A review of 100 iatrogenic nerve injuries: delays in referrals remain significant.

INTRODUCTION: This is a retrospective study of 100 consecutive patients with iatrogenic nerve injuries, as seen in a tertiary referral centre over a six-year period. MATERIALS AND METHODS: Patients who presented with new-onset nerve palsy involving a motor or mixed motor/sensory nerve following an operation were studied. RESULTS: There were 44 male and 56 female patients with a mean age of 53 years (range 5-87 years). The median duration from the index procedures to referral was six months (range 0 days to 12 years). Approximately one third of referrals were made over 12 months since the index procedures. Twenty patients recovered spontaneously and were managed expectantly. Eighty patients underwent secondary interventions. DISCUSSION: There remains a significant delay in referring postoperative nerve palsy to a nerve specialist. The majority of these cases will warrant secondary reconstructive surgery and delay in treatment may have a negative effect on the ultimate outcomes.

Prevalence of oral HPV in the adult sample population in Sydney.

BACKGROUND: Oropharyngeal squamous cell carcinomas are increasing in incidence. Risk factors include sexual behaviour, high-risk oral HPV infection and poor oral hygiene. We aimed to provide initial information on the prevalence and assess the feasibility of testing in dental settings. METHODS: Patients ≥18 years old attending dental clinics in Sydney, Australia, were recruited, oral hygiene assessed, and 10 mL saline oral rinses obtained. Rinses were tested for HBG and HPV by PCR. Participants completed demographic and behavioural questionnaires. RESULTS: The mean age was 48 years, of whom 131 (43.6%) were male. HPV genotypes, one each of 16, 66, 51, 35 and 58 in five participants, and 18 and 52 in one participant, were detected in six samples (2.0%), all men. Oral sex was reported by 89 (67.9%) male participants. One participant (4.3%) of the 23 with poor OH had at least one HPV genotype detected. DISCUSSION: With dental patients willing to provide rinse samples and disclose potentially sensitive information, we found the hrHPV prevalence of 2%. Given large proportions of the general population attending dental clinics regularly, dentists may be ideally placed to screen for oropharyngeal carcinoma and contribute to the currently limited knowledge of oral HPV prevalence in Australian adults. © 2022 Australian Dental Association.

The prevalence and effects of on-call stepdown on orthopaedic registrar training: the North West trainees' perspective.

INTRODUCTION: Safe staffing levels are increasingly being threatened by gaps in rotas. When a gap occurs in junior grade on-call rotas the orthopaedic registrar needs to step down and undertake the role of both junior and middle-grade doctor. This increased responsibility could compromise the safety and wellbeing of patients and doctors. This study quantifies the prevalence and effects for trainees of stepdown while on call. MATERIALS AND METHODS: An anonymous online and paper survey of trainees was conducted. The primary outcomes were the prevalence of stepdown in trainees' experience, the effects of stepdown on trainees and patients, and the overall impact on training and morale. RESULTS: The response rate was 93% (n = 51). Of the total, 55% of trainees had experienced stepdown, which occurred a minimum of 84 times, statistically more frequently for expected absences rather than unexpected absences (p = 0.002). Of the trainees who stepped down, 64% felt pressure to do so from seniors and 79% from hospital management. Some 50% of trainees felt that step down was managed in an unsafe manner; 40% of trainees stated that stepdown impacted on their own personal safety and 50% of trainees lost a training opportunity. Overall, 57% of trainees considered that stepdown and rota gaps affected their morale negatively. In 85% of cases there were no issues that resulted in patient harm. CONCLUSION: The survey results suggest that stepdown is common and it does impact negatively upon registrar training, safety and morale. Patient safety overall seems to be well protected.

Cubital Tunnel Decompression: Equivalent Outcome Scores when Procedure Performed with Local versus General Anesthetic.

