Adductor canal versus femoral triangle anatomical locations for continuous catheter analgesia after total knee arthroplasty: a multicentre randomised controlled study.

BACKGROUND: Adductor canal (AC) catheters are being used to provide continuous postoperative analgesia after total knee arthroplasty (TKA) surgery. There are anatomical arguments that most AC catheters are being inserted into the femoral triangle (FT) compartment of the thigh rather than the AC compartment. The clinical relevance of this is unknown with respect to motor weakness, quality of analgesia, and opioid consumption. We hypothesised that AC catheters provide superior functional mobilisation on postoperative Day 1 after TKA as measured using the Timed Up and Go (TUG) test. METHODS: In this multinational, multicentre, double-blinded RCT, catheters were inserted under ultrasound guidance into the anatomical AC and FT compartments. The standardised protocol included spinal anaesthesia without intrathecal morphine, fixed catheter infusion rates, and oral analgesia. RESULTS: Of 151 subjects recruited, 75 were in the AC group and 76 in the FT group. There was no statistically significant difference in TUG on postoperative Day 1 between AC (38 [29-55] s) and FT subjects (44 [32-64] s) (median [inter-quartile range]); P=0.11). There was no difference in TUG Day 2, AC (38 [27-53] s) vs FT (42 [31-59] s); P=0.66. There were no statistically significant differences for secondary endpoints of pain level, effectiveness of pain relief, interference of functional activities and interpersonal relationships by pain, and opioid consumption between groups. CONCLUSIONS: There were no differences in immediate postoperative functional mobility, analgesia, and opioid consumption provided by catheters inserted into the AC vs FT locations for TKA surgery. CLINICAL TRIAL REGISTRATION: ANZCTR12617001421325.

Psychometric evaluation of a direct observation of procedural skills assessment tool for ultrasound-guided regional anaesthesia.

Assessment tools must be investigated for reliability, validity and feasibility before being implemented. In 2013, the Australian and New Zealand College of Anaesthetists introduced workplace-based assessments, including a direct observation of a procedural skills assessment tool. The objective of this study was to evaluate the psychometric properties of this assessment tool for ultrasound-guided regional anaesthesia. Six experts assessed 30 video-recorded trainee performances of ultrasound-guided regional anaesthesia. Inter-rater reliability, assessed using absolute agreement intraclass correlation coefficients, varied from 0.10 to 0.49 for the nine individual nine-point scale items, and was 0.25 for a 'total score' of all items. Internal consistency was measured by correlation between 'total score' and 'overall performance' scale item (r = 0.68, p < 0.001). Construct validity was demonstrated by the 'total score' correlating with trainee experience (r = 0.51, p = 0.004). The mean time taken to complete assessments was 6 min 35 s.

Prevalence of ketoacidosis at diagnosis of childhood onset Type 1 diabetes in Wales from 1991 to 2009 and effect of a publicity campaign.

AIMS: To determine the proportion of cases of childhood Type 1 diabetes that present with ketoacidosis and any temporal trend. To assess the impact of a publicity campaign promoting earlier diagnosis. METHODS: We used an all-Wales register of incident cases with data on 2046 children from 1991 to 2009. The proportion with ketoacidosis at diagnosis was compared with the Yorkshire Childhood Diabetes Register. On World Diabetes Day posters were sent to every pharmacy, school and general practitioner surgery across Wales and radio interviews given. A questionnaire survey was conducted in Gwent to assess penetrance of the campaign. RESULTS: Annually, in 1991-2009 the proportion presenting with ketoacidosis varied between 20% and 33% (mean 25%) with no change over time. Similar proportions occurred in Yorkshire. Ketoacidosis was more common before age 5 years (37% of cases) than at age 5-9 years (20%) or 10-14 years (23%) (P < 0.001). From November 2006-2007 30% of cases presented with ketoacidosis and from November 2007-2008 25% cases presented with ketoacidosis. After the campaign (November 2008-2009) 26% presented with ketoacidosis (P = 0.72). The information had reached a low proportion of families. General practitioners referred immediately cases that presented to them. CONCLUSIONS: Over 20 years in Wales there has been no change in the proportion of children with Type 1 diabetes initially presenting with ketoacidosis. This presentation occurs in a higher proportion of new cases aged under 5 years. Publicity to increase awareness did not reduce the proportion with ketoacidosis at diagnosis in Wales. We need to get the educational message through to parents to reduce ketoacidosis at presentation.

Feasibility of cerebral near-infrared spectroscopy monitoring in the pre-hospital environment.

