Theatre ventilation.

INTRODUCTION: Owing to the COVID-19 pandemic, there has been significant disruption to all surgical specialties. In the UK, units have cancelled elective surgery and a decrease in aerosol generating procedures (AGPs) was favoured. Centres around the world advocate the use of negative pressure environments for AGPs in reducing the spread of infectious airborne particles. We present an overview of operating theatre ventilation systems and the respective evidence with relation to surgical site infection (SSI) and airborne pathogen transmission in light of COVID-19. METHODS: A literature search was conducted using the PubMed, Cochrane Library and MEDLINE databases. Search terms included "COVID-19", "theatre ventilation", "laminar", "turbulent" and "negative pressure". FINDINGS: Evidence for laminar flow ventilation in reducing the rate of SSI in orthopaedic surgery is widely documented. There is little evidence to support its use in general surgery. Following previous viral outbreaks, some centres have introduced negative pressure ventilation in an attempt to decrease exposure of airborne pathogens to staff and surrounding areas. This has again been suggested during the COVID-19 pandemic. A limited number of studies show some positive results for the use of negative pressure ventilation systems and reduction in spread of pathogens; however, cost, accessibility and duration of conversion remain an unexplored issue. Overall, there is insufficient evidence to advocate large scale conversion at this time. Nevertheless, it may be useful for each centre to have its own negative pressure room available for AGPs and high risk patients.

Long-term outcomes of real world 'watch and wait' data for rectal cancer after neoadjuvant chemoradiotherapy.

AIM: A 'watch and wait' (W&W) strategy after neoadjuvant long-course chemoradiotherapy (NACRT) remains controversial. Whilst encouraging short-term data exist, the strategy will be judged on long-term data. We present long-term, real-world UK data from a single National Health Service trust. METHODS: An analysis was performed of a prospectively maintained W&W database over 9 years between 2010 and 2018. Outcome measures include incidence and time to regrowth and overall and disease-free survival. RESULTS: We diagnosed 563 rectal cancers in 9 years. In all, 283 patients underwent rectal resection (50.3%). NACRT was used in 155 patients for margin-threatened tumours on staging MRI. Forty-nine patients (31.6%) experienced either a 'near complete' or a complete clinical response (cCR) at their 10 weeks post-NACRT assessment (MRI and endoscopy). The median age was 69 years (range 44-83), and the male to female ratio was 32:17. The median follow-up was 38 months (range 12-96). The median tumour distance from the anal verge was 7 cm (1-15 cm). Twenty-two patients had a cCR on initial assessment and 27 patients had a 'near' cCR. Of those 27 who experienced a 'near' cCR, 17 (63%) progressed to cCR on repeat assessment and 10 (37%) did not. Of these 10 patients, seven underwent standard surgical resection and three were unfit for surgery. R0 for the seven with delayed resection was 100%. Of 39 patients (22 cCR and 17 'near' cCR who progressed to cCR) (25.2% of those receiving NACRT), six patients experienced local regrowth (15.4%). The median time to local regrowth was 29 months (15-60 months). One of these six patients underwent salvage abdominoperineal resection, one was advised to have contact radiotherapy and four opted against surgery and also had contact radiotherapy. The overall survival was 100% at 2 years and 90% at 5 years. Disease-free survival was 90.47% at 2 years and 74.8% at 5 years. CONCLUSION: A W&W treatment strategy was employed safely in this patient cohort with acceptable rates of local regrowth and survival.

Sacrococcygeal dimensions and curvature are associated with resection quality in rectal cancer excision.

