Clinical features associated with ADB-BUTINACA exposure in patients attending emergency departments in England.

OBJECTIVE: Synthetic cannabinoid receptor agonists (SCRA) are commonly encountered new psychoactive substances. Here we report the recent detection of ADB-BUTINACA in samples from patients attending United Kingdom emergency departments with toxicity after suspected drug misuse and describe the associated clinical features. METHODS: Consenting adults (≥16 y) presenting to participating hospitals with toxicity after suspected drug misuse have been included in the Identification Of Novel psychoActive substances (IONA) study since March 2015. Demographic and clinical features are recorded and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry. RESULTS: By December 2021, analytical data were available for 1279 IONA participants and ADB-BUTINACA was detected in at least one sample from 10 (9 males, age range 16-51 median 45 years), all presenting since February 2021. Smoking 'spice' was reported by four patients, two had ingested edible "cannabis" gums and four reported heroin use (2 intravenous, 1 smoked, 1 route not known). Co-use of pregabalin (oral) and crack cocaine (smoked) were also reported. In 3 cases ADB-BUTINACA was the only substance detected, while in seven other substances of misuse were also detected including other SCRA, opioids, benzodiazepines cocaine and pregabalin. Clinical features reported in these 2 groups respectively included reduced level of consciousness (3/3, 6/7), agitation (0/3, 4/7), tachycardia (0/3, 3/7), seizures (1/3, 1/7), hallucinations (1/3, 1/7), hypotension (1/3, 1/7). Metabolic acidosis (1/3, 0/7) and respiratory acidosis (1/3, 0/7), All 10 patients recovered with supportive care, including intubation and ventilation for one case. The median length of hospital stay was 19 h (range 2.6-131 h). CONCLUSIONS: ADB-BUTINACA has recently emerged as a drug of misuse in England. Clinical features of toxicity are consistent with those of other SCRA and include reduced level of consciousness, respiratory and/or metabolic acidosis, seizures, confusion and hallucinations.

Treatment of fracture subluxations of the proximal interphalangeal joint using a ligamentotaxis device: a multidisciplinary approach.

Complex fracture subluxations of the proximal interphalangeal joint are often difficult to treat and their outcome variable. A number of methods for treatment of these injuries have been described. We have used a ligamentotaxis device (Ligamentotaxor, Arex, Palaiseau Cedex, France) since 2008. We performed 28 operations in 28 patients with complex proximal interphalangeal joint injuries over a 3-year period. Patients followed a standardized postoperative rehabilitation regime, including fixator adjustment as necessary. The mean age was 33 years (range 18-67). The mean time to surgery was 7 days. At final follow-up (mean 22 months, range 6-52) the mean proximal interphalangeal joint range of motion was 85° (range 60°-110°). The mean QuickDASH functional outcome score was 4.8 (range 0-36.4). Our results compare favourably with other devices reported in the literature.

A review of outcomes of the surgical management of femoroacetabular impingement.

INTRODUCTION: Femoroacetabular impingement (FAI) resulting from abnormal contact between the acetabulum and femur has been studied extensively in recent years owing to its association with acetabular labrum tears and possible contribution to the development of osteoarthritis. METHODS: A comprehensive PubMed, MEDLINE(®) and Embase™ literature search was conducted. Search terms included 'femoroacetabular impingement', 'pathophysiology', 'diagnosis', 'dGEMRIC', 'arthroscopic', 'open', 'mini-open' and 'outcome measure'. RESULTS: A range of radiographic features have been described, and computed tomography and magnetic resonance imaging are both commonly used in the diagnosis of the bony abnormalities in FAI. Treatment of FAI is surgical with methods of treatment ranging from open surgical hip dislocation to arthroscopic osteochondroplasty. CONCLUSIONS: In recent years, a trend towards the use of arthroscopic treatment for FAI has been seen, with promising results from a range of studies. However, only short-term outcome data are available and a range of different outcome measures have been used in studies to date. We present an overview of the outcomes for a range of surgical treatment methods for FAI and discuss the outcome measures used.

