Estimated cumulative X-ray exposure and additional cancer risk during the evaluation and treatment of scoliosis in children and young people requiring surgery.

INTRODUCTION: Clinicians and patients must weigh the benefits of radiological imaging against the risks of radiation exposure in the diagnosis and treatment of scoliosis. This report aims to estimate the cumulative absorbed and equivalent dose of radiation in patients undergoing surgical treatment for scoliosis, and to present this as an estimated risk of cancer compared to background radiation levels. METHODS: Retrospective review of estimated absorbed dose on the Computerised Radiology Information System (CRIS®). Patients undergoing surgical correction of scoliosis (age ≤ 25) from August 2010 to August 2015 investigated. Estimated absorbed dose [milligrays (mGy)] recorded. Pedicle screws inserted using image intensification. Equivalent dose [millisieverts (mSv)] and additional cancer risk calculated from the National Research Council document 'Health risks from exposure to low levels of ionising radiation' (2006). RESULTS: 271 patients identified. Mean age 15 (range 2-25). Mean total absorbed dose 2136 mGy [standard deviation (SD) 1700 mGy]. Mean number of plain spine radiographs was 8 (SD 3) with total 1884 mGy exposure (SD 1609 mGy). Additional dose provided by CT (mean 0.17 episodes), plain chest and abdominal radiographs and image intensification. Mean number of image intensification episodes was 1.1 with mean estimated exposure 180 mGy (SD 238 mGy). Image intensification accounted for 8% of the estimated absorbed dose during treatment. Estimated mean effective dose delivered was 20.952 mSv equating to an additional cancer risk of 0.27-0.45%. CONCLUSION: Additional cancer risk from cumulative imaging is small and equivalent to approximately 8 years of natural background radiation. Use of image intensification for pedicle screw insertion is a minor contribution (8%) to the total patient dose.

Diagnosis and treatment of confirmed and suspected primary hyperparathyroidism in equids: 17 cases (1999-2016).

BACKGROUND: Primary hyperparathyroidism is uncommon in equids. OBJECTIVES: To describe the diagnostic findings and efficacy of treatment in equids with primary hyperparathyroidism. STUDY DESIGN: Retrospective case series describing 16 horses and one mule. METHODS: Cases were identified by retrospective review of records at Cornell University and via an ACVIM listserv query. Inclusion criteria were an equid with hypercalcemia, normal renal function and high parathyroid hormone (PTH) or histopathological diagnosis of a parathyroid adenoma. Equids with normal PTH and PTH-related protein (PTHrP) in the face of hypercalcemia were included as suspect cases. RESULTS: The most common presenting complaints were weight loss (12/17) and hypercalcemia (10/17). PTH was above reference range in 12/17 cases. Suspected parathyroid tumours were localised in 12/14 equids imaged using ultrasonography alone (2/3), technetium 99m Tc sestamibi scintigraphy alone (1/1) or both modalities (9/10). Three horses did not have imaging performed. Surgical exploration successfully excised tumours in six of 10 cases. Five were located at the thoracic inlet, and surgery resulted in complete cure. One tumour was excised from the thyroid lobe, and the horse remained hypercalcemic. Four other cases explored surgically, four treated medically and three that were not treated also remained hypercalcemic. MAIN LIMITATIONS: The small study size prohibited statistical analysis. CONCLUSIONS: Parathyroid adenomas in equids can be successfully localised with ultrasonography and scintigraphy. Surgical excision appears more likely to be successful for single gland disease at the thoracic inlet.

Operating list composition and surgical performance.