Background Ulnar nerve compression at the cubital tunnel is the second commonest upper limb neuropathy. Unlike carpal tunnel surgery, most of decompression procedures for this condition are undertaken using general anesthesia (GA). This has inherent economic and patient safety implications. We aimed to assess if there is a difference in early and medium-term outcome scores in patients who have cubital tunnel decompression under general versus local anesthesia (LA). Materials and Methods We undertook a patient outcome evaluation of patients who were under the care of two upper limb surgeons. Patients were evaluated postoperatively using the patient-related ulnar nerve evaluation (PRUNE) questionnaire. Patients were contacted by phone, mail, and face to face in clinics. Results A total of 34 patients were identified in the study. Eleven were excluded from the study. Thirteen patients underwent surgery under LA. The LA group had their procedures performed using local infiltration of the surgical site with 20 mL of 0.5% bupivacaine with adrenaline. Ten patients had their procedures using standard GA and tourniquet. The average PRUNE score in the LA group was 33.8, and that in the GA group was 34.1. This difference in PRUNE score was not statistically significant p > 0.05. Discussion Our data suggest that there is no significant difference in early and midterm outcomes between patients who undergo cubital tunnel decompression using either GA or LA. We advocate the use of LA as it does lead to decreased anesthetic risk and has obvious economic benefits such as lowering the demands on theater and anesthetic resources.

Shift working reduces operative experience for trauma and orthopaedic higher surgical trainees: a UK multicentre study.

INTRODUCTION: In recent years there has been a rise in the number of trauma and orthopaedics trainees working on full shift patterns. Historically, most trauma and orthopaedics trainees worked 24 hours non-resident on-call shifts. The effect of this change in shift patterns has not previously been measured. As two trusts (one trauma unit, one major trauma centre) in our region underwent a change to full shift working, we assessed the impact on the trainees' operating experience. METHODS: Fifty-five logbooks were analysed across the two trusts over a two-year period, with comparisons made between pre- and post-shift working. RESULTS: Overall operating fell by 13% for trainees working full shift patterns, which was statistically significant. There was a loss of elective operating of 15% at the trauma unit and 32% at the major trauma centre for trainees doing shift work. The effect on trauma operating opportunities was mixed. Index operating was largely preserved. CONCLUSIONS: Shift working significantly impacts on surgical training opportunities. We explore approaches to minimising this effect.

Process evaluation of the midwifery initiated oral health-dental service program: perceptions of pregnant women.

BACKGROUND: Pregnant women in Australia seldom seek dental care and are unaware of its importance. To address these gaps the midwifery-initiated oral health dental service (MIOH-DS) program was comprehensive trialled and found effective. The aim of this study was to undertake a process evaluation of the MIOH-DS using the perspectives of pregnant women who participated in the trial. METHODS: A qualitative research design was utilized, whereby content analysis was undertaken on data from 11 semi-structured interviews with women who participated in the program. RESULTS: All participants were receptive of the MIOH-DS intervention, and found it to be an acceptable intervention that met their needs, and encouraged future positive oral health practices and health-seeking behaviours. They expressed that midwives were an appropriate professional to conduct oral health assessments, education and referrals to affordable dental services. Although some participants were initially apprehensive towards receiving treatment during pregnancy, dental staff members were able to appropriately educate and reassure them during treatment. CONCLUSIONS: The MIOH-DS represents a promising and acceptable intervention strategy for pregnant women to promote their oral health. Findings merit further investigation on whether positive outcomes achieved can be sustained when implemented in other national or international settings similar to the study setting.

Knowledge, attitude and practises of dentists towards oral health care during pregnancy: A cross sectional survey in New South Wales, Australia.

BACKGROUND: Studies internationally show a lack of consensus among dentists regarding perinatal oral health yet no study in Australia has explored the perceptions of dentists in this area. This study aims to determine the knowledge, perceptions and practises of dentists in New South Wales (NSW), Australia, about perinatal oral health. METHODS: An online survey was distributed to 1357 members of the Australian Dental Association (NSW) and 185 (13.4%) completed surveys were returned. RESULTS: Most dentists (99%) stated that pregnant women should receive a dental check, yet only 20% agreed that there was a good understanding among health professionals on this topic. Dentists were aware of safe dental practises during pregnancy but had limited knowledge about the association between periodontal disease and birth outcomes. Dentists were more likely to advise pregnant women to delay dental visits when there was a perceived lack of knowledge of the risks involved (odds ratio, 2.157) or were concerned about providing treatment without consent from their general practitioner (odds ratio, 2.449). Most dentists (95.7%) stated that they wanted further information about dental care during pregnancy. CONCLUSIONS: Findings suggest a need for continuing education for dentists and practise guidelines on perinatal oral health. Further research with a national sample is recommended to confirm these findings.

The oral health status, practices and knowledge of pregnant women in south-western Sydney.

