Trends in incidence and average waiting time for arthroplasty from 1998-2021: an observational study of 282,367 patients from the Scottish arthroplasty project.

BACKGROUND: Current waiting times for arthroplasty are reported as being the worst on record. This is a combination of increasing demand, the COVID-19 pandemic and longer standing shortage of capacity. The Scottish Arthroplasty Project (SAP) is a National Audit that analyses all joint replacements undertaken in the Scottish NHS and Independent Sector. The aim of this study was to investigate the long-term trend in provision and waiting time for lower limb joint replacement surgery. METHODS: All total hip replacements (THR) and total knee replacements (TKR) undertaken in NHS Scotland from 1998 to 2021 were identified. Waiting times data were analysed each year to determine the minimum, maximum, median, mean and standard deviation. RESULTS: In 1998, there were 4,224 THR and 2,898 TKR with mean (range, SD) waiting time of 159.5 days (1-1,685, 119.8) and 182.9 days (1-1,946, 130.1). The minimum waiting times were both in 2013 for 7,612 THR - 78.8 days (0-539, 46) and 7,146 TKR - 79.1 days (0-489, 43.7). The maximum waiting times recorded were in 2021 with 4,070 THR waiting 283.7 days (0-945, 215) and 3,153 TKR waiting 316.8 days (4-1,064, 217). CONCLUSIONS: This is the first robust large-scale national dataset showing trends in incidence and waiting time for THR and TKR over two decades. There was an expansion of activity with a reduction in waiting time, which peaked in 2013, followed by an increase in waiting time with a plateau and modest decline in the number of procedures.

Better safe than so ray: national survey of radiation protection amongst interventional radiology trainees in the United Kingdom.

OBJECTIVE: To establish the provision and use of radiation personal protective equipment (PPE) and dosimetry amongst UK interventional radiology (IR) trainees and highlight areas of improvement in order to enhance the radiation safety. METHODS: A survey questionnaire was designed by members of the British Society of Interventional Radiology (BSIR) trainee committee via survey monkey and distributed to UK IR trainees via the BSIR membership mailing list, local representatives and Twitter. The survey was open from 04/01/2021 to 20/02/2021. Only IR trainees in years ST4 and above were included. RESULTS: Of the 73 respondents, 62 qualified for analysis. Respondents (81% male) spent a median of 5.5 sessions (half day list) per week in the angiography suite and 58% (n=36) had difficulty finding appropriately sized lead aprons at least once a week. Overall 53% (n=33) had concerns about their radiation PPE. Furthermore 56% of trainees (n=35) experienced back pain among other symptoms attributed to wearing the lead aprons available to them. 77% (n=48) regularly wore lead glasses. For trainees requiring prescription glasses (n=22) overfit goggles were provided however 17 (77%) of these trainees felt the goggles compromised their ability to perform the procedure. Eye and finger dosimeters were used by 50% and 52% of respondents respectively. Compliance with body dosimetry was 99%. CONCLUSION: Provision of radiation PPE and dose monitoring for IR trainees is suboptimal, particularly access to adequate eye protection or suitably fitting leads. Based on the findings of this survey, recommendations have been made to promote the safety and radiation awareness of IR trainees. ADVANCES IN KNOWLEDGE: Radiation protection practices for IR trainees nationally are poor. Provision of suitable eye protection and well fitting lead body protection is low.

MPS VII - Extending the classical phenotype.

Mucopolysaccharidosis VII (or Sly syndrome) is an autosomal recessive disorder characterised by a deficiency in the enzyme Beta-glucuronidase (GUSB). Partial degradation of glycosaminoglycans (GAGs); chondroitin sulfate (CS), dermatan sulfate (DS) and heparan sulfate (HS) results in the accumulation of these fragments in the lysosomes of many tissues, eventually leading to multisystem damage. In some cases, early diagnosis on clinical grounds alone can be difficult due to the extreme variability of the clinical presentation and disease progression. We present a case report of a 31-year-old male patient diagnosed with MPS VII at the age of 28, who multiple specialists saw without suspecting the diagnosis due to the unusual presentation. The patient presented with a history of developmental delay, scoliosis, kyphosis, corneal clouding, abnormal gait, short stature, hearing impairment, slightly coarse facial features and progressive deterioration of fine motor skills since childhood. The patient had inguinal hernia repair at around 12 months, bilateral hearing impairment with a left bone-anchored hearing aid, and spinal surgery. During spinal surveillance MPS VII was suspected by a spinal surgeon with interest in MPS, and the diagnosis confirmed with a deficiency in beta-glucuronidase in leucocytes and marginally elevated urinary GAGs. Next-generation sequencing identified two mutations in the GUSB gene (OMIM 611499), c.526C > T p.(Leu176Phe) and c.1820G > C p.(Gly607Ala). Although the patient exhibited features of the severe form of non-classical manifestations, his metabolic condition has remained reasonably stable, surviving into adulthood with only symptomatic treatment. We present the ever-expanding phenotypic spectrum of this ultra-rare disease.