BACKGROUND: Recent reviews suggest that the way in which surgeons prepare for a procedure (warm up) can affect performance. Operating lists present a natural experiment to explore this phenomenon. The aim was to use a routinely collected large data set on surgical procedures to understand the relationship between case list order and operative performance. METHOD: Theatre lists involving the 35 procedures performed most frequently by senior surgeons across 38 private hospitals in the UK over 26 months were examined. A linear mixed-effects model and matched analysis were used to estimate the impact of list order and the cost of switching between procedures on a list while controlling for key prognosticators. The influence of procedure method (open versus minimally invasive) and complexity was also explored. RESULTS: The linear mixed-effects model included 255 757 procedures, and the matched analysis 48 632 pairs of procedures. Repeating the same procedure in a list resulted in an overall time saving of 0·98 per cent for each increase in list position. Switching between procedures increased the duration by an average of 6·48 per cent. The overall reduction in operating time from completing the second procedure straight after the first was 6·18 per cent. This pattern of results was consistent across procedure method and complexity. CONCLUSION: There is a robust relationship between operating list composition and surgical performance (indexed by duration of operation). An evidence-based approach to structuring a theatre list could reduce the total operating time.

The outreach worker role in an anticipatory care programme: a valuable resource for linking and supporting.

OBJECTIVES: Keep Well, an anticipatory care programme which commenced in Scotland in 2006, aims to reduce health inequalities through holistic health checks in primary care in deprived communities. A new, non-clinical outreach worker role was created to provide support and signposting to Keep Well patients following their health check. There is currently little evidence regarding how the role is perceived. The aim of this study was to understand how staff and patients view the Keep Well outreach worker role. STUDY DESIGN: A qualitative interview-based study was carried out between July and October 2010. METHODS: One-to-one interviews were conducted with 12 Keep Well staff and four patients. Interviews were transcribed, coded and analysed using a thematic analysis approach. RESULTS: The outreach worker role was viewed positively, particularly in terms of partnership working with practices and local services, and the benefits of support to patients. Referring patients to outreach workers reduced pressure on staff, who were able to spend more time on patients' physical health rather than mental health or lifestyle support. Support from an outreach worker enabled patients to make changes to their life and their health. Concerns were about staff turnover, poor referral rates, set-up of the project and misinterpretation of the role. CONCLUSION: Patients and staff perceive benefits from the outreach worker role in providing motivational support to patients from deprived areas.

Temporary ectopic implantation of digits prior to reconstruction of a hand without metacarpals.

Temporary ectopic implantation has been described for a variety of injuries, with several different implantation sites used. Although varied results have been achieved, many feel this technique has a role to play under special circumstances. We describe the ectopic implantation of digits to the contralateral forearm, with subsequent reconstruction of the injured hand when combined with microvascular toe transfer. The outcome was a functionally useful hand which could be incorporated into daily life, and a cosmetic appearance preferable to that of amputation. We feel ectopic implantation still has a valuable role to play in carefully selected cases.

Post operative neutrophilic inflammation in equine small intestine after manipulation and ischaemia.

REASONS FOR PERFORMING STUDY: Post operative ileus (POI) remains an important cause of post operative morbidity and mortality in the horse. However, clinical progression of naturally occurring cases of POI in both horse and man does not entirely support the 'neurogenic' hypothesis as the sole mechanism of POI; and the hypothesis that inflammation plays a major role at 12-24 h after surgery requires validation. HYPOTHESIS: An inflammatory infiltrate in the muscularis externa and myenteric plexus of equine jejunum is present 18 h following a period of ischaemia. METHODS: Samples of normal jejunum, jejunum from the proximal resection margins of clinical cases and jejunum obtained 18 h after 1 or 2 h ischaemia or manipulation alone were evaluated for neutrophil infiltration. Samples obtained 18 h after surgery were additionally evaluated for leucocyte activation using calprotectin immunohistochemistry. Results were evaluated by ANOVA and P < 0.05 was considered significant. RESULTS: Significant neutrophilic inflammation was identified in the samples from the proximal resection margins of clinical cases compared to uninjured jejunum. In experimental cases, neutrophilic inflammation appeared to be increased further by 18 h and was identified through all intestinal layers, particularly in the serosa, fascial planes around circular and longitudinal muscle fibres, and myenteric plexus. This elevated level of neutrophilic inflammation was mirrored by an increased number of calprotectin-positive cells in these intestinal layers, indicating leucocyte activation. CONCLUSIONS: Significant neutrophilic inflammation occurs in equine jejunal myenteric layers 18 h after surgery. POTENTIAL RELEVANCE: This neutrophilic inflammation coincides with the clinical time point at which POI is identified and may indicate that inflammatory pathways, rather than solely neurogenic pathways, are responsible for POI in the horse.