BACKGROUND: Technical factors affect oncologic outcomes in rectal cancer surgery. The anatomy of the bony pelvis can affect technical aspects of surgery, but is seldom considered preoperatively. We performed a morphometric analysis of the bony pelvis in patients having rectal cancer resection to assess its effect on surgical specimen quality. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients who had resection for rectal cancer from January 2014 to December 2017. Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) images were accessed and measurements of sacrococcygeal distance, sacrococcygeal recess depth/area, sacrococcygeal angulation, anteroposterior pelvic inlet/outlet, pubic height and interspinous distance were made. Outcome measures included anatomical variation, operating time and mesorectal specimen grade. In patients having extra-levator abdominoperineal excision (eLAPE) with coccygectomy, the completeness of coccygeal resection was assessed by postoperative CT scan. Data were analysed using binomial and multinomial logistic regression and linear regression. RESULTS: One hundred and twenty-two consecutive rectal cancer resections were performed (39 open, 42 laparoscopic, 12 laparoscopic-converted and 29 robotic). The median age was 72 years (range: 29-88 years). The male:female ratio was 83:39. Eighty-one patients had anterior resection, 8 had low Hartmann's resection and 32 had APE. Of those who had APE, 21 had eLAPE (all with coccygectomy). Females had a larger pelvic inlet (female: 124.9 mm, male: 114.9 mm), interspinous diameter(female:112.8 mm, male:97.6 mm), sacrococcygeal depth (female:42.6 mm, 39.35 mm) and sacrococcygeal area recess than males (female: 3697 mm2, male: 3481.5 mm2). Males had a greater pubic height (female: 51.8 mm, male: 54.05 mm) and greater sacrococcygeal distance (female: 116.7 mm, male: 123.65 mm) than females. In patients having anterior resection, tumour distance from the anal verge (p = 0.004), sacrococcygeal distance (p = 0.006) and sacrococcygeal curvature (p = 0.002) were associated with specimen quality. In patients who had eLAPE, median preoperative coccygeal length was 41 mm (IQR: 35.1-45.5). The median length of coccygeal resection was 9 mm (IQR: 1-17.45 mm). The median length of coccyx remaining postoperatively was 33 mm (IQR: 21.35-39 mm). CONCLUSIONS: Sacrococcygeal curvature and distance as well as tumour distance from the anal margin were associated with specimen quality in anterior resection. Coccygectomy was not performed as completely as surgeons thought. Surgeons should include sacrococcygeal bony anatomy in rectal cancer surgical planning to potentially improve outcomes in both anterior resection and eLAPE approaches.

Impact of contouring variability on oncological PET radiomics features in the lung.

Radiomics features extracted from oncological PET images are currently under intense scrutiny within the context of risk stratification for a variety of cancers. However, the lack of robustness assessment poses problems for their application across institutions and for broader patient populations. The objective of the current study was to examine the extent to which radiomics parameters from oncological PET vary in response to manual contouring variability in lung cancer. Imaging data employed in the study consisted of 26 PET scans with lesions in the lung being created through the use of an anthropomorphic phantom in conjunction with Monte Carlo simulations. From each of the simulated lesions, 25 radiomics features related to the gray-level co-occurrence matrices (GLCOM), gray-level size zone matrices (GLSZM), and gray-level neighborhood difference matrices (GLNDM) were extracted from ground truth contour and from manual contours provided by 10 raters in regard to four intensity discretization schemes with number of gray levels of 32, 64, 128, and 256, respectively. The impact of interrater variability in tumor delineation upon the agreement between raters on radiomics features was examined via interclass correlation and leave-p-out assessment. Only weak and moderate correlations were found between segmentation accuracy as measured by the Dice coefficient and percent feature error from ground truth for the vast majority of the features being examined. GLNDM-based texture parameters emerged as the top performing category of radiomcs features in terms of robustness against contouring variability for discretization schemes engaging number of gray levels of 32, 64, and 128 while GLCOM-based parameters stood out for discretization scheme engaging 256 gray levels. How and to what extent interrater reliability of radiomics features vary in response to the number of raters were largely feature-dependent. It was concluded that impact of contouring variability on PET-based radiomics features is present to varying degrees and could be experienced as a barrier to convey PET-based radiomics research to clinical relevance.

A prospective observational study testing liquid crystal phase change type thermometer placed on skin against oesophageal/pharyngeal placed thermometers in participants undergoing general anesthesia.

