Introducing a new proforma for the safe use of intraoperative tourniquets in orthopaedic surgery.

INTRODUCTION: The routine use of pneumatic tourniquets in orthopaedic surgery is widely adopted in current practice; however, practice varies considerably based mainly on anecdotal and cultural traditions. This Quality Improvement Project evaluated current service as per the newly published British Orthopaedic Association Standards for Trauma & Orthopaedics guideline on 'The Safe Use of Intraoperative Tourniquets'. METHODS: Patient records were reviewed retrospectively for all patients who underwent orthopaedic surgery in September 2021 at one NHS hospital trust. Simultaneously, a nine-question survey was distributed to the orthopaedic teams allowing assessment of non-quantifiable aspects of the guidelines. The results were delivered as a local presentation, and trust-wide dissemination of posters using the mnemonic 'PRESSURE' was used to educate staff. The quantitative audit was repeated twice, after this intervention (March 2022) and after the advent of a new electronic patient record system with an online proforma (January 2023). RESULTS: There was significant improvement (p<0.05) in all aspects of tourniquet documentation between the audit cycles. Maximum advised tourniquet duration was exceeded in <2% of cases regardless of guideline publication. Recommended pressures were used in less than one-third of cases in all audit cycles, with no significant change throughout. More than 50% of respondents sized their tourniquet on 'whatever looked best fit'. CONCLUSIONS: Despite tourniquet usage being part of the UK Trauma & Orthopaedic Surgery curriculum, this study is the first to highlight a lack of compliance with 'gold standard' guidelines and the need for increased training for staff to ensure patients are exposed to the safest possible environment. Although electronic proformas can aid recording of information, the limitation to change is cultural tradition and anecdotal experience.

No Value Found With Routine Early Postoperative Radiographs after Implant Removal in Pediatric Patients.

BACKGROUND: Implants are routinely removed in pediatric patients. Fracture through the prior implant site is a common worry after implant removal. Early post-implant removal radiographs are routinely used to evaluate the prior implant removal sites and to assess when a patient may return to normal activities. To our knowledge, the value of early, routine postoperative radiographs after elective implant removal in pediatric patients has not been studied. METHODS: A retrospective patient cohort of pediatric patients who had implant removal from an extremity from 2017 to 2019 was used in this study. Data were collected for patient demographics, implant site, reason for primary surgery, complications, number of postoperative radiographs, radiation exposure, cost of imaging, and whether the postoperative plan was changed by imaging. RESULTS: Two hundred ninety patients were included in the study. Postoperative plans were changed only in 0.69% of patients (n = 2) because of abnormal 2-week radiographs and 1.72% (n = 5) because of abnormal 6-week radiographs. However, the event's proportion difference (change of management) was not statically significant ( P = 0.182) between those who had a radiograph obtained and those who did not. The mean follow-up time was 16 months. The mean number of postoperative radiographs obtained was 3.74, the mean cost per radiograph was $103, and the mean postoperative radiation exposure was 1.34 mSv. No fractures were observed after implant removal. DISCUSSION: A retrospective review of the value of early, postoperative radiographs after routine orthopaedic implant removal found that postoperative radiographs at 2 and 6 weeks did not change the postoperative plan for most of the patients. Postoperative radiographs have an average cost of $103, and radiation exposure equal to approximately 6 months of natural background radiation. LEVEL OF EVIDENCE: Level III.

FMD vaccine allocation and surveillance resourcing options for a potential Australian incursion.

Australian Animal Disease Spread (AADIS) epidemiological simulation modelling of potential foot-and-mouth disease outbreaks in the state of Victoria, Australia examined the targeted use of limited vaccine supplies in combination with varying surveillance resources. Updated, detailed estimates of government response costs were prepared based on state level data inputs of required and available resources. Measures of outbreak spread such as duration and numbers of animals removed through depopulation of infected and vaccinated herds from the epidemiological modelling were compared to summed government response costs. This comparison illustrated the trade-offs between targeted control strategies combining vaccination-to-remove and varying surveillance capacities and their corresponding costs. For this intensive cattle and sheep producing region: (1) Targeting vaccination toward intensive production areas or toward specialized cattle operations had outbreak control and response cost advantages similar to vaccination of all species. The median duration was reduced by 27% and response costs by 11%. (2) Adding to the pool of outbreak surveillance resources available further decreased outbreak duration and outbreak response costs. The median duration was reduced by an additional 13% and response costs declined by an additional 8%. (3) Pooling of vaccine resources overcame the very early binding constraints under proportional allocation of vaccines to individual states with similar reductions in outbreak duration to those with additional surveillance resources. However, government costs rose substantially by over 40% and introduced additional risk of a negative consumer response. Increased knowledge of the outbreak situation obtained from more surveillance led to better-informed vaccination deployment decisions in the short timeframe they needed to be made.