BACKGROUND: Current evidence highlights the importance of oral health during pregnancy. However, little is known about the oral health of pregnant women in Australia. The aim of this study was to report the oral health status, knowledge and practices of pregnant women in south-western Sydney. METHODS: A cross-sectional survey of 241 pregnant women attending a large hospital in south-western Sydney. RESULTS: More than half (59.3%) reported dental problems during pregnancy, less than a third (30.5%) saw a dentist in the last six months, only 10% had received any information about perinatal oral health and many (>50%) were unaware of the potential impact of poor maternal oral health on pregnancy and infant outcomes. Analysis revealed a significant difference (<0.05) in the uptake of dental services among pregnant women who had higher household incomes, private health insurance, received information about perinatal oral health and knowledge about maternal oral health. CONCLUSIONS: The participants reported significant barriers to obtaining dental care including limited access to affordable dental services and lack of awareness about the importance of maternal oral health. The findings suggest the need for preventive strategies involving dentists and antenatal providers to improve maternal oral health in Australia.

Gene expression profiling in human endometrial cancer tissue samples: utility and diagnostic value.

OBJECTIVE: Recently, gene expression profiling techniques have been used on several human cancers to classify tumor subgroups with a specific biological behavior, which were previously undetected by the conventional histopathologic staging systems. In the current study, the clinical usefulness and prognostic value of gene expression profiling in human endometrial carcinomas were studied. METHODS: A macro cDNA array, containing cDNAs of 588 genes selected from different areas of cancer research, was used to generate gene expression profiles of tumor tissue samples. The gene expression profiles of 12 endometrial cancers, 3 benign (e.g. noncancer) endometrial tissue samples and 3 myometrial tissue samples, taken from human surgical specimen, were compared. RESULTS: The efficacy to generate a gene expression profile of these tissue samples was 77%. The RNA samples could be randomly taken from the tissue samples and were highly reproducible. Cluster analysis of gene expression profiles of the different samples showed that the benign endometrial and the myometrial samples clustered separately from the tumor samples, indicating that the gene expression profiles were tissue specific and not patient specific. Cluster analysis of the tumor samples revealed two distinct tumor clusters. Ranking of the tumors in the two clusters showed high similarity with the histopathologic classification [International Federation of Gynecology and Obstetrics (FIGO) grading]. CONCLUSION: Classification of endometrial tumors on basis of their gene expression profiles showed similarity with the FIGO grading system.

Oral health status, C-reactive protein and mortality--a 10 year follow-up study.

BACKGROUND: Epidemiological studies have reported a strong association between C-reactive protein (CRP) and cardiovascular diseases (CVD). Elevated CRP levels have been observed both in dentate individuals with chronic dental infections like periodontal disease and in those edentulous. The mechanisms behind these observations, especially the reasons for the elevation of CRP in the edentulous, are poorly understood. The comparative data on the importance of these inflammatory conditions in the oral cavity as causes of elevated CRP levels and CVD risk factors are also limited. OBJECTIVE: To determine if edentulism is associated with increased levels of CRP and investigate the possible mechanism for this association; and to study the influence of periodontal disease and edentulism on 10-year mortality. SUBJECTS: Of the 364 subjects aged 76, 81, and 86 years in 1990, 196 were dentate and 168 edentulous. By December 1999, 179 had died, almost half (n = 87) of them due to cardiovascular disease. RESULTS: Significantly more of the edentulous subjects had elevated (> or = 3 mg/L) CRP levels as compared to those with at least 20 teeth (p < 0.01). They also had high salivary microbial counts (p < 0.05), and more mucosal lesions (p < 0.0001) than those with at least 20 teeth. In multivariate analysis, high microbial counts (OR 2.3, CI 1.06-5.05) and mucosal lesions (OR 2.18, CI 1.03-4.61) were significantly associated with elevated CRP levels. The risk for all-cause mortality was non-significantly elevated among the edentulous (RR 1.48, CI 0.95-2.31) and dentate with periodontal disease (RR 1.58, CI 0.96-2.61). CVD mortality was significantly higher among the dentate with periodontal disease (RR 1.97, CI 1.01-3.85) when compared with dentate without periodontal disease. CONCLUSION: Among the edentulous, chronic infections like denture-related mucosal lesions are important determinants of elevated CRP, comparable to periodontal disease in the dentate. Elevated CRP per se and edentulism were not significantly associated with increased mortality. Periodontal disease was, however, still associated with a two-fold CVD mortality in this very old population.

Periodontal health status and treatment needs among the elderly.