BACKGROUND: Patient outcomes are influenced by intraoperative temperature management. Oesophageal/pharyngeal temperature monitoring is the standard of care at our institute but is not well tolerated in awake patients. Many non-invasive temperature monitors have been studied. Only the TraxIt® Wearable Children's Underarm Thermometer which contains liquid crystals that undergo phase changes according to temperature is available at our institution. We tested these non-invasive monitors against our standard of care which is the oesophageal/pharyngeal temperature monitor. METHODS: We conducted a prospective observational study of 100 patients receiving general anaesthesia for elective surgery. Patients were eligible for inclusion if they were ≥ 18 years old, were planned to have a general anaesthetic > 60 min during which no body cavity (chest or abdomen) would be opened. Patient temperature was measured with an oesophageal/pharyngeal thermistor probe and skin surface temperature monitors placed over the forehead, in the axilla, over the sternum, and behind the ear (over major vessels to the brain). Temperatures were recorded and then analysed using Altman-Bland plots. Pre-determined clinically relevant limits of agreement were set at -/+ 0.5 °C. RESULTS: From the 100 patients we collected 500 data points for each monitor with an average monitoring time of 102 min (30-300 min) across a range of surgical procedures. None of the skin surface temperature monitors achieved the pre-determined limits of agreement and results were impacted by the use of a forced air warmer. CONCLUSION: The TraxIt® Wearable Children's Underarm Thermometers are not suitable for temperature monitoring during general anaesthesia.

The role of the neutrophil:lymphocyte ratio (NLR) and the CRP:albumin ratio (CAR) in predicting mortality following emergency laparotomy in the over 80 age group.

INTRODUCTION: Emergency laparotomy in the elderly is an increasingly common procedure which carries high morbidity and mortality. Risk prediction tools, although imperfect, can help guide management decisions. Novel markers of surgical outcomes may contribute to these scoring systems. The neutrophil:lymphocyte ratio (NLR) and CRP:albumin ratio (CAR) have been associated with outcomes in malignancy and sepsis. We assessed the use of ratio NLR and CAR as prognostic indicators in patients over the age of 80 undergoing emergency laparotomy. METHODS: A retrospective analysis of all patients over the age of 80 who underwent emergency laparotomy during a 3 year period was conducted. Pre and post-operative NLR and CAR were assessed in relation to outcome measures including inpatient, 30-day and 90-day mortality. Statistical analysis was conducted with Mann-Whitney U, receiver operating characteristics, Spearmans rank correlation coefficient and chi-squared tests. RESULTS: One hundred and thirty-six patients over the age of 80 underwent emergency laparotomy. Median age was 84 years (range 80-96 years). Overall inpatient mortality was 19.2%. Pre-operative and post-operative NLR and CAR were significantly raised in patients with sepsis v no sepsis (p < 0.05). Pre-operative NLR was significantly associated with inpatient (p = 0.046), 30-day (p = 0.02) and 90-day mortality (p = 0.01) in patients with visceral perforation. A pre-operative NLR value of greater than 8 was associated with significantly increased mortality (p = 0.016, AUC:0.78). CAR was not associated with mortality. CONCLUSION: Pre-operative NLR is associated with mortality in patients with visceral perforation undergoing emergency laparotomy. NLR > 8 is associated with a poorer outcome in this group of patients. CAR was not associated with mortality in over-80s undergoing emergency laparotomy.

Ankle Arthrodesis: A Retrospective Analysis Comparing Single Column, Locked Anterior Plating to Crossed Lag Screw Technique.

