Frontal sinus fracture management: a systematic review and meta-analysis.

A systematic review of the frontal sinus fracture management literature was undertaken to document measurable outcomes, with emphasis on complications associated with the various treatment strategies. A comprehensive electronic search was undertaken in October 2018. Randomized controlled trials (RCT), controlled clinical trials, retrospective and prospective studies describing the management of frontal sinus fractures and complications were included. Twenty-four publications were included: one reporting a prospective RCT and 23 reporting consecutive case series studies (four prospective, 19 retrospective). These included 2388 patients (84.1% male, average age 23-43 years); 50.7% of cases were due to motor vehicle accidents and 61.8% had a concomitant intracranial injury. There were six categories for anterior table reconstruction, three endoscopic surgery categories, 11 for obliteration, and six for cranialization. Forest plots demonstrating complications based on the Clavien-Dindo classification of 1 ('low') and >3 ('high') were determined for total, early, and late complications, with heterogeneous effect sizes. Fractures with a nasofrontal outflow tract (NFOT) injury without obstruction can be treated with reconstruction if displaced, or managed conservatively if undisplaced. Obliteration and cranialization should be considered when there is obstruction of the NFOT. A computed tomography scan should be performed at 6 months to evaluate re-ventilation of the sinus. Endoscopic sinus surgery is a reasonable salvage re-ventilation procedure.

The clinical efficacy of PSMA PET/MRI in biochemically recurrent prostate cancer compared with standard of care imaging modalities and confirmatory histopathology: results of a single-centre, prospective clinical trial.

Prospective evidence for the clinical role and efficacy of prostate specific membrane antigen (PSMA) positron emission tomography (PET)/magnetic resonance imaging (MRI) combining MRI characterization and localization of lesions with PET avidity in comparison to conventional imaging is limited. In a prospective clinical trial, we aimed to evaluate the diagnostic yield and therapeutic impact of PSMA PET/MRI in men with biochemical recurrence (BCR) following curative therapy. A single-centre, prospective clinical trial at the Princess Alexandra Hospital recruited 30 patients with BCR. Patients underwent PSMA PET/MRI and concurrent conventional CT chest, abdomen, pelvis and whole-body bone scan. Biopsy was performed when safety possible for histological correlation of identified lesions. Clinical efficacy and impact of PSMA PET findings were evaluated. 30 patients with BCR were recruited (median PSA 0.69 ng/ml). PSMA avid lesions were present in 21 patients (70%). 23 patients were previously treated with definitive surgery, 6 patients received external beam radiotherapy and 1 patient had low dose rate brachytherapy. A total of 8 of 9 lesions biopsied were positive (88.9% histological correlation). PSMA PET/MRI detected local recurrence (p = 0.005) and pelvic lesions (p = 0.06) more accurately than conventional imaging. PSMA PET/MRI may be useful in staging men with biochemical recurrence, especially when PSA is low. Our data demonstrates a high detection rate, especially for locally recurrent disease, and highlights the role of this modality when PSA is low. This modality has the potential to significantly improve prostate cancer detection and may have implications for earlier salvage treatment, avoidance of futile local therapy and change patient management to lead to improved outcomes.

Total temporomandibular joint replacement prostheses: a systematic review and bias-adjusted meta-analysis.

The aim of the present study was to determine which prosthesis has resulted in the best outcomes after total temporomandibular joint replacement (TMJR). A comprehensive electronic search was undertaken in September 2015. Inclusion criteria encompassed studies that described one of the three current TMJR systems and that had pre- and postoperative data on at least two of the following TMJR indications: pain, diet, function, and maximum inter-incisal opening (MIO). Sixteen papers were included in the systematic review, reporting 10 retrospective studies and six prospective studies (no randomized controlled or case-controlled trials). A total 312 patients with 505 TMJ Concepts prostheses, 728 patients with 1048 Biomet prostheses, and 125 patients with 196 Nexus prostheses were included in the analysis. There was no real difference between the various TMJR systems in terms of pain or diet scores. Function scores improved with the TMJ Concepts, but this was the only prosthesis for which data were available. Biomet prostheses appeared to have a greater increase in MIO mean gain compared to TMJ Concepts and Nexus prostheses; however this was heavily biased by one study. Without this study, there was no real difference in MIO. It is concluded that the prostheses are similar, but most data are available for the TMJ Concepts prosthesis, with results being favourable.