The numbers of dentate elderly are growing rapidly in all industrialized countries, and epidemiological information about their oral health is urgently needed. Our study is part of the population-based Helsinki Ageing Study (HAS), and this paper describes the periodontal health status as well as the need for periodontal treatment among the dentate elderly born in 1904, 1909, and 1914 and living in January, 1989, in Helsinki, Finland (n = 175). The dental examinations were carried out during 1990 and 1991 at the Institute of Dentistry, University of Helsinki, Finland. The subjects' periodontal health was recorded by the CPITN (Community Periodontal Index of Treatment Needs) method. The mean number of remaining teeth was 15.1 among men and 14.0 among women, with the mean number of remaining sextants 3.7 and 3.5, respectively. Healthy periodontal tissues (CPI = 0) were found in 7% of the subjects. Bleeding on probing (CPI = 1) was recorded in 6%, and calculus and/or overhanging margins of restorations (CPI = 2) in 41% of the subjects, as the worst finding. Altogether, 46% of the subjects had deep periodontal pockets, 35% with at least one 4- to 5-mm pocket (CPI = 3), and 11% with at least one > or = 6-mm pocket (CPI = 4). Overall, 93% of the subjects required oral hygiene instruction, 87% scaling and root planing, and 11% complex periodontal treatment. The periodontal treatment need was significantly higher in men than in women; however, no significant differences were observed among the three age cohorts. The need for complex periodontal treatment was unexpectedly low, probably explained by the fact that there were many missing teeth, especially molars, perhaps lost due to poor periodontal health.

Periodontal conditions among the old elderly: five-year longitudinal study.

In the past three decades, there has been a significant rise in the number of old elderly (85+ years old) in Finland, and more of these individuals are retaining their natural teeth. Numerous cross-sectional studies have reported on the periodontal health of the elderly (aged 75+), but very few long-term follow-ups have been reported. This study forms a part of the population-based Helsinki Aging Study (HAS) and compares the periodontal health status and the treatment needs at baseline with those of the same population five years later. The baseline study, in 1990-91, examined the dentate elderly born in 1904, 1909, and 1914, living in Helsinki, Finland (n = 196). The follow-up study was completed in 1995-96 (n = 73). Periodontal status was recorded by means of the Community Periodontal Index of Treatment Needs (CPITN) in 175 dentate subjects (55 males and 120 females) who met the criteria at baseline, and in 57 dentate elderly (17 males and 40 females), aged 81, 86, and 91 years, who remained at follow-up. Among the 57 dentate elderly who participated in both baseline and follow-up examinations, the mean number of teeth decreased from 15.9 to 15.1, and the mean number of remaining sextants from 4.2 to 3.7. There were minor changes in the periodontal health status during this five-year period, with an increase in code 2 (from 43% to 58%) and a decrease in code 3 (from 38% to 25%). Nevertheless, the overall treatment needs remained unchanged. It can be concluded that the periodontal health of the elderly had remained stable for 5 years, and almost no change was observed in their treatment needs. Therefore, periodontal disease in the elderly who are relatively healthy is not caused by the aging process.

Gene expression profiles of human endometrial cancer samples using a cDNA-expression array technique: assessment of an analysis method.

The recently developed cDNA expression array technique can be used to generate gene-expression fingerprints of tumour specimens. To gain insight into molecular mechanisms involved in the development and progression of cancer, this cDNA expression array technique could be a useful tool, however, no established methods for interpreting the results are yet available. We used the Atlas cancer cDNA expression array (Clontech, USA) for analysing total RNA isolated from four human endometrial carcinoma samples (two cell-lines and two tissue samples), one benign endometrial tissue sample and a human breast cancer cell-line, in order to develop a method for analysing the array data. The obtained gene-expression profiles were highly reproducible. XY-scatterplots and regression analysis of the logarithmic transformed data provided a practical method to analyse the data without the need of preceding normalization. Three genes (Decorin, TIMP3 and Cyclin D1) were identified to be differentially expressed between the benign endometrial tissue sample and the endometrial carcinoma samples (tissue and cell-lines). These three genes may potentially be involved in cancer progression. A higher degree of similarity in gene-expression profile was found between the endometrial samples (tissue and cell-lines) than between the endometrial samples and the breast cancer cell-line, which is indicative for an endometrial tissue-specific gene-expression profile.

Massive solitary metastasis of hepatocellular carcinoma in the ovary two years after liver transplantation.