Ankle arthrodesis is performed to eliminate pain due to end-stage osteoarthritis, regardless of etiology. This procedure remains the reference standard treatment for end-stage ankle arthritis, despite recent advancements in total ankle replacement. The objective of the present study was to retrospectively evaluate the radiographic and clinical fusion rates and time to bony fusion for patients who underwent ankle arthrodesis using an anterior approach with a single column locked plate construct versus crossed lag screws. We identified 358 patients who had undergone ankle arthrodesis from January 2003 to June 2013. Of the 358 patients, 83 (23.2%) met the inclusion criteria for the present study. Of the 83 included patients, 47 received locked anterior (or anterolateral) plate fixation, and 36 received crossed lag screw constructs. The overall nonunion rate was 6.0% (n = 5), with 1 nonunion in the anterior plate group (2.1%) and 4 nonunions in the crossed lag screw group (11.1%; p = .217). No differences were identified between the 2 groups for normal talocrural angle [χ2 (1) = 0.527; p = .468], normal tibial axis/talar ratio [χ2 (1) = 0.004; p = .952], and lateral dorsiflexion angle (p = .565). Based on our findings in similar demographic groups, ankle arthrodesis using locked anterior plate fixation is a safe technique with similar complication rates and radiographic outcomes to those of crossed lag screws.

Arthroscopic Evaluation of Syndesmotic Instability in a Cadaveric Model.

BACKGROUND: Ankle fractures are among the most common lower extremity injuries. Proper care requires evaluation for syndesmotic ligament disruption. Ankle arthroscopy has been proposed as an intraoperative tool that can evaluate stability. Our focus was to evaluate the amount of displacement produced in the coronal, sagittal, and transverse planes visualized through ankle arthroscopy in a cadaveric model. METHODS: Seven below-knee specimens were mounted in a traction tower. Four groups were evaluated: no ligamentous disruption; anterior inferior tibiofibular ligament and interosseous ligament disruption; above plus anterior talofibular ligament and calcaneofibular ligament disruption; and posterior inferior tibiofibular ligament and transverse ligament disruption. Force was applied and measured using a digital scale. The amount of displacement of the fibula in relation to the center of the incisura was measured under arthroscopic evaluation using a calibrated probe. RESULTS: An intact syndesmosis and lateral ankle ligaments provided multiplanar stability. In group 2, syndesmosis diastasis was appreciated in the transverse-external rotation plane with as little as 6 lb of force. In group 3, a greater amount of displacement was appreciated with less force. Multiplane instability was visible in every specimen with as little as 2 lb of force. Group 4 specimens were completely disrupted and so grossly unstable that testing was impossible. CONCLUSION: Ankle arthroscopy has the potential to evaluate even partial disruption of the syndesmotic ligament complex. Instability in the sagittal and transverse planes was encountered early in the spectrum of disruption. Traditional evaluation methods have poor sensitivity for instability in these planes. CLINICAL RELEVANCE: Arthroscopic evaluation of subtle displacement in multiple planes may assist the surgeon in understanding the extent of the syndesmotic injury. Further studies are necessary to determine to what extent instability requires fixation as well as the role for arthroscopy in assessing anatomic reduction of the syndesmosis after fixation is performed.

Comparing fixation used for calcaneal displacement osteotomies: a look at removal rates and cost.

BACKGROUND: The calcaneal displacement osteotomy is a procedure frequently used by foot and ankle surgeons for hindfoot angular deformity. Traditional techniques use compression screw fixation that can result in prominent hardware. While the results of the procedure are generally good, a common concern is the development of plantar heel pain related to prominent hardware. The primary purpose of this study is to retrospectively compare clinical outcomes of 2 fixation methods for the osteotomy. Secondarily a cost analysis will compare implant costs to hardware removal costs. METHODS: Records were reviewed for patients who had undergone a calcaneal displacement osteotomy fixated with either lag screw or a locked lateral compression plate (LLCP). Neuropathy, previous ipsilateral calcaneus surgery, heel pad trauma, or incomplete radiographic follow-up were exclusionary. RESULTS: Thirty-two patients (19.4%) required hardware removal from the screw fixation group compared to 1 (1.6%) of the LLCP group, which is significant (P < .05). Time to radiographic healing was not significantly different (P = .87). The screw fixation group required more follow-up visits over a longer period of time (P < .05). Implant cost was remarkably different with screw fixation costing on average $247.12, compared to the LLCP costing $1175.59. Although the LLCP cost was significantly higher, cost savings were identified when the cost of removal and removal rates were included. CONCLUSION: This study demonstrates that this device provides adequate stabilization for healing in equivalent time to screw fixation. The LLCP required decreased rates of hardware removal with fewer postoperative visits over a shorter period of time. Significant savings were demonstrated in the LLCP group despite the higher implant cost. LEVELS OF EVIDENCE: Therapeutic, Level III, Retrospective Comparative Study.