BACKGROUND: Traumatic brain injury (TBI) is a significant cause of death and severe disability from trauma. Pre-hospital care of patients with TBI may be aided by non-invasive monitoring of cerebral tissue oxygenation. This pilot observational study was designed to assess if cerebral tissue oximetry using near-infrared spectroscopy (NIRS) is feasible in the pre-hospital and transport environment. METHODS: After ethics committee review, we undertook a feasibility trial in healthy volunteers, transported by road ambulance or helicopter, to assess if monitoring signals could be obtained in the outside environment and during patient transport. RESULTS: A total of 33 road ambulance transports and 32 helicopter transports were undertaken. For monitoring commenced outdoors, 33 of 66 probes applied (50%) provided adequate monitoring signal. For road transports, 33 out of 33 transports (100%) resulted in successful bilateral monitoring for more than 70% of the sampling period. For helicopter transports, four transports were cut short by battery failure during the mission and 24 of 28 transports (85.7%) resulted in successful bilateral monitoring for more than 70% of the sampling period. While patient and transport platform movement did not impact on monitoring signals, exposure to ambient light provided a challenge in obtaining monitoring signals that is nevertheless manageable with increased probe shielding. CONCLUSIONS: NIRS monitoring is feasible in the pre-hospital environment, opening up the possibility for further research of the role of this modality in this setting.

Endocrine immune-related adverse events: Adrenal, parathyroid, diabetes insipidus, and lipoatrophy.

Immune checkpoint inhibitors are being prescribed increasingly widely for a range of malignancies. They are effective at treating certain cancers, but also have significant side effects. Evidence suggests that efficacy is greatest in patients who experience one or more immune-related adverse events (irAEs). Common irAEs include skin and hepatic reactions, and a range of immune-related endocrinopathies. These include hypophysitis, thyroid disease, and autoimmune diabetes mellitus, and rarer endocrinopathies such as primary adrenal insufficiency, diabetes insipidus, parathyroid disease, autoimmune polyglandular syndrome, lipodystrophy, and ACTH-dependent Cushing's syndrome. Herein, we review the current literature related to these rarer immunotherapy-induced endocrinopathies.

A prospective analysis of the role of silicon in wound care.

Silicon is an important micronutrient associated with the development of bone and connective tissue. This article discusses the properties of silicon, its absorption in the human body and its current and potential use in wound management.

Silver absorption and antibacterial efficacy of silver dressings.

OBJECTIVE: To evaluate the patterns of silver release from selected sustained silver-release dressings and the protective role of proteins in wound exudate and wound scale. The bactericidal action of silver in chronic wound therapy is also examined. METHOD: Sequential microbiological examination of wound swabs from seven patients with chronic wounds and sampling of wound exudate and wound scale. Silver content was measured using atomic absorption spectrometry. The ability of Contreet Foam to absorb exudate and release silver was studied in punch biopsy wounds in a rodent model. RESULTS: Silver accumulation in wound exudate correlated well with its viscosity and protein content. Silver bound to wound scale and debris was approximately proportional to the silver ion release from dressings. Bacterial burden was controlled, but not eliminated, following chronic silver therapy. CONCLUSION: Silver dressings (Acticoat-7, Actisorb Silver, Contreet Foam, Aquacel Ag and Flamazine) were found to be safe for use in chronic wound therapy. Excess silver ion is bound by wound exudate and wound scale as a protective mechanism. Silver-release dressings are not likely to result in germ-free wounds. Further studies are needed to examine potential silver resistance.

Interspecies variations in response to topical application of selected zinc compounds.

The dermal irritancy of six zinc compounds was examined in three animal models. In open patch tests involving five daily applications, zinc chloride (1% aqueous solution) was severely irritant in rabbit, guinea-pig and mouse tests, inducing epidermal hyperplasia and ulceration; aqueous zinc acetate (20%) was slightly less irritant. Zinc oxide (20% suspension dilute Tween 80), zinc sulphate (1% aqueous solution) and zinc pyrithione (20% suspension) were not overtly irritant, but induced a marginal epidermal hyperplasia and increased hair growth. Zinc undecylenate (20% suspension) was not irritant. Epidermal irritancy in these studies is related to the interaction of zinc ion with epidermal keratin. The compounds studied were not consistently bacteriostatic in the three species tested.

Experimental evaluation of local reactions due to Dacron used in Tenckhoff catheters for peritoneal dialysis.

Inbred male Wistar rats were implanted subcutaneously with samples of Dacron and Silastic tubing as used in Tenckhoff catheters for peritoneal dialysis, to evaluate their capacity to evoke toxic reactions. Implants of Dacron induced a modest to severe granulomatous reaction with giant cell formation persisting for at least 30 days. Thereafter, this reaction subsided, with Dacron fibers being surrounded by fibrous sheaths. Silastic tubing induced a mild local reaction that regressed by day 10. Predictably, adverse reactions, including erosions, abscesses, and prolonged inflammatory changes noted in clinical patients implanted with Tenckhoff catheters may be attributable to misplacements of the catheters, recurrent infections, or toxic materials from extraneous sources, but not the materials used.