Alpha power indexes task-related networks on large and small scales: A multimodal ECoG study in humans and a non-human primate.

Performing different tasks, such as generating motor movements or processing sensory input, requires the recruitment of specific networks of neuronal populations. Previous studies suggested that power variations in the alpha band (8-12Hz) may implement such recruitment of task-specific populations by increasing cortical excitability in task-related areas while inhibiting population-level cortical activity in task-unrelated areas (Klimesch et al., 2007; Jensen and Mazaheri, 2010). However, the precise temporal and spatial relationships between the modulatory function implemented by alpha oscillations and population-level cortical activity remained undefined. Furthermore, while several studies suggested that alpha power indexes task-related populations across large and spatially separated cortical areas, it was largely unclear whether alpha power also differentially indexes smaller networks of task-related neuronal populations. Here we addressed these questions by investigating the temporal and spatial relationships of electrocorticographic (ECoG) power modulations in the alpha band and in the broadband gamma range (70-170Hz, indexing population-level activity) during auditory and motor tasks in five human subjects and one macaque monkey. In line with previous research, our results confirm that broadband gamma power accurately tracks task-related behavior and that alpha power decreases in task-related areas. More importantly, they demonstrate that alpha power suppression lags population-level activity in auditory areas during the auditory task, but precedes it in motor areas during the motor task. This suppression of alpha power in task-related areas was accompanied by an increase in areas not related to the task. In addition, we show for the first time that these differential modulations of alpha power could be observed not only across widely distributed systems (e.g., motor vs. auditory system), but also within the auditory system. Specifically, alpha power was suppressed in the locations within the auditory system that most robustly responded to particular sound stimuli. Altogether, our results provide experimental evidence for a mechanism that preferentially recruits task-related neuronal populations by increasing cortical excitability in task-related cortical areas and decreasing cortical excitability in task-unrelated areas. This mechanism is implemented by variations in alpha power and is common to humans and the non-human primate under study. These results contribute to an increasingly refined understanding of the mechanisms underlying the selection of the specific neuronal populations required for task execution.

Summarization of Injury and Fatality Factors Involving Children and Youth in Grain Storage and Handling Incidents.

This article summarizes data gathered on 246 documented cases of children and youth under the age of 21 involved in grain storage and handling incidents in agricultural workplaces from 1964 to 2013 in the U.S. that have been entered into the Purdue Agricultural Confined Space Incident Database. The database is the result of ongoing efforts to collect and file information on documented injuries, fatalities, and entrapments in all forms of agricultural confined spaces. While the frequency of injuries and fatalities involving children and youth in agriculture has decreased in recent years, incidents related to agricultural confined spaces, especially grain storage and handling facilities, have remained largely unchanged during the same period. Approximately 21% of all documented incidents involved children and youth (age 20 and younger), and more than 77% of all documented incidents were fatal, suggesting an under-reporting of non-fatal incidents. Findings indicate that the majority of youth incidents occurred at OSHA exempt agricultural worksites. The states reporting the most incidents were Indiana, Iowa, Nebraska, Illinois, and Minnesota. Grain transport vehicles represented a significant portion of incidents involving children under the age of 16. The overwhelming majority of victims were male, and most incidents (50%) occurred in June, October, and November. Recommendations include developing intervention strategies that target OSHA exempt farms, feedlots, and seed processing facilities; preparing engineering design and best practice standards that reduce the exposure of children and youth to agricultural confined spaces; and developing gender-specific safety resources that incorporate gender-sensitive strategies to communicate safety information to the population of young males with the greatest risk of exposure to the hazards of agricultural confined spaces.

Areas V1 and V2 show microsaccade-related 3-4-Hz covariation in gamma power and frequency.