The use of Tightrope device as the sole method of fixation in treating lateral end clavicle fractures.

BACKGROUND: Lateral end clavicle fractures can be challenging due to the small and often comminuted lateral fragment, problems with union and stability and implant morbidity. We retrospectively reviewed outcomes of Tightrope device in isolation to treat lateral end clavicle fractures. METHODS: Subjective and objective measures were assessed for 29 patients. The subjective comprised of functional clinical scores: Oxford shoulder score and EuroQoL5D. The objective measures were maintenance of fracture reduction, bone healing and complications. RESULTS: Median age was 36 years and 72% of cases were male patients. Average clinical follow up time was 21 months. Evaluation of latest radiographs showed that all reductions were maintained post-operatively. Twenty-two fractures had united and one patient had established non-union. Functional outcomes showed predominantly good results with Oxford shoulder score average of 41, EuroQoL5D index score of 0.78 and EuroQol Visual Analogue Scale 76. The overall post-operative complication rate was 10%; only one case requiring a secondary procedure. DISCUSSION: In our series, using the Tightrope as the sole device to treat displaced lateral end of clavicle fractures resulted in good radiological and functional outcomes, with minimal complications requiring secondary procedures. We believe the Tightrope device is a good method of fixing these challenging fractures and advocate its use.

Economic benefits of implementing trading zones for Australian livestock disease outbreaks of limited duration.

OBJECTIVE: The objective is to estimate the economic benefits of trading zones as part of foot-and-mouth disease (FMD) control measures for limited duration outbreaks. DESIGN: The proposed trading zones for FMD at the state level are determined using multiple tools. Eleven individual incursion scenarios in six Australian states are simulated within the Australian Animal Disease Spread epidemiological model to identify the potential geographic extent of outbreaks, as well as the number of animals infected and the duration of outbreaks. The disease spread information is used to identify the boundaries of trading zones. The outbreak duration data are combined with historical export data to estimate the share of Australian exports that could be embargoed. The market impacts of the potential export embargoes including changes in equilibrium quantities, prices and revenue are simulated within the Australian Bureau of Agricultural and Resource Economics and Sciences' AgEmissions partial equilibrium model of Australian agriculture. RESULTS: Results emphasize the importance of jurisdictional and outbreak characteristics in determining trading zones. Should Australia effectively implement trading zones at the state level in response to small FMD outbreaks, the potential reductions of embargoed exports lead to a reduction in estimated producer revenue losses compared with losses under a national embargo. Producer revenue losses are reduced between $3 billion and $9 billion estimated in present value terms over 10 years at a 7% discount rate. CONCLUSION: Economic analysis of the implications of trading zones identifies additional investments that would be of value to livestock industries.

[Spontaneous craniocervical dissection]. / Spontane Dissektionen der hirnversorgenden Arterien.

Spontaneous craniocervical dissection is one of the main causes of stroke in juvenile and middle-aged patients. It is caused by intramural hematoma which may result in stenosis or even occlusion of the artery. Clinical manifestation varies from local pain to ischemic complications. The imaging modality of choice is magnetic resonance imaging (MRI) which is able to detect all characteristic signs of dissection. Intramural hematoma is detected with thin slice fat-saturated 3D black-blood images. However, with the use of special imaging techniques, questionable findings can be clarified and especially the more difficult to detect intradural dissection can be accurately diagnosed. Acute treatment depends on the severity of neurological symptoms and their duration. Factors like the location of the dissection, cerebral infarction or hemorrhage influence the choice of medication for primary and secondary prophylaxis. Resorption of the intramural hematoma often leads to spontaneous recanalization within a few months.