The aetiology of delay to commencement of adjuvant chemotherapy following colorectal resection.

PURPOSE: Timely administration of adjuvant chemotherapy following colorectal resection is associated with improved outcome. We aim to assess the factors which are associated with delay to adjuvant chemotherapy in patients who underwent colorectal resection as part of an enhanced recovery protocol. METHOD: A univariate and multivariate analysis of patient data collected as part of a prospectively maintained database of colorectal cancer patients between 2007 and 2012. RESULTS: 166 patients underwent colorectal resection followed by adjuvant chemotherapy. Median postoperative hospital stay was 6 days, and time to commencement of adjuvant chemotherapy was 50 days. Longer inpatient stay correlated with increased time to adjuvant chemotherapy (P = 0.05). Factors found to be independently associated with duration of hospital stay and time to commencement of adjuvant chemotherapy included stoma formation (P = 0.032), anastaomotic leak (P = 0.027), and preoperative albumin (P = 0.027). The use of laparoscopic surgery was associated with shorter time to adjuvant chemotherapy but did not reach significance (P = 0.143). CONCLUSION: A number of independent variables associated with delay to adjuvant therapy previously not described have been identified. Further work may be required to elucidate the effect that these variables have on long-term outcome.

Spontaneous antibodies against Engrailed-2 (EN2) protein in patients with prostate cancer.

We reported the expression of the homeodomain-containing transcription factor Engrailed-2 (EN2) in prostate cancer and showed that the presence of EN2 protein in the urine was highly predictive of prostate cancer. This study aimed to determine whether patients with prostate cancer have EN2 autoantibodies, what the prevalence of these antibodies is and whether they are associated with disease stage. The spontaneous immunoglobulin (Ig)G immune response against EN2 and for comparison the tumour antigen New York Esophageal Squamous Cell Carcinoma 1 (NY-ESO-1), were tested by enzyme-linked immunosorbent assay (ELISA) in three different cohorts of prostate cancer patients as well as a group of men genetically predisposed to prostate cancer. Thirty-two of 353 (9·1%) of the SUN cohort representing all stages of prostate cancer demonstrated EN2 IgG responses, 12 of 107 patients (11·2%) in the advanced prostate cancer patients showed responses, while only four of 121 patients (3·3%) with castrate-resistant prostate cancer showed EN2 autoantibodies. No significant responses were found in the predisposed group. Anti-EN2 IgG responses were significantly higher in patients with prostate cancer compared to healthy control males and similarly prevalent to anti-NY-ESO-1 responses. While EN2 autoantibodies are not a useful diagnostic or monitoring tool, EN2 immunogenicity provides the rationale to pursue studies using EN2 as an immunotherapeutic target.

Circumferential resection margin (CRM) positivity after MRI assessment and adjuvant treatment in 189 patients undergoing rectal cancer resection.

PURPOSE: The management of rectal cancer relies on accurate MRI staging. Multi-modal treatments can downstage rectal cancer prior to surgery and may have an effect on MRI accuracy. We aim to correlate the findings of MRI staging of rectal cancer with histological analysis, the effect of neoadjuvant therapy on this and the implications of circumferential resection margin (CRM) positivity following neoadjuvant therapy. METHODS: An analysis of histological data and radiological staging of all cases of rectal cancer in a single centre between 2006 and 2011 were conducted. RESULTS: Two hundred forty-one patients had histologically proved rectal cancer during the study period. One hundred eighty-two patients underwent resection. Median age was 66.6 years, and male to female ratio was 13:5. R1 resection rate was 11.1%. MRI assessments of the circumferential resection margin in patients without neoadjuvant radiotherapy were 93.6 and 88.1% in patients who underwent neoadjuvant radiotherapy. Eighteen patients had predicted positive margins following chemoradiotherapy, of which 38.9% had an involved CRM on histological analysis. CONCLUSIONS: MRI assessment of the circumferential resection margin in rectal cancer is associated with high accuracy. Neoadjuvant chemoradiotherapy has a detrimental effect on this accuracy, although accuracy remains high. In the presence of persistently predicted positive margins, complete resection remains achievable but may necessitate a more radical approach to resection.

