were Oxford Shoulder scores and a satisfaction survey. RESULTS: Forty-three consecutive cases of revision acromioclavicular joint excision over 14 years (37 after arthroscopic excision with subacromial decompression, 5 after arthroscopic excision with rotator cuff repair, 1 after open excision). Continuing acromioclavicular joint pain was associated with incomplete resection from arthroscopic surgery, which was the primary indication for revision surgery. Revision occurred a mean 14.2 months after primary surgery (standard deviation 7.6 months). Mean Oxford Shoulder score was preoperatively 18 (standard deviation 8.1) and 23.4 (standard deviation 11.1) after primary surgery, which did not reach significance until after revision surgery with a mean 31.7 (standard deviation 13.6; P = 0.021). Median follow up was 15 months (interquartile range 4-31 months). A survey at a mean of 6 years (standard deviation 2.3) post-revision surgery found that 65% of patients felt improved, 77% would have their surgery again and 69% of patients felt satisfied. The incidence of postoperative frozen shoulder was 14.3%. CONCLUSION: Functional outcomes after revision surgery showed improvement from scores taken before primary surgery; however, long-term satisfaction rates were relatively low.

Plutonium and other radionuclides persist across marine-to-terrestrial ecotopes in the Montebello Islands sixty years after nuclear tests.

Since the 1956 completion of nuclear testing at the Montebello Islands, Western Australia, this remote uninhabited island group has been relatively undisturbed (no major remediations) and currently functions as high-value marine and terrestrial habitat within the Montebello/Barrow Islands Marine Conservation Reserves. The former weapons testing sites, therefore, provide a unique opportunity for assessing the fate and behaviour of Anthropocene radionuclides subjected to natural processes across a range of shallow-marine to island-terrestrial ecological units (ecotopes). We collected soil, sediment and biota samples and analysed their radionuclide content using gamma and alpha spectrometry, photostimulated luminescence autoradiography and accelerator mass spectrometry. We found the activity levels of the fission and neutron-activation products have decreased by ~hundred-fold near the ground zero locations. However, Pu concentrations remain elevated, some of which are high relative to most other Australian and international sites (up to 25,050 Bq kg-1 of 239+240+241Pu). Across ecotopes, Pu ranked from highest to lowest in the following order: island soils > dunes > foredunes > marine sediments > and beach intertidal zone. Low values of Pu and other radionuclides were detected in all local wildlife tested including endangered species. Activity concentrations ranked (highest to lowest) terrestrial arthropods > terrestrial mammal and reptile bones > algae > oyster flesh > whole crab > sea turtle bone > stingray and teleost fish livers > sea cucumber flesh > sea turtle skin > teleost fish muscle. The three detonations (one from within a ship and two from 30 m towers) resulted in differing contaminant forms, with the ship detonation producing the highest activity concentrations and finer more inhalable particulate forms. The three sites are distinct in their 240/239Pu and 241/239Pu atom ratios, including the Pu transported by natural process or within migratory living organisms.

Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes.

OBJECTIVE: To describe recent trends in prevalence, outcomes and indicators of care for women with pre-existing type I or type II diabetes. DESIGN: Regional population-based survey. SETTING: All maternity units in the North of England. POPULATION: A total of 1258 pregnancies in women with pre-existing diabetes delivered between 1996 and 2004. METHODS: Data from the Northern Diabetic Pregnancy Survey. Outcome of pregnancy cross-validated with the Northern Congenital Abnormality Survey and the Northern Perinatal Mortality Survey. MAIN OUTCOME MEASURES: Perinatal mortality, congenital anomaly and total adverse perinatal outcome (perinatal mortality and live births with congenital anomaly). RESULTS: The prevalence of pregestational diabetes increased from 3.1 per 1000 births in 1996-98 to 4.7 per 1000 in 2002-04 (test for linear trend, P < 0.0001), driven mainly by a sharp increase in type II diabetes. Perinatal mortality declined from 48 per 1000 births in 1996-98 to 23 per 1000 in 2002-04 (P = 0.064). There was a significant reduction in total adverse perinatal outcome rate (P = 0.0194) from 142 per 1000 in 1996-98 to 86 per 1000 in 2002-04. There were substantial improvements in indicators of care before and during pregnancy and in glycaemic control throughout pregnancy, but indicators of preconceptual care, such as use of folic acid, remained disappointing. CONCLUSION: We observed improvements in pregnancy care and outcomes for women with diabetes in a region with an established audit and feedback cycle. There remains considerable scope for further improvement, particularly in periconceptual glycaemic control. The rising prevalence of type II diabetes presents a challenge to further improvement.

Selenium speciation influences bioaccumulation in Limnodynastes peronii tadpoles.