Glenoid track measurement using magnetic resonance imaging arthrography is predictive of recurrent instability following arthroscopic shoulder stabilisation.

PURPOSE: The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR. METHODS: Over a 9-year period (2008-2017), 215 patients underwent ABR. Median age was 26 years (IQR 22-32.5; range 14-77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76 months (range 21-125 months). Survivorship analysis was undertaken using Kaplan-Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability. RESULTS: 56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1 year, 27% at 5 years and 28% at 7 years. No significant difference in instability was seen between men and women 7 years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45-20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02-5.20; p < 0.0001). CONCLUSIONS: This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population. LEVEL OF EVIDENCE: III (cohort study).

Hand-arm vibration and outcomes of surgery for Dupuytren's contracture.

BACKGROUND: Dupuytren's contracture was recently designated a prescribed occupational disease when it occurs in patients with previous hand-arm vibration (HAV) exposure. AIMS: The aims of this study were to describe the impact of self-reported HAV exposure on upper limb function and satisfaction following surgery for Dupuytren's contracture. METHODS: Paired pre- and postoperative Quick version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient satisfaction questionnaires were prospectively collected from all patients undergoing surgery for Dupuytren's contracture over a 6-year period. Patients self-reported HAV exposure duration. RESULTS: Results were available for 425 hands (65%) at mean 13 months postoperatively. There were 111 patients (26%) that reported HAV exposure. The prevalence of HAV exposure was significantly greater in male compared with female patients (32% versus 4%; P < 0.001). A statistically significant difference in preoperative (difference 7.47; 95% confidence interval 4.78-10.17; P < 0.001) and postoperative QuickDASH score (difference 6.78; 95% confidence interval 2.69-10.88; P < 0.001) was observed between the two groups, but difference in QuickDASH improvement was not significantly different (difference 1.76; 95% confidence interval -1.58 to 5.10; P > 0.05). No significant difference in satisfaction rate or return to work was observed between the two groups. CONCLUSIONS: Previous HAV exposure influenced the pre and postoperative function in patients undergoing surgery for Dupuytren's contracture, but had no effect on satisfaction or return to work. Further prospective research will be required to determine whether the introduction of a compensatory framework will have a more profound effect on the functional outcomes of surgery.

Comorbid status influences quality of life following carpal tunnel decompression.

The aim of this study was to characterize the change in health-related quality of life following carpal tunnel decompression. Pre- and postoperative Euroqol 5 Dimensions scores were collected prospectively over three years. Outcomes were available for 435 of 563 patients (77%); mean age was 62 years. Comorbid status was described using the Charlson Comorbidity Index. Change in Euroqol 5 Dimensions scores declined with increasing age and Charlson Comorbidity Index: the greatest improvement in quality of life occurred in the youngest group (+0.07 vs. -0.07 in the oldest group; p < 0.001) and patients with the lowest Comorbidity Index (+0.05 vs. -0.07 in the highest comorbidity group; p < 0.001). Charlson Comorbidity Index was an independent predictor of worse change in Euroqol 5 Dimensions scores on regression analysis. Carpal tunnel decompression results in significant improvement in health-related quality of life in younger patients with minimal comorbidities, but not in older patients with more comorbidities. We advise interpreting the Euroqol 5 Dimensions scores with caution in this patient cohort. LEVEL OF EVIDENCE: III (cohort study).

Occupation classification predicts return to work after carpal tunnel decompression.