Experiences and attitudes of hereditary cancer screening patients in a consumer directed testing model.

BACKGROUND: Since 2015, the Information is Power initiative has offered free and reduced cost hereditary cancer screening to the North Alabama population with a consumer-initiated model. Patients received pre-test and post-test education through a genetic counseling video. Positive results also received a call from a genetic counselor. OBJECTIVE: We surveyed past Information is Power patients to assess if video education and electronic result delivery addressed the needs of a hereditary cancer screening population. METHODS: An electronic survey was sent out to Information is Power patients who opted into research contact. The survey assessed participant knowledge, satisfaction with result delivery, and perceived uncertainty after receiving test results. RESULTS: 213 participants completed the survey. Eighteen percent of participants would have preferred individual communication with a genetics specialist about their results. Over 99 % of survey participants correctly interpreted a positive result, while 73 % correctly interpreted a negative result. Overall, participants were certain about the impact of their genetic test results. PRACTICE IMPLICATIONS: These findings support a model of population genetic testing and genetic counseling that is sustainable while meeting the educational needs of most participants. Observed misconceptions surrounding a negative result should be highlighted in future population screening patient resources to meet patient needs.

Challenges and Opportunities Developing Mathematical Models of Shared Pathogens of Domestic and Wild Animals.

Diseases that affect both wild and domestic animals can be particularly difficult to prevent, predict, mitigate, and control. Such multi-host diseases can have devastating economic impacts on domestic animal producers and can present significant challenges to wildlife populations, particularly for populations of conservation concern. Few mathematical models exist that capture the complexities of these multi-host pathogens, yet the development of such models would allow us to estimate and compare the potential effectiveness of management actions for mitigating or suppressing disease in wildlife and/or livestock host populations. We conducted a workshop in March 2014 to identify the challenges associated with developing models of pathogen transmission across the wildlife-livestock interface. The development of mathematical models of pathogen transmission at this interface is hampered by the difficulties associated with describing the host-pathogen systems, including: (1) the identity of wildlife hosts, their distributions, and movement patterns; (2) the pathogen transmission pathways between wildlife and domestic animals; (3) the effects of the disease and concomitant mitigation efforts on wild and domestic animal populations; and (4) barriers to communication between sectors. To promote the development of mathematical models of transmission at this interface, we recommend further integration of modern quantitative techniques and improvement of communication among wildlife biologists, mathematical modelers, veterinary medicine professionals, producers, and other stakeholders concerned with the consequences of pathogen transmission at this important, yet poorly understood, interface.

Evaluating vaccination strategies to control foot-and-mouth disease: a country comparison study.

Vaccination is increasingly being recognised as a potential tool to supplement 'stamping out' for controlling foot-and-mouth disease (FMD) outbreaks in non-endemic countries. Infectious disease simulation models provide the opportunity to determine how vaccination might be used in the face of an FMD outbreak. Previously, consistent relative benefits of specific vaccination strategies across different FMD simulation modelling platforms have been demonstrated, using a UK FMD outbreak scenario. We extended this work to assess the relative effectiveness of selected vaccination strategies in five countries: Australia, New Zealand, the USA, the UK and Canada. A comparable, but not identical, FMD outbreak scenario was developed for each country with initial seeding of Pan Asia type O FMD virus into an area with a relatively high density of livestock farms. A series of vaccination strategies (in addition to stamping out (SO)) were selected to evaluate key areas of interest from a disease response perspective, including timing of vaccination, species considerations (e.g. vaccination of only those farms with cattle), risk area vaccination and resources available for vaccination. The study found that vaccination used with SO was effective in reducing epidemic size and duration in a severe outbreak situation. Early vaccination and unconstrained resources for vaccination consistently outperformed other strategies. Vaccination of only those farms with cattle produced comparable results, with some countries demonstrating that this could be as effective as all species vaccination. Restriction of vaccination to higher risk areas was less effective than other strategies. This study demonstrates consistency in the relative effectiveness of selected vaccination strategies under different outbreak start up conditions conditional on the assumption that each of the simulation models provide a realistic estimation of FMD virus spread. Preferred outbreak management approaches must however balance the principles identified in this study, working to clearly defined outbreak management objectives, while having a good understanding of logistic requirements and the socio-economic implications of different control measures.