Case report of a 47-year-old woman with a mass in the lower abdomen, was referred to us by the surgeon, two years after orthotopic liver transplantation for hepatocellular carcinoma (HCC). Serum alpha-fetoprotein (AFP), which was elevated at the time of initial diagnosis, was in the normal range. Frozen section examination during exploratory laparotomy showed appearances consistent with metastatic HCC in the ovary. This was confirmed at the final pathological examination. Definitive pathological conclusions were based on the findings of tumor cells arranged in trabecular and papillary aggregates, and the presence of bile-pigment, along with the patients history. This is the sixth case of metastatic HCC in the ovary being described in literature and the first case in which this metastasis was not accompanied by elevated AFP.

Magnetic resonance imaging (MRI) in endometrial carcinoma; preoperative estimation of depth of myometrial invasion.

BACKGROUND: The incidence of pelvic and aortic lymph node involvement in endometrial carcinoma depends on both tumor differentiation grade and myometrial invasion depth. It was evaluated whether magnetic resonance imaging (MRI) provides a preoperative technique to assess the depth of myometrial invasion. METHODS: The study includes 34 patients with an endometrial carcinoma. MRI (T5 Gyroscan, Philips) was made a few days before operation. Myometrial invasion was divided in four categories. Cervical invasion was classified as absent, superficial or deep. For comparison an in vitro MRI of the uterus was made directly after the operation. Histo-pathological examination of the uterus was used as a golden standard of the depth of myometrial invasion. RESULTS: The estimation by MRI of the myometrial invasion depth was correct in 25 out of 31 patients. In three patients estimation was not possible, because of bad image quality. In four patients the MRI underestimated the cervical invasion. CONCLUSIONS: Preoperative MRI in patients with an endometrial carcinoma can be used to estimate myometrial and cervical invasion. Therefore, in combination with the histological grading of the tumor, a preoperative MRI can be used to select patients at high risk of nodal involvement.

The incidence of cervical intraepithelial neoplasia among women with renal transplant in relation to cyclosporine.

OBJECTIVE: To evaluate the policy of an annual smear to screen renal transplant recipients for cervical intraepithelial neoplasia and invasive carcinoma and to determine the incidence of abnormal smears and CIN before and after the introduction of cyclosporine (1983). DESIGN: A retrospective study over the period 1971 to 1992. SUBJECTS: Postmenarchial women who received renal transplants and who were on immunosuppressive treatment for at least one month. MEAN OUTCOME MEASURES: Cytology and histology results. RESULTS: A total of 144 women who received renal transplantation were eligible for our study. Observation time varied from 1 to 227 months (median 59 months) with a mean for the group transplanted before 1983 (Group A) of 103 months, and for the group transplanted after 1983 (Group B) of 46 months. Of these women, 25 had an abnormal smear. Of these, 14 were confirmed by histology and repeated smears of the other 11 patients were negative. Within the 60 women in Group A with an abnormal smear, six had CIN I or CIN II, three had CIN III and one showed adenocarcinoma of the endometrium. Among the 84 women in Group B, four had CIN I or CIN II and none had CIN III. The overall incidence of abnormal cytology was 17.3%, with no invasive cervical carcinoma in this group. CONCLUSIONS: Our policy of screening is adequate. With the introduction of cyclosporine the incidence of abnormal cytology and histology has a tendency to decrease. However, the duration of risk is not comparable yet.

The occurrence of diversion colitis in patients with a sigmoid neovagina.

Diversion colitis is an inflammatory process occurring in segments of the colorectum surgically diverted from the fecal stream. Clinical symptoms of this condition are rectal discomfort, pain, discharge, and bleeding. We diverted isolated segments of sigmoid to create neovaginas in patients with aplasia vaginae and in male to female transsexuals. In contrast to what is reported in most studies of diversion colitis, the neovagina consists of an isolated segment not connected to the anus in patients without any pre-existing bowel disease. To investigate the occurrence of diversion colitis in these sigmoid-neovaginas we studied biopsy specimens from 13 patients. Most of the patients complained of discharge and slight blood loss from their sigmoid-neovagina. Microscopic examination of the biopsy specimens showed lymphocytic infiltration in all cases. Four cases showed an acute inflammatory infiltrate in the lamina propria. Our results indicate that the changes observed on clinical and histopathologic examinations represent the entity of mild diversion colitis. We conclude that diversion colitis also occurs in a sigmoid neovagina.