Neuronal gamma-band synchronization (25-80 Hz) in visual cortex appears sustained and stable during prolonged visual stimulation when investigated with conventional averages across trials. However, recent studies in macaque visual cortex have used single-trial analyses to show that both power and frequency of gamma oscillations exhibit substantial moment-by-moment variation. This has raised the question of whether these apparently random variations might limit the functional role of gamma-band synchronization for neural processing. Here, we studied the moment-by-moment variation in gamma oscillation power and frequency, as well as inter-areal gamma synchronization, by simultaneously recording local field potentials in V1 and V2 of two macaque monkeys. We additionally analyzed electrocorticographic V1 data from a third monkey. Our analyses confirm that gamma-band synchronization is not stationary and sustained but undergoes moment-by-moment variations in power and frequency. However, those variations are neither random and nor a possible obstacle to neural communication. Instead, the gamma power and frequency variations are highly structured, shared between areas and shaped by a microsaccade-related 3-4-Hz theta rhythm. Our findings provide experimental support for the suggestion that cross-frequency coupling might structure and facilitate the information flow between brain regions.

The global burden of major infectious complications following prostate biopsy.

We present a systematic review providing estimates of the overall and regional burden of infectious complications following prostate biopsy. A directly standardized prevalence estimate was used because it reflects the burden of disease more explicitly. Complications included sepsis, hospitalization, bacteraemia, bacteriuria, and acute urinary retention after biopsy. There were 165 articles, comprising 162 577 patients, included in the final analysis. Our findings demonstrate that transrectal biopsy was associated with a higher burden of hospitalization (1·1% vs. 0·9%) and sepsis (0·8% vs. 0·1%) compared to transperineal biopsy, while acute urinary retention was more prevalent after transperineal than transrectal biopsy (4·2% vs. 0·9%). The differences were statistically non-significant because of large heterogeneity across countries. We also demonstrate and discuss regional variations in complication rates, with Asian studies reporting higher rates of sepsis and hospitalization.

Factors associated with vancomycin nephrotoxicity in the critically ill.

Vancomycin is a glycopeptide antibiotic commonly used in the management of methicillin-resistant Staphylococcus aureus infection. The recent increase in prevalence of methicillin-resistant Staphylococcus aureus with reduced susceptibility to vancomycin has prompted experts to advocate for higher target trough serum concentrations. This study aimed to evaluate the potential consequences of more aggressive vancomycin therapy, by examining the association between higher serum concentrations and acute kidney injury (AKI) in a population of critically ill patients. We collected data for all patients who received vancomycin over a five-year period and evaluated the prevalence of new-onset AKI using the Risk, Injury, Failure, Loss and End-stage (RIFLE) kidney disease criteria. One-hundred and fifty-nine patients provided complete data, with 8.8% manifesting new onset AKI while receiving vancomycin. The median age was 57 (44 to 68) years, while the median trough serum concentration was 16 (10 to 19) mg/l. Multivariate logistic regression analysis identified mean trough concentration (OR=1.174, P=0.024), APACHE II score (OR=1.141, P=0.012) and simultaneous aminoglycoside prescription (OR=18.896, P=0.002) as significant predictors of AKI. These data suggest higher trough vancomycin serum concentrations are associated with greater odds of AKI in the critically ill.

Determination of Entrapment Victim Extrication Forces with and without Use of a Grain Rescue Tube.

The forces required to extricate a test mannequin from a grain mass when buried at different depths with and without a grain restraint system were determined. When there was no grain restraint system in place, the vertical force required to pull the mannequin from the grain when it was buried waist deep and to the underarms was 1259 and 1766 N (283 and 397 lb(f)), respectively. It increased to 1584 N (356 lb(f)) (+26%) and 2153 N (484 lb(f)) (+22%), respectively, with the restraint in place due to the changes in grain properties brought about by the insertion of the rescue tube. It was concluded that the use of a grain restraint during extrication of a victim does not reduce the forces required and that forcefully pulling an entrapped victim, especially with mechanical assistance, with or without a grain restraint system could result in severe injuries and possible death due to the forces exerted on the victim. The authors recommend that these findings be incorporated into current grain extrication training for emergency first responders.

Safety culture and the 5 steps to safer surgery: an intervention study.

