30-day complication rates and patient-reported outcomes following day case primary lumbar microdiscectomy in a regional NHS spinal centre.

INTRODUCTION: Advances in surgical and anaesthesia technique have reduced length of stay for lumbar discectomy. Current evidence suggests that daycase surgery is associated with improved patient satisfaction, faster recovery, reduced infection rates and financial savings. We present our microdiscectomy daycase protocol, together with 30-day postoperative complication rates and patient reported outcomes in an NHS setting. METHODS AND METHODS: We retrospectively studied all patients that met a locally agreed daycase protocol for lumbar microdiscectomy and were operated upon and discharged on the same calendar day between 1 March 2013 and 31 December 2015. RESULTS: A total of 134 patients underwent primary daycase microdiscectomy (70 males, 64 females). The cohort had a mean age of 41 years (range 16-82 years). Some 96% (n = 129) were single-level procedures, 93% were unilateral (n = 125) and 81% (n = 109) took place at either L4/L5 or L5/S1. All patients were discharged on the same day as admission and operation. Four patients re-presented to hospital within 30 days and three were discharged from the emergency department within four hours following a clinical review. One patient required an inpatient stay for a washout of a superficial postoperative infection. Significant improvements (P < 0.05) were found postoperatively for back pain and leg pain on self-reported visual analogue scores and Oswestry Disability Index. CONCLUSION: In this study, we present a safe and effective protocol for day case lumbar microdiscectomy. Our 30-day postoperative complication rate of under 1% is comparable to that of traditional inpatient primary lumbar microdiscectomy. Patient-reported outcome measures revealed significant improvement in both pain and functional scores.

The positive predictive value of asymmetrical skin creases in the diagnosis of pathological developmental dysplasia of the hip.

Aims: The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH). Patients and Methods: Between 1 January 1996 and 31 December 2016, all patients referred to our unit from primary or secondary care with risk factors for DDH were assessed in a "one stop" clinic. All had clinical and sonographic assessment by the senior author (RWP) with the results being recorded prospectively. The inclusion criteria for this study were babies and children referred with asymmetrical skin creases. Those with a neurological cause of DDH were excluded. The positive predictive value (PPV) for pathological DDH was calculated. Results: A total of 105 patients met the inclusion criteria. There were 71 girls and 34 boys. Only two were found to have pathological DDH. Both also had unilateral limited abduction of the hip in flexion and a positive Galeazzi sign with apparent leg-length discrepancy. Thus, if the specialist examination of a patient with asymmetrical skin creases was normal, the PPV for DDH was 0%. Conclusion: Isolated asymmetrical skin creases are an unreliable clinical sign in the diagnosis of pathological DDH. Greater emphasis should be placed on the presence of additional clinical signs to guide radiological screening in babies and children. Cite this article: Bone Joint J 2018;100-B:675-9.

Giant sigmoid diverticulitis mimicking acute appendicitis.

Giant colonic diverticula are a rare manifestation of diverticular disease and there are fewer than 150 cases described in the literature. They may have an acute or chronic presentation or may remain asymptomatic and be found incidentally. As the majority (over 80%) of giant diverticula are located in the sigmoid colon, they usually present with left-sided symptoms but due to the variable location of the sigmoid loop, right-sided symptoms are possible. We describe the acute presentation of an inflamed giant sigmoid diverticulum with right iliac fossa pain. We discuss both the treatment options for this interesting condition and also the important role of computed tomography in the diagnosis and management of abdominal pain in elderly patients.

Elevated plasma MMP1 and MMP9 are associated with abdominal aortic aneurysm rupture.

BACKGROUND: The role of matrix metalloproteinases (MMPs) in abdominal aortic aneurysm (AAA) formation is well established. However the changes in plasma MMP levels with AAA rupture have not been reported. The aim of this study was to determine circulating levels of MMPs in non-ruptured and ruptured AAA immediately prior to open repair. METHODS: Concentrations of MMPs and their endogenous tissue inhibitors (TIMPs) were quantified using ELISA in pre-operative plasma samples from non-ruptured and ruptured AAA. RESULTS: MMP1 and MMP9 were elevated in the plasma of ruptured AAA versus non-ruptured AAA. A four-fold elevation in pre-operative plasma MMP9 was associated with non-survival at 30 days from rupture surgery compared with those surviving for greater than 30 days. CONCLUSION: In conclusion, these findings support the role of MMPs in AAA pathogenesis. Elevation of MMP9 was associated with ruptured aneurysm related 30-day mortality and may represent a survival indicator in this group.

The physiological effects of elevated intra-abdominal pressure following aneurysm repair.