BACKGROUND: The relationship between hand function, employment status and return to work (RTW) after carpal tunnel decompression (CTD) is unclear. AIMS: To investigate predictors of RTW following CTD. METHODS: We prospectively collected pre-operative and 1-year post-operative outcomes and RTW data for all patients undergoing CTD at one centre between 29 May 2014 and 29 May 2017. We used the Standard Occupation Classification 2010. RESULTS: Pre- and post-operative results were available for 469 (79%) of the 597 patients who had CTD surgery. Pre-operatively, 219 (47%) were employed, 216 (46%) were retired, 26 (6%) were not working due to long-term illness and eight (2%) were unemployed. Complete data sets were available for 178 (81%) of the 219 employed patients, of whom 161 (90%) were able to RTW. Of the rest, five (3%) had changed jobs and 12 (7%) were unable to work. Median RTW time was 4 weeks (interquartile range [IQR] 2-6 weeks). Significantly more patients undertaking manual labour were unable to RTW (15% versus 5%; P < 0.05). There was no significant difference in mean number of weeks absent between manual (5.7; 95% confidence interval [CI] 4.9-6.5) and non-manual workers (6.2; 95% CI 4.8-7.6) (P > 0.05). Median pre-operative (difference 15.9; 95% CI 4.5-25) and post-operative (difference 43.2; 95% CI 13.6-43.2) hand function scores were significantly worse in patients who did not RTW (P < 0.05). CONCLUSIONS: Most patients can RTW within 1 year of CTD. Failure to RTW is more likely in manual workers and patients with poorer pre-operative hand function.

The Potential of Utilizing Mid-Energy X-Rays for In-Line Phase Sensitive Breast Cancer Imaging.

OBJECTIVE: The objective of this study is to demonstrate the potential of utilizing mid-energy x-rays for in-line phase-sensitive breast cancer imaging by phantom studies. METHODS: The midenergy (50-80kV) in-line phase sensitive imaging prototype was used to acquire images of the contrast-detail mammography (CDMAM) phantom, an ACR accreditation phantom, and an acrylic edge phantom. The low-dose mid-energy phase-sensitive images were acquired at 60 kV with a radiation dose of 0.9 mGy, while the high-energy phase-sensitive images were acquired at 90 kV with a radiation dose of 1.2 mGy. The Phase-Attenuation Duality (PAD) principle for soft tissue was used for the phase retrieval. A blind observer study was conducted and paired-sample T-test were performed to compare the mean differences in the two imaging systems. RESULTS: The correct detection ratio for the CDMAM phantom for phase-contrast images acquired by the low-dose mid-energy system was 56.91%, whereas images acquired by the high-energy system correctly revealed only 40.97% of discs. The correct detection ratios were 57.88% and 43.41% for phase-retrieved images acquired by the low-dose mid-energy and high-energy imaging systems, respectively. The reading scores for all three groups of objects in the ACR phantom were higher for the mid energy imaging system as compared to the high-energy system for both phase-contrast and phase- retrieved images. The calculated edge enhancement index (EEI) from the acrylic edge phantom image for the mid-energy system was higher than that calculated for the high-energy imaging system. The quantitative analyses showed a higher Contrast to Noise Ratio (CNR) as well as a higher Figure of Merit (FOM) in images acquired by the low-dose mid-energy imaging system. CONCLUSION: The PAD based retrieval method can be applied in mid-energy system without remarkably affecting the image quality, and in fact, it improves the lesion detectability with a patient dose saving of 25%.

Enzymatically oxidized phospholipids restore thrombin generation in coagulation factor deficiencies.

Hemostatic defects are treated using coagulation factors; however, clot formation also requires a procoagulant phospholipid (PL) surface. Here, we show that innate immune cell-derived enzymatically oxidized phospholipids (eoxPL) termed hydroxyeicosatetraenoic acid-phospholipids (HETE-PLs) restore hemostasis in human and murine conditions of pathological bleeding. HETE-PLs abolished blood loss in murine hemophilia A and enhanced coagulation in factor VIII- (FVIII-), FIX-, and FX-deficient human plasma . HETE-PLs were decreased in platelets from patients after cardiopulmonary bypass (CPB). To explore molecular mechanisms, the ability of eoxPL to stimulate individual isolated coagulation factor/cofactor complexes was tested in vitro. Extrinsic tenase (FVIIa/tissue factor [TF]), intrinsic tenase (FVIIIa/FIXa), and prothrombinase (FVa/FXa) all were enhanced by both HETE-PEs and HETE-PCs, suggesting a common mechanism involving the fatty acid moiety. In plasma, 9-, 15-, and 12-HETE-PLs were more effective than 5-, 11-, or 8-HETE-PLs, indicating positional isomer specificity. Coagulation was enhanced at lower lipid/factor ratios, consistent with a more concentrated area for protein binding. Surface plasmon resonance confirmed binding of FII and FX to HETE-PEs. HETE-PEs increased membrane curvature and thickness, but not surface charge or homogeneity, possibly suggesting increased accessibility to cations/factors. In summary, innate immune-derived eoxPL enhance calcium-dependent coagulation factor function, and their potential utility in bleeding disorders is proposed.