Factors affecting final facial nerve outcome following vestibular schwannoma surgery.

OBJECTIVE: To determine factors affecting facial nerve outcome of vestibular schwannoma surgery. METHODS: This retrospective cohort study comprised 652 patients. The outcome measure was House-Brackmann classification at two years post-operatively. Univariate and multivariate analyses were carried out to determine the factors affecting facial nerve outcome. The incidence rates of hemifacial spasm, metallic taste and crocodile tear syndrome were recorded. RESULTS: For tumours less than 1.5 cm, 95 per cent of outcomes were normal, 100 per cent were satisfactory (House-Brackmann grades I-III) and 0 per cent were unsatisfactory (grades IV-VI). For tumours 1.5-2.4 cm, 83 per cent of outcomes were normal, 99 per cent were satisfactory and 1 per cent were unsatisfactory. For tumours 2.5-3.4 cm, 68 per cent of outcomes were normal, 96 per cent were satisfactory and 4 per cent were unsatisfactory. For tumours 3.5-4.4 cm, 52 per cent of outcomes were normal, 80 per cent were satisfactory and 20 per cent were unsatisfactory. For tumours larger than 4.4 cm, 50 per cent of outcomes were normal, 72 per cent were satisfactory and 28 per cent were unsatisfactory. CONCLUSION: Tumour size and operation year were significant predictors of facial nerve outcome. The surgical learning curve was steepest for the first 50 patients.

A history of shoulder surgery.

Shoulder surgery has emerged from being a marginalised sub-speciality to being an area of much research and advancement within the last seventy years. This has been despite the complexity of the joint, and success majorly rests on parallel development of biomedical technology. This article looks at the past and present of shoulder surgery and discusses future directions in the speciality.

Outcome of translabyrinthine surgery for vestibular schwannoma in neurofibromatosis type 2.

OBJECTIVES: To analyse the long-term outcome of translabyrinthine surgery for vestibular schwannoma (VS) in neurofibromatosis type 2 (NF2). RESEARCH TYPE: Retrospective cohort study. SETTING: Two tertiary referral NF2 units. PATIENTS: One hundred and forty eight translabyrinthine operations for patients with VS were performed. Preoperative stereotactic radiotherapy had been performed on 12(9.4%) patients. RESULTS: Mean tumour size was 3.1 cm. Total tumour excision was achieved in 66% of cases, capsular remnants were left in 24% of cases, and subtotal excision was achieved in 5% and partial removal was achieved in 5%. The radiological residual/recurrence rate was 13.9%. The perioperative mortality was 1.6%. At 2 years postoperatively, facial function was expressed in terms of House-Brackmann score (HB): HB 1 in 53.4%, HB 1/2 in 61.3%, HB 1-3 in 83.2% and HB 4-6 in 16.8%. All nine patients who underwent surgery following failed stereotactic radiotherapy had HB 3 function or better. Among 9.5% of the cases, 14 facial nerves were lost during surgery and repaired using direct anastomosis or grafting. There was no tinnitus present preoperatively in 27% of the cases, and 22% of patients developed tinnitus postoperatively. In patients with preoperative tinnitus, 61% remained the same, 17% got it resolved and only in 21% it worsened. The preoperative hydrocephalus rate was 26%, and among 15% of the cases five ventriculo-peritoneal (VP) shunts were performed. The cerebrospinal fluid leak rate was 2.5%. Fifty-six patients underwent auditory brainstem implantation (ABI) and two patients had cochlear implant (CI) sleepers inserted. CONCLUSIONS: The management of patients with NF2 presents the clinician with a formidable challenge with many patients still presenting themselves late with the neurological compromise and a large tumour load. There is still an argument for the management by observation until the neurological compromise dictates interventional treatment particularly with the option of hearing rehabilitation with ABI or CI. The translabyrinthine approach provides a very satisfactory means of reducing the overall tumour volume.

Biodegradable antibiotic delivery systems.

Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity. This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.

Research in castration-resistant prostate cancer: what does the future hold?

