Out of hours magnetic resonance imaging for suspected cauda equina syndrome: lessons from a comparative study across two centres.

BACKGROUND: Cauda equina syndrome, a rare but disabling spinal surgical emergency, requires prompt investigation, ideally using magnetic resonance imaging as patients may require decompressive surgery. Out of hours access to magnetic resonance imaging is only routinely available in major trauma centres and neurosurgical units. Patients in regional hospitals with suspected cauda equina syndrome may require transfer for diagnostic imaging. We retrospectively studied the proportion of patients referred with suspected cauda equina syndrome who required out of hours transfer for magnetic resonance imaging and decompressive surgery. MATERIALS ANDS METHODS: Retrospective cohort study of patients referred using online referral platforms with suspected acute cauda equina syndrome and transferred out of hours between 6pm to 8am on weekdays and all day on weekends to two of the largest neurosurgical units in the UK in Birmingham and Cambridge. RESULTS: A total of 441 patients were referred across both sites with a suspicion of acute cauda equina syndrome; 339 patients were transferred for diagnostic scans and only 16 of them (4.7%) were positive for cauda equina compression, necessitating prompt decompressive surgery. Of the patients with negative magnetic resonance scans, 50% had their discharge or transfer back to referring hospitals delayed by more than 24 hours. CONCLUSIONS: Over 95% of patients who were transferred for imaging did not undergo emergency decompression. The authors propose a greater role for the provision of out of hours magnetic resonance imaging in all hospitals admitting emergency patients to streamline management.

Establishing scald prevention measures in UK maternity units from takeaway drinks.

AIM: To identify policies on the consumption of hot drinks by patients and visitors on all perinatal and postnatal wards in the United Kingdom, and to seek the opinions of members of the wider burns MDT as to whether standardised patient education or regulation of hot drinks around newborn babies is required. METHODS: All maternity units with postnatal wards across the United Kingdom were surveyed to establish availability of hot drinks on site and whether these were permitted on postnatal wards around infants. An online questionnaire was distributed to members of the British Burn Association to ascertain opinions on hot drinks policies. RESULTS: Hot takeaway drinks were permitted around newborn infants in 194 of surveyed postnatal wards and were only banned by two units. The online survey received 49 responses from different members of the British Burn Association. Thirty responders (61%) supported a takeaway hot drink ban, while those against the policy would alternatively encourage patient education, dedicated drinking areas and introduction of safety measures. CONCLUSIONS: Almost every postnatal unit in the UK has access to hot drink retailers on site allowing parents and visitors to bring them into close contact with babies. With varying local regulations, this poses potentially serious consequences during feeding or carrying. We propose a standardised antenatal education be made available, together with standardised designated areas on wards for parents and visitors to consume hot drinks away from infants.

Poorly differentiated cutaneous squamous cell carcinomas have high incomplete excision rates with UK minimum recommended pre-determined surgical margins.

BACKGROUND: In the UK, the British Association of Dermatology-British Association of Plastic, Reconstructive and Aesthetic Surgery (BAD-BAPRAS) guidelines recommend excision of high-risk cutaneous squamous cell carcinomas (cSCCs), including poorly differentiated cSCCs, with a minimum peripheral margin of 6 mm1. OBJECTIVES: We assess whether the BAD-BAPRAS minimum margin achieves histological clearance in poorly differentiated cSCCs. PATIENTS AND METHODS: Demographics, surgical notes and histological reports from all patients having a primary cSCC excised at the Plastic Surgery Department of Addenbrooke's Hospital, Cambridge, UK, between January 2017 and April 2018 were analysed. Ordinal regression was performed for excision margin status versus histological grade by using size and site as co-variates. RESULTS: Of 296 cSCCs, 38(12.8%) were poorly differentiated. Patients with poorly differentiated cSCCs were older (81.1 years vs. 76.7 years, p = 0.038), had lesions on the face or scalp (89.2% vs. 52.1%, p = 0.0001), and had lymphovascular (10.5% vs. 0%, p = 0.001) or perineural invasion (15.8% vs. 2%, p = 0.002). Well-differentiated cSCCs were excised with an average peripheral margin of 4.72 mm (95% CI 4.25-5.18 mm), while poorly differentiated cSCCs were excised with a margin of 6.42 mm(95% CI 5.58-7.28 mm). Close or involved peripheral margins were seen in 3% of well-differentiated lesions but in 13.2% of poorly differentiated lesions (OR=45.02; p = 0.003). Deep margins were close in 13.1% (none involved) of well-differentiated lesions but close or involved in 50% of poorly differentiated lesions (OR=11.94; p = 0.001). CONCLUSIONS: We demonstrate that poorly differentiated cSCCs are frequently incompletely excised in both peripheral and deep planes, despite adherence to guidelines. The UK BAD-BAPRAS guidelines should be urgently updated in line with international consensus.

A characterization of white matter pathology following spinal cord compression injury in the rat.

Our laboratory has previously described the characteristics of neuronal injury in a rat compression model of spinal cord injury (SCI), focussing on the impact of this injury on the gray matter. However, white matter damage is known to play a critical role in functional outcome following injury. Therefore, in the present study, we used immunohistochemistry and electron microscopy to examine the alterations to the white matter that are initiated by compression SCI applied at T12 vertebral level. A significant loss of axonal and dendritic cytoskeletal proteins was observed at the injury epicenter within 1day of injury. This was accompanied by axonal dysfunction, as demonstrated by the accumulation of ß-amyloid precursor protein (ß-APP), with a peak at 3days post-SCI. A similar, acute loss of cytoskeletal proteins was observed up to 5mm away from the injury epicenter and was particularly evident rostral to the lesion site, whereas ß-APP accumulation was prominent in tracts proximal to the injury. Early myelin loss was confirmed by myelin basic protein (MBP) immunostaining and by electron microscopy, which also highlighted the infiltration of inflammatory and red blood cells. However, 6weeks after injury, areas of new Schwann cell and oligodendrocyte myelination were observed. This study demonstrates that substantial white matter damage occurs following compression SCI in the rat. Moreover, the loss of cytoskeletal proteins and accumulation of ß-APP up to 5mm away from the lesion site within 1day of injury indicates the rapid manner in which the axonal damage extends in the rostro-caudal axis. This is likely due to both Wallerian degeneration and spread of secondary cell death, with the latter affecting axons both proximal and distal to the injury.

Fungal flora in human skin and skin appendages infections in the region of Lódz, Poland.

In the years 1987-95, 3550 patients with mycotic skin infections were divided into two groups: a group of 2282 (64.3%) subjects with dermatophytosis and a group of 1268 (35.7%) subjects with other fungal infections. Among dermatophytes the most common infectious agent was Trichophyton mentagrophytes (33%), followed by T. rubrum (30%) and Microsporum canis (11%). A total of 17% of all infections were caused by Candida sp.