Spinal dysplasia with stump tail and hind limb paralysis in a laboratory bred cat.

A case is presented of a specified pathogen free bred cat which was apparently tail-less at birth and at three weeks of age revealed hind limb paralysis. The animal was euthanized at 4 weeks and X-radiography revealed an abnormal spinal curvature, greatly reduced caudal vertebrae and abnormal pelvic development. A small tail was dissected at post-mortem, but other abnormalities were not seen.

Silver. I: Its antibacterial properties and mechanism of action.

Silver products have two key advantages: they are broad-spectrum antibiotics and are not yet associated with drug resistance. This article, the first in a two-part series, describes the main mechanism of action of this metallic element.

Silver. 2: Toxicity in mammals and how its products aid wound repair.

The second article examining the role of this metallic element in a wound environment discusses toxicity in individual cells, animals and humans and considers how different silver-based dressings assist in wound healing.

How safe is silver in wound care?

Use of silver in burns, chronic ulcers and diabetic ulcers can lead to circulatory absorption and deposits in wound sites, liver, kidney and other organs. Despite this, the risks of lasting tissue damage or functional disorders are low.

Contreet Foam and Contreet Hydrocolloid: an insight into two new silver-containing dressings.

In vitro laboratory tests and preliminary clinical trials have found that two silver-containing dressings, Contreet Foam and Contreet Hydrocolloid, promote healing in infected and chronic venous leg ulcers and diabetic foot ulcers.

A reappraisal of the role of cerium in burn wound management.

A rare earth element, cerium, was introduced as an antibacterial agent in 1976 but has rarely been used due to the emphasis on wound excision. Used in combination with silver sulphadiazine, it may improve patient survival when excision is not possible.

Morphological variations in keratinising epithelia in the beagle.

Six keratinising epithelia in the beagle have been studied using conventional histology and fluorescence methods to identify the nature of the keratin present. Three patterns of differentiation were identified, those present in areas of hairy skin, the foot pad and the tongue and nasal tip. In the first group, the epidermis is generally thin and exhibits a low mitotic rate but the keratin formed is mature. In the foot pad and tongue, which are examples of pressure keratinisation, the epidermis is appreciably thicker because of the presence of a phospholipid-rich cornified layer. A third form of keratinisation is seen in the nasal tip and in regions of the tongue, characterised by parakeratotic changes, high phospholipid accumulation and other features reported previously in keratinising epithelia subject to prolonged hydration.

Trace metals in keratinising epithelia in beagle dogs.

The concentrations of the trace elements zinc, copper and iron and the minerals calcium and magnesium were measured in keratinising epithelia from 12 beagle dogs. The richly vascular tissues of the snout and tongue that showed parakeratotic changes, contained the highest concentrations of iron, zinc and copper. Zinc, calcium and magnesium concentrations were high in the pressure keratinisation tissue of the footpad. There was a high concentration of calcium in the nose tip. The thin skin of the back contained the lowest concentration of all five elements.

Skeletal abnormality of sheep: clinical radiological and pathological account of occurrence of dwarf lambs.

Details are given of the clinical, radiological and pathological appearance of dwarf lambs. Twenty-seven of 110 lambs born were affected, occurring as singletons, twins or one of a pair of twins. All affected lambs were dead within a few minutes of birth. They were short and plump with a domed head and shortened nose, short paddle-like limbs, a narrow thorax and swollen abdomen. The defect involved chondrocyte dysplasia, producing defective endochondral ossification and the presence of abnormal cartilage in the respiratory tract. No specific genetic or environmental cause was identified.

Iron: a cosmetic constituent but an essential nutrient for healthy skin.

Iron compounds have an established role as colorants in many cosmetic products applied to the skin, hair and nails. Evidence is reviewed showing that in addition to its importance as an essential nutrient necessary for oxygen metabolism and mitrochondrial function, iron exhibits a fundamental importance as a trace metal in the normal growth and functional maturation of the skin and in the health of hair and nails. The implications of iron from cosmetic sources in the nutrition of human skin is discussed.

Lack of teratogenic dangers with halothane.

Chronic exposure of pregnant Sprague Dawley rats to a range of halothane concentrations from 50-3200 p.p.m. for 8 hours a day on days 8-12 of gestation failed to demonstrate significant teratogenicity in terms of foetal loss, growth, or skeletal abnormalities. Exposure to 1600 p.p.m. showed significant changes only in foetal weights, which were slightly decreased.