Prostate cancer (PCa) is the most common non-skin cancer diagnosed in North America, and it affects 1 in 6 men. Patients with recurrent or metastatic pca will inevitably develop castration-resistant disease after an initial period of hormone responsiveness. The standard first-line treatment for men with castration-resistant pca (CRPC) is docetaxel, but further treatment options are limited. This review summarizes the research being conducted in CRPC, with specific regard to immunotherapy and to novel targeted therapies directed against the androgen axis, vascular endothelial growth factor, chaperone proteins, the phosphoinositide 3 kinase/Akt/phosphatase and tensin homolog/mammalian target of rapamycin pathway, and endothelin-1.

Management of the patient and family with neurofibromatosis 2: a consensus conference statement.

A consensus conference on neurofibromatosis 2 (NF2) was held in 2002 at the request of the United Kingdom (UK) Neurofibromatosis Association, with particular emphasis on vestibular schwannoma (VS) surgery. NF2 patients should be managed at specialty treatment centres, whose staff has extensive experience with the disease. All NF2 patients and their families should have access to genetic testing because presymptomatic diagnosis improves the clinical management of the disease. Some clinical manifestations of NF2, such as ocular abnormalities, can be detected in infancy; therefore, clinical screening for at-risk members of NF2 families can start at birth, with the first magnetic resonance (MRI) scan at 10-12 years of age. Minimal interference, maintenance of quality of life, and conservation of function or auditory rehabilitation are the cornerstones of NF2 management, and the decision points to achieve these goals for patients with different clinical presentations are discussed.

Team working to improve outcome in vestibular schwannoma surgery.

The concept of the 'learning curve' in the early years of consultant appointment is no longer acceptable and yet, for most complex operations, learning is a career-long process. Sub-specialization offers part of the solution to this problem by concentrating expertise, but there remains the question of how to introduce new team members without adversely affecting patient outcome. Shortened training and an increasingly aware public, who are more questioning of the experience and outcomes of those treating them, has required the surgical profession to move away from individual consultant practice and embrace team-working. When, in 1997, a second neurosurgeon joined the skull base team at Addenbrooke's Hospital, his introduction to acoustic neuroma surgery was mentored and operative cases were carefully selected at first. In this article, we discuss our experience with consultant mentoring, and compare the results of the first 100 translabyrinthine acoustic neuroma operations performed under this system with the first cohort of a similar number of patients published from Cambridge in 1989.

Desarrollo de un método de PCR-múltiple para la identificación de Ureaplasma parvum y Ureaplasma urealyticum / [Development of a multiple PCR method for the identification of Ureaplasma parvum and Ureaplasma urealyticum]

Ureaplasma parvum and Ureaplasma urealyticum, also known as biovar parvum and biovar T960, respectively, could be associated with several disorders in men, women, and mainly, in newborn children with under weight. Several methods have been developed in order to identify the species or biovars of ureaplasmas. We developed a Multiplex-PCR method using the UPS-UPSA and UUS2-UUA2 primers, specific for U. parvum and U. urealyticum, respectively. This Multiplex-PCR method was used to identify cultures of clinical positive samples to Ureaplasma spp. by the [quot ]MYCOFAST Evolution-2[quot ] Kit. Of 56 positive cultures to Ureaplasma spp. from newborn children, 70

were U. parvum and 30

U. urealyticum; in 76 positive samples in women, 83

corresponded to U. parvum and 17

to U. urealyticum, while in 63 positive samples of men, 76

identified U. parvum and 24

U. urealyticum. The PCR-multiplex method showed specificity for the identification of the biovars or species of ureaplasmas of clinical interest.

Cauda equina syndrome: what is the relationship between timing of surgery and outcome?

The role of urgent surgery in improving the outcome of cauda equina compression following lumbar central disc prolapse remains controversial. Some series claim improved outcome from emergency decompression whilst others have found no benefit. Resolution of this issue is important because the opportunity to reverse neurological impairment may already have been lost by the time of hospital admission. Removal of a large central disc prolapse can be considerably more difficult than routine discectomy, and may require an extensive exposure. When performed under less than optimal conditions, as often exists in the emergency setting, surgery may even add to rather than alleviate morbidity. This article reviews the pathophysiology of cauda equina syndrome, its definition, and the controversies surrounding management. Where urinary retention with overflow incontinence extists at presentation we believe that urgent decompression confers no benefit.