Despite being essential for animal health and fitness, Se has a relatively narrow range between deficiency and toxicity, and excess Se can cause a variety of adverse effects in aquatic organisms. Amphibians are particularly vulnerable to contaminants during larval aquatic life stage, because they can accumulate toxic ions through various routes including skin, gills, lungs and digestive tract. Few attempts have been made to understand the tissue-specific accumulation of trace elements, including the impacts of chemical speciation in developing amphibian larvae. We used radiolabelled 75Se to explore the biokinetics and tissue distributions of the two dominant forms occurring in surface waters, selenite (SeIV) and selenate (SeVI). Tadpoles of the native Australian frog Limnodynastes peronii were exposed to Se in both forms, and live-animal gamma spectroscopy was used to track accumulation and retention over time. Tissue biodistributions were also quantified at the end of the uptake and depuration phases. Results showed the bioconcentration of SeIV to be 3 times greater compared to SeVI, but rates of elimination were similar for both forms. This suggests a change of Se speciation within the organism prior to excretion. Depuration kinetics were best described by a one-phase exponential decay model, and tadpoles retained approximately 19% of the accumulated Se after 12 days of depuration in clean water. Selenium bioaccumulation was greatest in digestive and excretory organs, as well as the eye, which may directly relate to previously reported Se-induced impairments. Results demonstrate how the use of radiotracing techniques can significantly improve our understanding of trace element toxicokinetics and tissue distributions in developing amphibians. From an environmental monitoring perspective, the findings highlight the importance of considering chemical speciation as this could influence the accuracy of risk assessment.

An unusual rugby injury.

We describe an unusual sports injury in a young man, a combination of obturator hip dislocation with an ipsilateral anterior cruciate ligament injury. Traumatic non-prosthetic hip dislocations, particularly obturator hip dislocations, are extremely rare sports injuries and have not previously been reported in conjunction with a knee ligament injury. The severe pain and obvious deformity from the hip injury can distract from other injuries, particularly to the ipsilateral knee. This case reinforces the need for a thorough assessment of the knee joint, before hip reduction if possible and certainly after reduction of the dislocation.

Reverse total shoulder arthroplasty using a trabecular metal glenoid base plate: functional and radiological outcomes at two to five years.

AIM: We present the medium-term clinical results of a reverse total shoulder arthroplasty with a trabecular metal glenoid base plate. PATIENTS AND METHODS: We reviewed 125 consecutive primary reverse total shoulder arthroplasties (RTSA) implanted in 124 patients for rotator cuff arthropathy. There were 100 women and 24 men in the study group with a mean age of 76 years (58 to 89). The mean follow-up was 32 months (24 to 60). No patient was lost to follow-up. RESULTS: There were statistically significant improvements in the mean range of movement and Oxford Shoulder Score (p < 0.001). Kaplan-Meier survivorship at five years was 96.7% (95% confidence interval 91.5 to 98.7) with aseptic glenoid failure as the end point. Radiologically, 63 shoulders (50.4%) showed no evidence of notching, 51 (40.8%) had grade 1 notching, ten (8.0%) had grade 2 notching and one (0.8%) had grade 4 notching. Radiolucency around the glenoid base plate was found in one patient (0.8%) and around the humeral stem in five (4.0%). In all, three RTSA (2.4%) underwent revision surgery for aseptic mechanical failure of the glenoid within 11 months of surgery due to malseating of the glenosphere. CONCLUSION: The clinical results of this large independent single unit series are comparable to those from previous series of RTSA reported in the literature. A trabecular metal base plate is safe and effective in the medium-term. Cite this article: Bone Joint J 2016;98-B:969-75.

Dietary ingestion of fine sediments and microalgae represent the dominant route of exposure and metal accumulation for Sydney rock oyster (Saccostrea glomerata): A biokinetic model for zinc.

Past studies disagree on the extent to which dissolved or dietary uptake contribute to metal bioaccumulation in the filter-feeding Sydney rock oyster (Saccostrea glomerata) in urbanized estuaries. Although most data support the assumption that fine sediments are a major route of metal uptake in these bivalves, some studies based in the Sydney estuary, Australia, have indicated a poor correlation. In the present study, seawater, sediment and microalgae were radiolabelled with (65)Zn tracer and exposed to S. glomerata to assess the influence of dissolved and dietary sources to Zn bioaccumulation. Oysters in the dissolved-phase uptake experiment (5, 25 and 50 µg L(-1) (65)Zn for 4 d followed by 21 days of depuration) readily accumulated (65)Zn for all three concentrations with an uptake rate constant of 0.160±0.006 L dry weight g(-1) d(-1). Oysters in the dietary assimilation experiment (1h pulse-feed of either (65)Zn-radiolabelled suspended fine-fraction (<63 µm) sediment or the microalgae Tetraselmis sp.) accumulated (65)Zn, with assimilation efficiencies of 59 and 67% for fine sediment and microalgae, respectively. The efflux rates were low for the three experiments (0.1-0.5% d(-1)). A bioaccumulation kinetic model predicts that uptake of Zn will occur predominantly through the dietary ingestion of contaminated fine sediment particles and microalgae within the water column, with considerably greater metal bioaccumulation predicted if oysters ingested microalgae preferentially to sediments. However, the model predicts that for dissolved Zn concentrations greater than 40 µg L(-1), as observed during precipitation events, the uptake of the dissolved phase may contribute ≥50% to accumulation. Overall, the results of the present study suggest that all three sources may be important exposure routes to S. glomerata under different environmental conditions, but contributions from dietary exposure will often dominate.