Cyanide Toxicity of Freshly Prepared Smoothies and Juices Frequently Consumed.

AIMS: This study was conducted to detect the presence of cyanide in popular fruit and vegetable smoothies and juices marketed as raw and natural. STUDY DESIGN: Eleven (11) popular varieties of drinks were analyzed for total cyanide (TCN). Drinks contained raw vegetables and fruits, flax seeds, whole apples with seeds, raw almond milk, and pasteurized almond milk as ingredients. PLACE AND STUDY DURATION: Samples were collected from health food eateries located within Las Vegas, Nevada (USA) during the summer of 2017. METHODOLOGY: Fifty milliliters (mL) of a homogenized smoothie and juice drink and 1 gram of flax seeds were subjected to the above-referenced methods for sample preparation per USEPA Methods 9012B (digestion) followed by USEPA method 9014 (colorimetry). RESULTS: The highest TCN was detected in drinks containing raw flax seed followed by unpasteurized raw almond milk, then fresh whole apple juice. No TCN was observed in drinks that contained none of the above mentioned items (e.g. flax seed, raw almond milk) or those utilizing pasteurized ingredients. CONCLUSION: This study observed that TCN is present in smoothies and juices containing raw flax seeds, fresh whole apples, and/or unpasteurized almond milk. Concentrations were detected as high as 341 µg L-1 in commercially available smoothies containing vegetables, raw flax seeds, almond milk and fruits. Smoothies with vegetables, fruits, unpasteurized almond milk, and no flax seeds contained 41 ug L-1 TCN, while similar smoothies with pasteurized almond milk contained negligible to 9.6 ug L-1 CN-. Unpasteurized almond milk and raw flax seeds were the major sources of TCN in drinks. With the increased demand for raw and natural foods, there is a potential sublethal exposure of TCN by consumers.

A late presentation of Loeys-Dietz syndrome associated with an aortic root aneurysm.

Loeys-Dietz syndrome (LDS) is characterised by a mutation in the transforming growth factor beta receptor, and is strongly associated with aortic aneurysms and rupture. Most cases of LDS present in the second decade of life, with the average life expectancy being 37 years. We report a case of suspected LDS (owing to significant family history of the disorder) that presented in the seventh decade of life. Our patient had aortic root dilation and was initially believed to have Marfan syndrome. However, subsequent tests were negative. On further investigation of her family history, it was revealed that she had a strong positive family history of aortic rupture and aneurysms associated with genetically confirmed atypical LDS. By reporting this case, we aim to highlight the importance of considering inherited connective tissue disorders when a patient presents with aortic aneurysms or dissections associated with a strong family history of aortic pathology.

A late presentation of Loeys-Dietz syndrome associated with an aortic root aneurysm.

Loeys-Dietz syndrome (LDS) is characterised by a mutation in the transforming growth factor beta receptor, and is strongly associated with aortic aneurysms and rupture. Most cases of LDS present in the second decade of life, with the average life expectancy being 37 years. We report a case of suspected LDS (owing to significant family history of the disorder) that presented in the seventh decade of life. Our patient had aortic root dilation and was initially believed to have Marfan syndrome. However, subsequent tests were negative. On further investigation of her family history, it was revealed that she had a strong positive family history of aortic rupture and aneurysms associated with genetically confirmed atypical LDS. By reporting this case, we aim to highlight the importance of considering inherited connective tissue disorders when a patient presents with aortic aneurysms or dissections associated with a strong family history of aortic pathology.

Testing the differential effects of acceptance and attention-based psychological interventions on intrusive thoughts and worry.

BACKGROUND: Worry is a key component of anxiety and may be an effective target for therapeutic intervention. We compared two psychological processes (attention and acceptance) on the frequency of intrusive worrying thoughts in an experimental worry task. METHOD: 77 participants were randomised across three groups and completed either a 10 min attention or acceptance-based psychological exercise, or progressive muscle relaxation control. We subsequently measured anxiety, and the content and frequency of intrusive thoughts before and after a 'worry induction task'. RESULTS: Groups did not differ in baseline worry, anxiety or thought intrusions. Both attention and acceptance-based groups experienced fewer negative thought intrusions (post-worry) compared to the relaxation control group. The acceptance exercise had the largest effect, preventing 'worry induction'. Increases in negative intrusive thoughts predicted subjective anxiety. DISCUSSION: We provide evidence that acceptance and attention psychological exercises may reduce anxiety by reducing the negative thought intrusions that characterise worry.