Characterization of salt interferences in second-harmonic generation detection of protein crystals.

Studies were undertaken to assess the merits and limitations of second-harmonic generation (SHG) for the selective detection of protein and polypeptide crystal formation, focusing on the potential for false positives from SHG-active salts present in crystallization media. The SHG activities of salts commonly used in protein crystallization were measured and quantitatively compared with reference samples. Out of 19 salts investigated, six produced significant background SHG and 15 of the 96 wells of a sparse-matrix screen produced SHG upon solvent evaporation. SHG-active salts include phosphates, hydrated sulfates, formates and tartrates, while chlorides, acetates and anhydrous sulfates resulted in no detectable SHG activity. The identified SHG-active salts produced a range of signal intensities spanning nearly three orders of magnitude. However, even the weakest SHG-active salt produced signals that were several orders of magnitude greater than those produced by typical protein crystals. In general, SHG-active salts were identifiable through characteristically strong SHG and negligible two-photon-excited ultraviolet fluorescence (TPE-UVF). Exceptions included trials containing either potassium dihydrogen phosphate or ammonium formate, which produced particularly strong SHG, but with residual weak TPE-UVF signals that could potentially complicate discrimination in crystallization experiments using these precipitants.

Characteristics of pain in hospitalized medical patients, surgical patients, and outpatients attending a pain management centre.

BACKGROUND: The characteristics and psychological impact of pain suffered by medical inpatients has been relatively under-investigated. The aim of this study was to compare the pain experience of medical, surgical inpatients, and patients attending a pain management centre. Some aspects of the quality of pain scoring and prescribing were also audited. METHODS: Medical inpatients with significant pain (moderate or severe pain on a verbal rating scale) were assessed using a battery of psychometric questionnaires. Comparator samples of surgical inpatients and patients attending the pain management centre were recruited. RESULTS: The prevalence of significant pain did not differ between the medical group (n=37) and the surgical group (n=38) (16.7% and 19.9%). Chronic pain was common in the medical group (54%) and the surgical group (50%). There were no differences in psychometric variables between the medical and surgical groups. Clinically significant scores for anxiety and depression (HADS ≥11) were common in all groups (30-38%). There was less concordance between patient-reported pain scores and nurse-recorded pain scores in the medical group than the surgical group and analgesic prescribing differed between the two groups. CONCLUSIONS: The characteristics of pain in the medical and surgical groups were similar, with high levels of anxiety and depression. The pain management group differed from the inpatient groups, with higher levels of psychopathology and poorer coping. These findings provide some insight into the complex nature of pain in hospital inpatients, and may inform where limited resources should be utilized to provide greatest patient benefit.

A multi-tiered intervention to address behavioural and cognitive changes after diagnosis of primary brain tumour: a feasibility study.

PURPOSE: Untreated behavioural and cognitive changes after primary brain tumour (PBT) can result in challenging behaviours (CBs), with limited documentation on treatment approaches. This study explored the feasibility of employing a Behavioural Consultancy approach to manage CBs, targeting individuals with PBT, family and treating staff. METHODS: Participants were patients and families of two hospitals and health professionals from cancer/neurological services. A single-case experimental design piloted skill-based training and environmental changes in managing socio-behavioural impairments in a person with a low grade astrocytoma. A half-day workshop to train family members (n = 7) in compensatory strategy use to manage CBs after PBT was piloted. Finally, a 1-day workshop was provided to 43 health professionals in managing CBs after PBT. For both workshops, a pre-post impact evaluation was conducted employing a purpose-designed Strategies Use Measure. RESULTS: All three interventions demonstrated positive results. The single case showed a 71% decrease in the target behaviour (time spent talking) post-intervention. Some attrition to these gains was observed at two follow-up time points (3 and 5 months). Participants from both workshops demonstrated significant post-intervention increases in perceived knowledge of Strategy Use (family members z = 2.03, p < 0.05; health professionals z = 4.95, p < 0.00; Wilcoxon signed-rank test). CONCLUSIONS: These initial studies highlight the potential of employing an integrated multi-tiered intervention based on a Behavioural Consultancy model to manage CBs after PBT.