Efficacy of low and high dose inhaled corticosteroid in smokers versus non-smokers with mild asthma.

BACKGROUND: Cigarette smokers with asthma are insensitive to short term inhaled corticosteroid therapy, but efficacy when given for a longer duration at different doses is unknown. METHODS: Ninety five individuals with mild asthma were recruited to a multicentre, randomised, double blind, parallel group study comparing inhaled beclomethasone in doses of 400 microg or 2000 microg daily for 12 weeks in smokers and non-smokers. The primary end point was the change in morning peak expiratory flow (PEF). Secondary end points included evening PEF, use of reliever inhaler, number of asthma exacerbations, spirometric parameters, and asthma control score. RESULTS: After 12 weeks of inhaled beclomethasone there was a considerable difference between the morning PEF measurements of smokers and non-smokers with asthma (-18 (95% CI -35 to -1), adjusted p = 0.035). Among those receiving 400 microg daily there was a difference between the mean (95% CI) morning PEF (l/min) in smokers and non-smokers (-25 (95% CI -45 to -4), adjusted p = 0.019) and in the number of asthma exacerbations (6 v 1 in smokers and non-smokers, respectively, p = 0.007). These differences were reduced between smokers and non-smokers receiving 2000 microg inhaled beclomethasone daily. CONCLUSIONS: Compared with non-smokers, smokers with mild persistent asthma are insensitive to the therapeutic effect of low dose inhaled corticosteroid treatment administered for a 12 week period. The disparity of the response between smokers and non-smokers appears to be reduced with high dose inhaled corticosteroid. These findings have important implications for the management of individuals with mild asthma who smoke.

Clinical diagnosis of tears of the rotator cuff.

We have studied the reported clinical assessment of the presence and extent of a rotator cuff tear in 42 patients presenting to a special shoulder clinic. This pre-operative diagnosis was compared with the findings at operation. The clinical tests had a sensitivity of 91% and a specificity of 75%. It is important to exploit clinical examination before resorting to costly and sometimes harmful special investigations.

Apolipoprotein(a): expression and characterization of a recombinant form of the protein in mammalian cells.

We have stably expressed a recombinant form of apo(a) in a human embryonic kidney cell line. The engineered protein (predicted mass of 250 kDa) contains 17 copies of the apo(a) domain, which resembles kringle 4 of plasminogen, followed by the plasminogen-like kringle 5 and protease-like domain of apo(a). The recombinant protein [r-apo(a)] was isolated from cell culture media by immunoaffinity chromatography, and its physical properties were studied. As is the case for apo(a) isolated from plasma-derived Lp(a), r-apo(a) is highly glycosylated (23% by weight), containing both N- and O-linked glycans, which results in an observed molecular mass of 500 kDa by SDS-PAGE. The high sialic acid content was reflected in a pI of 4.3 for the r-apo(a). Two subpopulations of r-apo(a) secreted by the permanent cell line were identified with respect to lysine-Sepharose binding; the majority of the r-apo(a) bound specifically to this matrix and was eluted with epsilon-aminocaproic acid (epsilon-ACA). When the r-apo(a) plasmid was used to transfect a human hepatoma cell line, lipoprotein particles were secreted containing the disulfide-linked complex of apoB-100 and the r-apo(a). The density of these particles was shown to be heterogeneous, with the majority of the r-Lp(a) floating in the density range of plasma-derived Lp(a).