Formaldehyde and acetaldehyde exposure and risk characterization in California early childhood education environments.

Little information is available about air quality in early childhood education (ECE) facilities. We collected single-day air samples in 2010-2011 from 40 ECE facilities serving children ≤6 years old in California and applied new methods to evaluate cancer risk in young children. Formaldehyde and acetaldehyde were detected in 100% of samples. The median (max) indoor formaldehyde and acetaldehyde levels (µg/m3 ) were 17.8 (48.8) and 7.5 (23.3), respectively, and were comparable to other California schools and homes. Formaldehyde and acetaldehyde concentrations were inversely associated with air exchange rates (Pearson r = -0.54 and -0.63, respectively; P < 0.001). The buildings and furnishings were generally >5 years old, suggesting other indoor sources. Formaldehyde levels exceeded California 8-h and chronic Reference Exposure Levels (both 9 µg/m3 ) for non-cancer effects in 87.5% of facilities. Acetaldehyde levels exceeded the U.S. EPA Reference Concentration in 30% of facilities. If reflective of long-term averages, estimated exposures would exceed age-adjusted 'safe harbor levels' based on California's Proposition 65 guidelines (10-5 lifetime cancer risk). Additional research is needed to identify sources of formaldehyde and acetaldehyde and strategies to reduce indoor air levels. The impact of recent California and proposed U.S. EPA regulations to reduce formaldehyde levels in future construction should be assessed.

VOC exposures in California early childhood education environments.

Little information exists about exposures to volatile organic compounds (VOCs) in early childhood education (ECE) environments. We measured 38 VOCs in single-day air samples collected in 2010-2011 from 34 ECE facilities serving California children and evaluated potential health risks. We also examined unknown peaks in the GC/MS chromatographs for indoor samples and identified 119 of these compounds using mass spectral libraries. VOCs found in cleaning and personal care products had the highest indoor concentrations (d-limonene and decamethylcyclopentasiloxane [D5] medians: 33.1 and 51.4 µg/m³, respectively). If reflective of long-term averages, child exposures to benzene, chloroform, ethylbenzene, and naphthalene exceeded age-adjusted "safe harbor levels" based on California's Proposition 65 guidelines (10-5 lifetime cancer risk) in 71%, 38%, 56%, and 97% of facilities, respectively. For VOCs without health benchmarks, we used information from toxicological databases and quantitative structure-activity relationship models to assess potential health concerns and identified 12 VOCs that warrant additional evaluation, including a number of terpenes and fragrance compounds. While VOC levels in ECE facilities resemble those in school and home environments, mitigation strategies are warranted to reduce exposures. More research is needed to identify sources and health risks of many VOCs and to support outreach to improve air quality in ECE facilities.

Clinical improvements following bilateral anterior capsulotomy in treatment-resistant depression.

BACKGROUND: The purpose of this study was to evaluate a programme of lesion surgery carried out on patients with treatment-resistant depression (TRD). METHOD: This was a retrospective study looking at clinical and psychometric data from 45 patients with TRD who had undergone bilateral stereotactic anterior capsulotomy surgery over a period of 15 years, with the approval of the Mental Health Act Commission (37 with unipolar depression and eight with bipolar disorder). The Beck Depression Inventory (BDI) before and after surgery was used as the primary outcome measure. The Montgomery-Asberg Depression Rating Scale was administered and cognitive aspects of executive and memory functions were also examined. We carried out a paired-samples t test on the outcome measures to determine any statistically significant change in the group as a consequence of surgery. RESULTS: Patients improved on the clinical measure of depression after surgery by -21.20 points on the BDI with a 52% change. There were no significant cognitive changes post-surgery. Six patients were followed up in 2013 by phone interview and reported a generally positive experience. No major surgical complications occurred. CONCLUSIONS: With the limitations of an uncontrolled, observational study, our data suggest that capsulotomy can be an effective treatment for otherwise TRD. Performance on neuropsychological tests did not deteriorate.

An extremely rare case of a high-grade pleomorphic cardiac sarcoma and likely cerebral metastasis in a young patient.