BACKGROUND: Improvements in safety culture have been postulated as one of the mechanisms underlying the association between the introduction of the World Health Organisation (WHO) Surgical Safety Checklist with perioperative briefings and debriefings, and enhanced patient outcomes. The 5 Steps to Safer Surgery (5SSS) incorporates pre-list briefings, the three steps of the WHO Surgical Safety Checklist (SSC) and post-list debriefings in one framework. We aimed to identify any changes in safety culture associated with the introduction of the 5SSS in orthopaedic operating theatres. METHODS: We assessed the safety culture in the elective orthopaedic theatres of a large UK teaching hospital before and after introduction of the 5SSS using a modified version of the Safety Attitude Questionnaire - Operating Room (SAQ-OR). Primary outcome measures were pre-post intervention changes in the six safety culture domains of the SAQ-OR. We also analysed changes in responses to two items regarding perioperative briefings. RESULTS: The SAQ-OR survey response rate was 80% (60/75) at baseline and 74% (53/72) one yr later. There were significant improvements in both the reported frequency (P<0.001) and perceived importance (P=0.018) of briefings, and in five of the six safety culture domain scores (Working Conditions, Perceptions of Management, Job Satisfaction, Safety Climate and Teamwork Climate) of the SAQ-OR (P<0.001 in all cases). Scores in the sixth domain (Stress Recognition) decreased significantly (P=0.028). CONCLUSIONS: Implementation of the 5SSS was associated with a significant improvement in the safety culture of elective orthopaedic operating theatres.

Parametric variation of gamma frequency and power with luminance contrast: A comparative study of human MEG and monkey LFP and spike responses.

Gamma oscillations contribute significantly to the manner in which neural activity is bound into functional assemblies. The mechanisms that underlie the human gamma response, however, are poorly understood. Previous computational models of gamma rely heavily on the results of invasive recordings in animals, and it is difficult to assess whether these models hold in humans. Computational models of gamma predict specific changes in gamma spectral response with increased excitatory drive. Hence, differences and commonalities between spikes, LFPs and MEG in the spectral responses to changes in excitatory drive can lead to a refinement of existing gamma models. We compared gamma spectral responses to varying contrasts in a monkey dataset acquired previously (Roberts et al., 2013) with spectral responses to similar contrast variations in a new human MEG dataset. We found parametric frequency shifts with increasing contrast in human MEG at the single-subject and the single-trial level, analogous to those observed in the monkey. Additionally, we observed parametric modulations of spectral asymmetry, consistent across spikes, LFP and MEG. However, while gamma power scaled linearly with contrast in MEG, it saturated at high contrasts in both the LFP and spiking data. Thus, while gamma frequency changes to varying contrasts were comparable across spikes, LFP and MEG, gamma power changes were not. This indicates that gamma frequency may be a more stable parameter across scales of measurements and species than gamma power. The comparative approach undertaken here represents a fruitful path towards a better understanding of gamma oscillations in the human brain.

Worker hazards associated with the use of grain vacuum systems.

Over the past two decades, there has been more widespread use of pneumatic handling of grain at commercial grain storage facilities and on farms as these operations have increased grain storage capacity and handle larger volumes of grain and feed In some cases, manufacturers have suggested that the use of these systems is a safer alternative to removing residual grain manually in conjunction with the use of sweep augers. The use of grain vacuum systems has also been increasingly documented as a strategy in responding to grain storage fires and human entrapment and engulfment in flowing grain. With greater utilization of these machines have come reports of entrapments and engulfments. This article summarizes 27 such documented incidents, including 21 fatalities, that resulted from the use of portable grain vacuum systems. It includes specific recommendations for engineering, educational, and regulatory strategies to reduce the risks associated with the use of these systems.

The relative reliability of actively participating and passively observing raters in a simulation-based assessment for selection to specialty training in anaesthesia.

Selection to specialty training is a high-stakes assessment demanding valuable consultant time. In one initial entry level and two higher level anaesthesia selection centres, we investigated the feasibility of using staff participating in simulation scenarios, rather than observing consultants, to rate candidate performance. We compared participant and observer scores using four different outcomes: inter-rater reliability; score distributions; correlation of candidate rankings; and percentage of candidates whose selection might be affected by substituting participants' for observers' ratings. Inter-rater reliability between observers was good (correlation coefficient 0.73-0.96) but lower between participants (correlation coefficient 0.39-0.92), particularly at higher level where participants also rated candidates more favourably than did observers. Station rank orderings were strongly correlated between the rater groups at entry level (rho 0.81, p < 0.001) but weaker at the two higher level centres (rho 0.52, p = 0.018; rho 0.58, p = 0.001). Substituting participants' for observers' ratings had less effect once scores were combined with those from other selection centre stations. Selection decisions for 0-20% of candidates could have changed, depending on the numbers of training posts available. We conclude that using participating raters is feasible at initial entry level only.