Decision-making for foot-and-mouth disease control: Objectives matter.

Formal decision-analytic methods can be used to frame disease control problems, the first step of which is to define a clear and specific objective. We demonstrate the imperative of framing clearly-defined management objectives in finding optimal control actions for control of disease outbreaks. We illustrate an analysis that can be applied rapidly at the start of an outbreak when there are multiple stakeholders involved with potentially multiple objectives, and when there are also multiple disease models upon which to compare control actions. The output of our analysis frames subsequent discourse between policy-makers, modellers and other stakeholders, by highlighting areas of discord among different management objectives and also among different models used in the analysis. We illustrate this approach in the context of a hypothetical foot-and-mouth disease (FMD) outbreak in Cumbria, UK using outputs from five rigorously-studied simulation models of FMD spread. We present both relative rankings and relative performance of controls within each model and across a range of objectives. Results illustrate how control actions change across both the base metric used to measure management success and across the statistic used to rank control actions according to said metric. This work represents a first step towards reconciling the extensive modelling work on disease control problems with frameworks for structured decision making.

Comparison of alternatives to passive surveillance to detect foot and mouth disease incursions in Victoria, Australia.

This study aimed to evaluate strategies to enhance the early detection of foot and mouth disease incursions in Australia. Two strategies were considered. First, improving the performance of the current passive surveillance system. Second, supplementing the current passive system with active surveillance strategies based on testing animals at saleyards or through bulk milk testing of dairy herds. Simulation modelling estimated the impact of producer education and awareness by either increasing the daily probability that a farmer will report the presence of diseased animals or by reducing the proportion of the herd showing clinical signs required to trigger a disease report. Both increasing the probability of reporting and reducing the proportion of animals showing clinical signs resulted in incremental decreases in the time to detection, the size and the duration of the outbreak. A gold standard system in which all producers reported the presence of disease once 10% of the herd showed clinical signs reduced the median time to detection of the outbreak from 20 to 15days, the duration of the subsequent outbreak from 53 to 42days and the number of infected farms from 46 to 32. Bulk milk testing reduced the median time to detection by two days and the number of infected farms by six but had no impact on the duration of the outbreak. Screening of animals at saleyards provided no improvement over the current passive surveillance system alone while having significant resource issues. It is concluded that the most effective way to achieve early detection of incursions of foot and mouth disease into Victoria, Australia is to invest in improving producer reporting.

Cutaneous Chromatophoromas in Captive Snakes.

Chromatophoromas are neoplasms arising from pigment-bearing cells (chromatophores) of the dermis. While isolated cases have been reported in the literature, the prevalence and biological behavior of chromatophoromas in snakes are unknown. Forty-two chromatophoromas were identified among 4663 submissions (0.9%) to a private diagnostic laboratory in a 16-year period. The most commonly affected snakes were colubrids (23 cases, 55%) and vipers (8 cases, 19%). The San Francisco garter snake was the most commonly affected species (6 cases; 14% of all affected snake species and 3.7% of all garter snake submissions). No sex predilection was found. The age of 28 snakes ranged from 5 to 27 years. Single cutaneous chromatophoromas were most commonly observed and presented as pigmented cutaneous masses or plaques along any body segment. Euthanasia or death due to progressive neoplastic disease or metastasis was reported in 8 (19%) and 4 (10%) cases, respectively. The survival time of 4 animals ranged from 4 to 36 months. Microscopically, xanthophoromas, iridophoromas, melanocytic neoplasms, and mixed chromatophoromas were identified, with melanocytic neoplasms being most common. Microscopic examination alone was generally sufficient for the diagnosis of chromatophoroma, but immunohistochemistry for S-100 and PNL-2 may be helpful for diagnosing poorly pigmented cases. Moderate to marked nuclear atypia appears to be consistently present in cutaneous chromatophoromas with a high risk of metastasis, while mitotic count, lymphatic invasion, the level of infiltration, and the degree of pigmentation or ulceration were not reliable predictors of metastasis.