To date, there have been less than a 100 confirmed case reports of primary cardiac malignant fibrous histiocytomas, a rare form of sarcoma. In this report, we discuss the case of a 15-year-old girl who initially presented with a histiocytic cerebral sarcoma that was treated with aggressive resection and chemotherapy. Three years later, the same patient developed increasing shortness of breath and was found to have a high-grade pleomorphic undifferentiated cardiac sarcoma that likely represents the primary tumour from which the cerebral lesion metastasised. This represents an extremely unique case; in 2010, a research group in Germany claimed the very first description of a true cardiac sarcoma with brain metastasis [1]. However, even as far back as 1960, there were three case reports [2] and more extensive sarcoma studies recently have revealed further cases [3]. Nevertheless, there have probably been less than 10 cases in the literature up until this point.

Interpretation of the QuickDASH score after open carpal tunnel decompression: threshold values associated with patient satisfaction.

UNLABELLED: We studied the correlation between change in the QuickDASH score and the absolute post-operative QuickDASH score with patient satisfaction after open carpal tunnel decompression. Threshold values in the QuickDASH score, the point at which the sensitivity and specificity are maximal in predicting patient satisfaction, were identified. During the study period, outcome data were compiled for 937 carpal tunnel decompressions, which included 219 (23%) male and 718 (77%) female patients with a mean age of 58 years (standard deviation (SD) 14). There was a significant improvement (mean difference 32, 95% confidence interval (CI) 30 to 34) in the QuickDASH from a mean of 54 (SD 20) to 22 (SD 23) at 1 year after surgery. There were 808 (86%) patients who defined their outcome as satisfactory at 1 year. The identified threshold values for the post-operative QuickDASH score (⩽34 points) and the change (⩾20 points) in the score were highly predictive of patient satisfaction. However, these threshold values varied significantly according to the baseline pre-operative score. The threshold values identified in the QuickDASH can be used to interpret the score. However, the influence of the pre-operative baseline score should be taken into account when comparing different cohorts of patients or using the values to power future studies. LEVEL OF EVIDENCE IV: Prognosis, observational cohort study.

Fifth metatarsal fractures - Is routine follow-up necessary?

BACKGROUND: Fifth metatarsal fractures are common, and the outcome with conservative treatment is generally very satisfactory. Operative treatment is only used for selected injuries, particularly stress fractures. Traditionally these patients are routinely reviewed at a fracture clinic, mainly due to the perceived risk of non-union with a Jones' fracture. In 2011 we introduced a standardised protocol to promote weight bearing as pain allowed with an elasticated support or a removable boot. Patients were discharged with structured advice and a help-line number to access care if required, but no further face-to-face review was arranged. More complex cases were reviewed at a "virtual clinic." Our hypothesis was that the introduction of this standardised protocol would be safe, patient-centred and significantly reduce unnecessary outpatient clinic review. PATIENTS AND METHODS: We audited fracture clinic attendance and outcomes 1 year before and 1 year after the protocol was introduced in 2011. All radiographs taken at the Emergency Department (ED) presentation were reviewed and classified independently for validation. RESULTS: From 2009 to 2010, 279 patients who presented to the ED with fifth metatarsal fractures were referred to a fracture clinic. Of these 279 patients, 267 (96%) attended the fracture clinic, resulting in an overall total of 491 outpatient attendances. Three (1%) were treated operatively for delayed/non-union. From 2011 to 2012, 339 patients presented to the ED with fifth metatarsal fractures - only 67 (20%) were referred to a fracture clinic. 62 (18%) attended clinic appointments with 102 appointments in total. Five (1%) required operative intervention. CONCLUSION: Our study showed no added clinical value for routine outpatient follow-up of fifth metatarsal fractures. Patients can be safely discharged and allowed to bear weight at the time of initial ED presentation if they are provided with appropriate information and ready access to experienced fracture clinic staff.

Antitumour potential of BPT: a dual inhibitor of cdk4 and tubulin polymerization.