Post-partum retreatment with iridium-192 wire brachytherapy for meningioma recurring in pregnancy.

We report the case history of a female patient who had received radical radiotherapy for a malignant meningioma at the age of 11 years. Thirteen years later, during her first pregnancy, she presented with a recurrence. The tumour was surgically debulked, but complications related to postoperative sepsis, the location of the tumour, and the extent of her previous treatment made the delivery of adjuvant radiotherapy problematic. The tumour bed was treated using an interstitial implant of 192Ir wires to a dose of 60 Gy in 100 hours. The patient remains well with no evidence of tumour recurrence or brain necrosis 2 years later. We discuss the role of female sex hormones in meningioma and the difficulties of radical retreatment of tumours in the central nervous system. The various techniques of brachytherapy in the brain are highlighted. The specific advantages of 192Ir in this patient are discussed.

Occipito-clival intradiploic meningocoele following skull fracture in infancy.

An adolescent presented with an intradiploic meningocoele 11 years after an occipital skull fracture. Surgical treatment consisted initially of cranioplasty, but the lesion then progressed to involve much of the skull base, requiring cystoperitoneal shunt insertion. The pathogenesis and treatment of post-traumatic intradiploic meningocoele is discussed.

A consistent set of neutron kerma coefficients from thermal to 150 MeV for biologically important materials.

Neutron cross sections for nonelastic and elastic reactions on a range of elements have been evaluated for incident energies up to 150 MeV. These cross sections agree well with experimental cross section data for charged-particle production as well as neutron and photon production. Therefore they can be used to determine kerma coefficients for calculations of energy deposition by neutrons in matter. Methods used to evaluate the neutron cross sections above 20 MeV, using nuclear model calculations and experimental data, are described. Below 20 MeV, the evaluated cross sections from the ENDF/B-VI library are adopted. Comparisons are shown between the evaluated charged-particle production cross sections and measured data. Kerma coefficients are derived from the neutron cross sections, for major isotopes of H, C, N, O, Al, Si, P, Ca, Fe, Cu, W, Pb, and for ICRU-muscle, A-150 tissue-equivalent plastic, and other compounds important for treatment planning and dosimetry. Numerous comparisons are made between our kerma coefficients and experimental kerma coefficient data, to validate our results, and agreement is found to be good. An important quantity in neutron dosimetry is the kerma coefficient ratio of ICRU-muscle to A-150 plastic. When this ratio is calculated from our kerma coefficient data, and averaged over the neutron energy spectra for higher-energy clinical therapy beams [three p (68) + Be beams, and a d (48.5) + Be beam], a value of 0.94 +/- 0.03 is obtained. Kerma ratios for water to A-150 plastic, and carbon to oxygen, are also compared with measurements where available.

Changes in root canal morphology in simulated curved canals over-instrumented with a variety of stainless steel and nickel titanium files.

The purpose of this project was to observe the amount of apical and mid-curve transportation produced by a range of nickel titanium (NiTi), titanium alloy and stainless steel (SS) files. Tests were carried out in simulated curved root canals produced in epoxy resin blocks. Seven commercially available file types were tested using sizes 15 to 40. Instrumentation was carried out to 1 mm beyond the apex. Changes in canal dimensions were measured at 10x magnification under a shadowgraph. There were substantial differences in the amount and the pattern of apical and mid-curve transportation produced. The amount of transportation increased with each subsequent size of file. Under the same conditions, nickel titanium files produced significantly less transportation than stainless steel files. The least apical transportation was obtained with the NiTi Mity Turbo and the most by the SS K file and SS Hedstrom file. The least mid-curve transportation was produced by the NiTi Mity Turbo and the most by the SS Hedstrom file.