Mechanical stability of the AO internal spinal fixation system compared with that of the Hartshill rectangle and sublaminar wiring in the management of unstable burst fractures of the thoracic and lumbar spine.

STUDY DESIGN: A radiographic comparison of the mechanical efficacy of the Hartshill rectangle and that of the AO internal spinal skeletal fixation systems in the management of unstable burst fractures of the thoracic and lumbar spine. OBJECTIVES: To study the restoration and maintenance of normal spinal anatomy after open reduction and internal fixation of unstable burst fractures of the thoracic and lumbar spine. SUMMARY OF BACKGROUND DATA: There are laboratory studies documenting the biomechanical advantages of the AO internal spinal skeletal fixation systems. There have been no previous comparisons of the internal spinal skeletal fixation system with the Hartshill rectangle and sublaminar wiring in matched patient groups. METHODS: Radiographs obtained before surgery, immediately after surgery, and at 2 years after surgery were used to assess the restoration and maintenance of normal spinal anatomy in 14 patients who had undergone stabilization with the Hartshill System and in 12 patients who had undergone internal fixation using the AO internal spinal skeletal fixation system. RESULTS: The initial restoration of normal spinal anatomy was good using both systems. However, on examination 2 years after surgery, it was found that the AO system provided significantly superior maintenance of both middle (P < 0.01) and anterior column anatomy (P < 0.001). CONCLUSION: The AO internal spinal skeletal fixation systems is associated with significantly superior maintenance of spinal anatomy 2 years after surgery.

Treatment of anaemia after joint replacement. A double-blind, randomised, controlled trial of ferrous sulphate versus placebo.

After total hip and knee replacement arthroplasty, patients may become anaemic and may be prescribed oral iron. There is, however, no published evidence that this is of benefit when used postoperatively. We treated 72 patients who were anaemic after primary total hip and knee arthroplasty by randomly allocating them to receive six weeks of either oral ferrous sulphate (35 patients) or a placebo (37 patients). Both groups of patients were similar in all aspects except for the treatment given. There was no statistically significant difference in the change of haemoglobin levels between the two groups. We therefore believe that the prescription of iron to all anaemic patients post-operatively should be avoided. The level of serum ferritin should be monitored at preoperative assessment.

Colour Doppler ultrasound in the diagnosis, management and follow-up of a digital flexor pulley injury.

We present the case of a rock climber with a rupture of the A3 flexor sheath pulley. The diagnosis was confirmed with Colour Doppler Imaging (CDI) and with B-mode ultrasound imaging, and the surgical repair was evaluated in the same way. Vertical displacement of the flexor tendon meant that using CDI measurements of the longitudinal movements was not possible. However, using computer analysis of digitized B-mode images from texture patterns identified in the tendons, the vertical and longitudinal components of movement during flexion were calculated. The repair of the pulley was shown to produce tendon movement ratios nearer those of the control digit of the opposite hand.

Functional benefit of Dupuytren's surgery.

The results of surgery for Dupuytren's disease were prospectively assessed to see if there is a correlation between hand function, the degree of deformity and the post-operative result. A total of 42 patients were followed-up for 6 months. The mean flexion deformity was 81 degrees pre-operatively and 32 degrees post-operatively. The mean Sollerman score improved from 71 (out of 80) pre-operatively to 77 post-operatively. There was a significant correlation between the degree of deformity and the Sollerman score, and also between the improvement in deformity after surgery, and the Sollerman score. We conclude that hand function is worsened by increasing deformity in Dupuytren's disease and improved by correction of the deformity.

Medium-term clinical results of a linked total elbow replacement system.

Medium-term results of the Discovery elbow replacement are presented. We reviewed 51 consecutive primary Discovery total elbow replacements (TERs) implanted in 48 patients. The mean age of the patients was 69.2 years (49 to 92), there were 19 males and 32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69). A total of six patients were lost to follow-up. Statistically significant improvements in range movement and Oxford Elbow Score were found (p < 0.001). Radiolucent lines were much more common in, and aseptic loosening was exclusive to, the humeral component. Kaplan-Meier survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for aseptic loosening. In four TERs, periprosthetic infection occurred resulting in failure. A statistically significant association between infection and increased BMI was found (p = 0.0268). Triceps failure was more frequent after the Mayo surgical approach and TER performed after previous trauma surgery. No failures of the implant were noted. Our comparison shows that the Discovery has early clinical results that are similar to other semi-constrained TERs. We found continued radiological surveillance with particular focus on humeral lucency is warranted and has not previously been reported. Despite advances in the design of total elbow replacement prostheses, rates of complication remain high.