Tracheal intubation in the critically ill: a multi-centre national study of practice and complications.

BACKGROUND: Complications associated with tracheal intubation may occur in up to 40% of critically ill patients. Since practice in emergency airway management varies between intensive care units (ICUs) and countries, complication rates may also differ. We undertook a prospective, observational study of tracheal intubation performed by critical care doctors in Scotland to identify practice, complications, and training. METHODS: For 4 months, we collected data on any intubation performed by doctors working in critical care throughout Scotland except those in patients having elective surgery and those carried out before admission to hospital. We used a standardized data form to collect information on pre-induction physical state and organ support, the doctor carrying out the intubation, the techniques and drugs used, and complications noted. RESULTS: Data from 794 intubations were analysed. Seventy per cent occurred in ICU and 18% occurred in emergency departments. The first-time intubation success rate was 91%, no patient required more than three attempts at intubation, and one patient required surgical tracheostomy. Severe hypoxaemia ( <80%) occurred in 22%, severe hypotension (systolic arterial pressure <80 mm Hg) in 20%, and oesophageal intubation in 2%. Three-quarters of intubations were performed by doctors with more than 24 months formal anaesthetic training and all but one doctor with <6 months training had senior supervision. CONCLUSIONS: Tracheal intubation by critical care doctors in Scotland has a higher first-time success rate than described in previous reports of critical care intubation, and technical complications are few. Doctors carrying out intubation had undergone longer formal training in anaesthesia than described previously, and junior trainees are routinely supervised. Despite these good results, further work is necessary to reduce physiological complications and patient morbidity.

Combination of a fusogenic glycoprotein, pro-drug activation and oncolytic HSV as an intravesical therapy for superficial bladder cancer.

BACKGROUND: There are still no effective treatments for superficial bladder cancer (SBC)/non-muscle invasive bladder cancer. Following treatment, 20% of patients still develop metastatic disease. Superficial bladder cancer is often multifocal, has high recurrences after surgical resection and recurs after intravesical live Bacillus Calmette-Guérin. Oncovex(GALV/CD), an oncolytic herpes simplex virus-1, has shown enhanced local tumour control by combining oncolysis with the expression of a highly potent pro-drug activating gene and the fusogenic glycoprotein. METHODS: In vitro fusion/prodrug/apoptotic cell-based assays. In vivo orthotopic bladder tumour model, visualised by computed microtomography. RESULTS: Treatment of seven human bladder carcinoma cell lines with the virus resulted in tumour cell killing through oncolysis, pro-drug activation and glycoprotein fusion. Oncovex(GALV/CD) and mitomycin C showed a synergistic effect, whereas the co-administration with cisplatin or gemcitabine showed an antagonistic effect in vitro. Transitional cell cancer (TCC) cells follow an apoptotic cell death pathway after infection with Oncovex(GALV/CD) with or without 5-FC. In vivo results showed that intravesical treatment with Oncovex(GALV/CD) + prodrug (5-FC) reduced the average tumour volume by over 95% compared with controls. DISCUSSION: Our in vitro and in vivo results indicate that Oncovex(GALV/CD) can improve local tumour control within the bladder, and potentially alter its natural history.

Radiotherapy treatment of keloid scars with a kilovoltage X-ray parallel pair.

An established treatment for keloids is surgery and radiotherapy, using a single applied field. However, earlobe keloids lend themselves to a parallel opposed pair approach. Delivery with a superficial X-ray unit is practicable and improves homogeneity within the treatment volume. It has been implemented in this centre since 2007.