The marine natural product fascaplysin (1) is a potent Cdk4 (cyclin-dependent kinase 4)-specific inhibitor, but is toxic to all cell types possibly because of its DNA-intercalating properties. Through the design and synthesis of numerous fascaplysin analogues, we intended to identify inhibitors of cancer cell growth with good therapeutic window with respect to normal cells. Among various non-planar tryptoline analogues prepared, N-(biphenyl-2-yl) tryptoline (BPT, 6) was identified as a potent inhibitor of cancer cell growth and free from DNA-binding properties owing to its non-planar structure. This compound was tested in over 60 protein kinase assays. It displayed inhibition of Cdk4-cyclin D1 enzyme in vitro far more potently than many other kinases including Cdk family members. Although it blocks growth of cancer cells deficient in the mitotic-spindle checkpoint at the G0/G1 phase of the cell cycle, the block occurs primarily at the G2/M phase. BPT inhibits tubulin polymerization in vitro and acts as an enhancer of tubulin depolymerization of paclitaxel-stabilized tubulin in live cells. Western blot analyses indicated that, in p53-positive cells, BPT upregulates the expression of p53, p21 and p27 proteins, whereas it downregulates the expression of cyclin B1 and Cdk1. BPT selectively kills SV40-transformed mouse embryonic hepatic cells and human fibroblasts rather than untransformed cells. BPT inhibited the growth of several human cancer cells with an IC50<1 µM. The pharmacokinetic study in BALB/c mice indicated good plasma exposure after intravenous administration. It was found to be efficacious at 1/10th the maximum-tolerated dose (1000 mg/kg) against human tumours derived from HCT-116 (colon) and NCI-H460 (lung) cells in SCID (severe-combined immunodeficient) mice models. BPT is a relatively better anticancer agent than fascaplysin with an unusual ability to block two overlapping yet crucial phases of the cell cycle, mitosis and G0/G1. Its ability to effectively halt tumour growth in human tumour-bearing mice would suggest that BPT has the potential to be a candidate for further clinical development.

The Minimum Competences in Non-surgical Oncology that Medical Students Need to Acquire in Order to be Safe Foundation Year 1 (F1) Doctors: A Delphi Survey.

AIMS: To develop a consensus on the minimum competences in non-surgical oncology that medical students need to acquire in order to be safe Foundation Year 1 (F1) doctors. MATERIALS AND METHODS: A two-round Delphi survey was conducted by e-mail with an expert panel of 24 consultant oncologists who had expressed an interest in undergraduate education. RESULTS: The response rate to round 1, which asked panellists to list the competences they thought were important, was 50%. The competences they generated contained 86 different concepts. These were categorised according to the learning outcomes in Tomorrow's Doctors. The panellists were then asked to rate the importance of each proposed competence between 1 and 9 on a Likert scale to give a measure of the perceived importance and consensus. The panellists generated competences in all the main categories of learning outcomes in Tomorrow's Doctors. The scores were highest and the consensus greatest for those competences related to the doctor as a practitioner and the doctor as a professional. CONCLUSION: The Delphi survey was an effective method of obtaining the judgement of an expert panel and in measuring the degree of consensus. The results of the survey were valuable in informing the design of a UK non-surgical oncology curriculum.

Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance.

OBJECTIVES: Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance. DESIGN: A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change. SETTING: An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system. PARTICIPANTS: 2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol. OUTCOME MEASURES: Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance. RESULTS: Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment. CONCLUSIONS: This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

A comparison of the use of uncemented hydroxyapatite-coated bipolar and cemented femoral stems in the treatment of femoral neck fractures: a case-control study.

We performed a case-control study to compare the rates of further surgery, revision and complications, operating time and survival in patients who were treated with either an uncemented hydroxyapatite-coated Corail bipolar femoral stem or a cemented Exeter stem for a displaced intracapsular fracture of the hip. The mean age of the patients in the uncemented group was 82.5 years (53 to 97) and in the cemented group was 82.7 years (51 to 99) We used propensity score matching, adjusting for age, gender and the presence or absence of dementia and comorbidities, to produce a matched cohort receiving an Exeter stem (n = 69) with which to compare the outcome of patients receiving a Corail stem (n = 69). The Corail had a significantly lower all-cause rate of further surgery (p = 0.016; odds ratio (OR) 0.18, 95% CI 0.04 to 0.84) and number of hips undergoing major further surgery (p = 0.029; OR 0.13, 95% CI 0.01 to 1.09). The mean operating time was significantly less for the Corail group than for the cemented Exeter group (59 min [12 to 136] vs 70 min [40 to 175], p = 0.001). The Corail group also had a lower risk of a peri-prosthetic fracture (p = 0.042; OR 0.19, 95% CI 0.01 to 1.42) . There was no difference in the mortality rate between the groups. There were significantly fewer complications in the uncemented group, suggesting that the use of this stem would result in a decreased rate of morbidity in these frail patients. Whether this relates to an improved functional outcome remains unknown.