OBJECTIVES: Elevated intra-abdominal pressure (IAP) may cause widespread organ dysfunction (abdominal compartment syndrome) through effects on the respiratory, cardiac, renal and gastro-intestinal systems. The aim of this study was to document IAP following aneurysm surgery, and to determine the effect of IAH on outcome. DESIGN: Prospective observational study. SETTING: University Hospital. SUBJECTS: The patient cohort comprised 75 patients undergoing infra-renal aneurysm repair (53 non-ruptured [40 conventional--1 death, 13 endovascular] and 22 conventionally repaired ruptured AAA--8 deaths). IAP was quantified by bladder manometry at the termination of the procedure and at 24 h intervals in patients who remained intubated. Physiological indices of organ function were recorded. Statistical analysis utilized the unpaired t-test, Fischer's exact test and Pearson's correlation. RESULTS: IAP was significantly higher at abdominal closure following ruptured aneurysm repair (15.4 mmHg [SE 1.6]) than conventional (10.5 [0.89]) or endovascular elective repair (6.4 [1.0]) of non-ruptured AAA. The sensitivity and specificity of IAP to predict subsequent mortality was analysed using a receiver characteristic operating curve. This analysis demonstrated that a cut off of 15 mmHg was the most useful for indicating patients at risk (sensitivity 0.66, specificity 0.79). Physiological indices of organ dysfunction (pH[P = 0.027], base excess [p = 0.005], peak inspiratory pressure [p = 0.0015], CVP and urine output [p = 0.0029]) were significantly impaired in patients with IAP > or = 15 mmHg, in comparison to patients with lower pressures. IAP correlated significantly with indices of cardiac (CVP p = 0.038), respiratory (PaO2/FiO2, p = 0.026), and renal function (urine output p = 0.046). CONCLUSIONS: These data suggest that the management of IAH may have a role following repair of ruptured AAA. High intra-abdominal pressures rarely complicate elective or endovascular aneurysm repair.

Differing features of proteins in membranes may result in antioxidant or prooxidant action: opposite effects on lipid peroxidation of alcohol dehydrogenase and albumin in liposomal systems.

The influence of 3 thiol-containing compounds, bovine serum albumin (fatty acid free: BSA), glutathione (GSH) and yeast alcohol dehydrogenase (YADH) on lipid peroxidation in multilamellar liposomes, prepared from ox-brain phospholipid, was investigated. Thiol-compounds were added either before liposome formation, or after liposome formation; and their effects compared to a positive control. Bovine serum albumin (BSA), an acidic hydrophilic protein, displays a small, concentration dependent, antioxidant effect when added to preformed liposomes. A much larger antioxidant effect was observed when the BSA was entrapped inside the liposome, by adding BSA just prior to liposome preparation. In contrast, a Zn(2+) containing redox enzyme, YADH, a basic hydrophobic membrane-associating protein, displays a large pro-oxidant effect at much lower concentrations especially when entrapped inside the liposome. This was observed also with GSH; but per mole of -SH, YADH was about 18 times as powerful a pro-oxidant perhaps because of structural changes to the membrane. Oxidized glutathione and N-acetylcysteine were also pro-oxidant (cysteine and cystine showed little effect). Formation of thiyl radicals may occur in the presence of iron ions with these pro-oxidant sulphur-containing compounds. Partial protection against lipid peroxidation was observed with EDTA, desferrioxamine and protoporphyrin (IX), potent iron-chelating agents.

Building round the ward.

This month's special feature is devoted to computers and nursing. We look at the possibilities and pitfalls in selecting a nursing management system, ask whether senior nurses are making the most of resource management and quality assurance programmes, and find promising results from an experiment with handheld computers by community nurses.

A kainate receptor linked to nitric oxide synthesis from arginine.

In slices of young rat cerebellum, the glutamate analogue kainate induced a large accumulation of cyclic GMP, which was inhibited by non-N-methyl-D-aspartate antagonists. Quisqualate and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate evoked only small cyclic GMP responses and inhibited the effect of kainate. When tested in cerebellar cell suspensions, glutamate was also a potent antagonist of the cyclic GMP response to kainate. Superoxide dismutase enhanced the response in the isolated cells, whereas haemoglobin and methylene blue were inhibitory. The response in slices was Ca2+ dependent, augmented by arginine, and inhibited by L-NG-monomethylarginine in a manner that could be reversed by additional arginine. It is concluded that stimulation of kainate receptors leads to activation of the enzyme that synthesizes nitric oxide from arginine and that activation of soluble guanylate cyclase by the released nitric oxide accounts for the cyclic GMP generation.

Comparative efficiency of some rapid agglutination antigens for Mycoplasma gallisepticum infection.

Varying compositions of growth media for Mycoplasma galli-septicum were used in attempts to produce rapid slide agglutination antigens of high yield and improved specificity. Some of the media barely supported growth, others yielded antigen no better than that from conventional media. Two media gave good results. One was a conventional medium with horse serum replaced by foetal calf serum. The other was a conventional medium containing 10% horse serum, but at high pH (8.4). When compared with four commercial antigens in tests using antisera to M. gallisepticum, M. synoviae or gamma-globulin both experimental antigens had superior specificity, without loss of sensitivity.