Assessing the delay to detection and the size of the outbreak at the time of detection of incursions of foot and mouth disease in Australia.

The time delay to detection of an outbreak of an emergency animal disease directly affects the size of the outbreak at detection and the likelihood that the disease can be eradicated. This time delay is a direct function of the efficacy of the surveillance system in the country involved. Australia has recently completed a comprehensive review of its general surveillance system examining regional variation in both the behaviour of modelled outbreaks of foot and mouth disease and the likelihood that each outbreak will be detected and reported to government veterinary services. The size of the outbreak and the time delay from introduction to the point where 95% confidence of detection was reached showed significant (p < 0.05) regional variation with the more remote northern areas experiencing smaller outbreaks that are less likely to spread and less likely to be reported to government services than outbreaks in the more developed southern areas of Australia. Outbreaks in the more densely populated areas may take up to 43 days until a 95% confidence of detection is achieved and at that time, the outbreak may involve up to 53 farms.

Estimating Resource Requirements to Staff a Response to a Medium to Large Outbreak of Foot and Mouth Disease in Australia.

A recent report to the Australian Government identified concerns relating to Australia's capacity to respond to a medium to large outbreak of FMD. To assess the resources required, the AusSpread disease simulation model was used to develop a plausible outbreak scenario that included 62 infected premises in five different states at the time of detection, 28 days after the disease entered the first property in Victoria. Movements of infected animals and/or contaminated product/equipment led to smaller outbreaks in NSW, Queensland, South Australia and Tasmania. With unlimited staff resources, the outbreak was eradicated in 63 days with 54 infected premises and a 98% chance of eradication within 3 months. This unconstrained response was estimated to involve 2724 personnel. Unlimited personnel was considered unrealistic, and therefore, the course of the outbreak was modelled using three levels of staffing and the probability of achieving eradication within 3 or 6 months of introduction determined. Under the baseline staffing level, there was only a 16% probability that the outbreak would be eradicated within 3 months, and a 60% probability of eradication in 6 months. Deployment of an additional 60 personnel in the first 3 weeks of the response increased the likelihood of eradication in 3 months to 68%, and 100% in 6 months. Deployment of further personnel incrementally increased the likelihood of timely eradication and decreased the duration and size of the outbreak. Targeted use of vaccination in high-risk areas coupled with the baseline personnel resources increased the probability of eradication in 3 months to 74% and to 100% in 6 months. This required 25 vaccination teams commencing 12 days into the control program increasing to 50 vaccination teams 3 weeks later. Deploying an equal number of additional personnel to surveillance and infected premises operations was equally effective in reducing the outbreak size and duration.

Chordomas at High Prevalence in the Captive Population of the Endangered Perdido Key Beach Mouse (Peromyscus polionotus trissyllepsis).

The Perdido Key beach mouse (Peromyscus polionotus trissyllepsis) is a critically endangered subspecies of the oldfield mouse. The captive population, currently maintained by 3 Florida zoos, is entirely derived from just 3 wild-caught ancestor mice. Necropsy and histopathology revealed chordoma of the vertebral column in 38 of 88 (43%) mice. The tumors were locally expansile and invasive masses of large physaliferous (vacuolated) cells with small, round, hyperchromatic nuclei, similar to the "classic" form of chordomas described in humans. Primary tumors rarely contained small amounts of bone and cartilaginous matrix, characteristic of the "chondroid" form. Neoplastic cells contained abundant granules positive by the periodic acid-Schiff reaction. Brachyury and cytokeratin AE1/AE3 were detected in neoplastic cells by immunohistochemistry, but uncoupling protein 1 was not identified. Primary tumors occurred along the entire vertebral column--cervical, 5 of 38 (13%); thoracic, 16 (42%); lumbar, 13 (34%); and sacral, 10 (26%)--and 10 (26%) mice had multiple primary masses. Metastases to the lungs were noted in 13 of the 38 (34%) mice. Mice diagnosed with chordomas postmortem ranged from 424 to 2170 days old, with a mean of 1399 days. The prevalence of chordoma was not significantly different between males (n = 23 of 50; 46%) and females (n = 15 of 38; 39%).