Laceration of anterior mitral leaflet postpercutaneous balloon mitral valvuloplasty for rheumatic mitral stenosis.

A 37-year-old Caucasian female with known rheumatic mitral stenosis was admitted for Balloon mitral valvuloplasty which was complicated with a laceration of anterior mitral leaflet (A2 scallop) resulting in severe mitral regurgitation. Intra-aortic balloon pump (IABP) was instituted and the patient was referred for emergency mitral surgery. During surgery anterior mitral leaflet was excised. Most of the posterior leaflet was preserved. Mitral valve was replaced with St Jude mitral mechanical valve. Operation was uneventful and patient's recovery was uncomplicated. Complications associated with mitral valvuloplasty include ventricular perforation, leaflet laceration, rupture of chordae, sepsis, cardiac tamponade and premature ventricular contractions. Torrential mitral regurgitation postvalvuloplasty is a serious, life-threatening complication. Considering the risk of serious complication associated with percutaneous mitral balloon valvuloplasty (PMBV), this procedure should be performed in qualified cardiac catheterisation labs with a backup facility of cardiac surgery to deal with any potential life-threatening complications.

Determination of effort required to insert a rescue tube into various grain types.

This study was conducted to quantify the forces required to insert the individual panels of a grain rescue tube into four grains of varying moisture contents. The study was conducted to address issues raised by emergency rescue personnel involved with extrication of victims entrapped in grain using a fabricated or commercially available grain containment system. These rescue aids are used to separate or protect the victim from the grain mass, enabling safe rescue. Conclusions drawn from the study included documentation that as the moisture content of the grain increases, the amount of resistance against tube insertion increases substantially. It was found that although the moisture content may be similar across several types of grain, the amount of work required to insert a rescue tube into the grain can vary. It was also concluded that the cohesiveness, angle of internal friction, and static coefficient of friction of the grain on the tube surface, which vary with moisture content and type of grain, were primary factors affecting the amount of effort needed to insert the tube. This article recommends that a consensus standard be developed covering the design and testing of grain rescue tube containment systems.

Development of workplace-based assessments of non-technical skills in anaesthesia.

Non-technical skills are recognised as crucial to good anaesthetic practice. We designed and evaluated a specialty-specific tool to assess non-technical aspects of trainee performance in theatre, based on a system previously found reliable in a recruitment setting. We compared inter-rater agreement (multir-ater kappa) for live assessments in theatre with that in a selection centre and a video-based rater training exercise. Twenty-seven trainees participated in the first in-theatre assessment round and 40 in the second. Round- 1 scores had poor inter-rater agreement (mean kappa = 0.20) and low reliability (generalisability coefficient G = 0.50). A subsequent assessor training exercise showed good inter-rater agreement, (mean kappa = 0.79) but did not improve performance of the assessment tool when used in round 2 (mean kappa = 0.14, G = 0.42). Inter-rater agreement in two selection centres (mean kappa = 0.61 and 0.69) exceeded that found in theatre. Assessment tools that perform reliably in controlled settings may not do so in the workplace.

Nutritional intake and oxidative stress in chronic heart failure.

BACKGROUND AND AIMS: Patients with chronic heart failure (CHF) are known to be at risk of malnutrition, and cardiac cachexia is an adverse prognostic indicator. The aim of this study was to determine the dietary adequacy of CHF patients compared with Dietary Reference Values, to compare the nutritional intake and status of CHF patients to a healthy comparison group, and finally to determine whether nutritional intake and status depended on New York Heart Association (NYHA) functional class. METHODS AND RESULTS: Patients with CHF (n = 39) and a comparison group of 27 healthy participants, who did not have CHF, were asked to complete a four-day food diary, and energy and nutrient intakes were calculated. F(2α)-isoprostanes were measured in urine as an indicator of oxidative stress and antioxidants were measured in serum or plasma. Overall 73% of the CHF patients were consuming less than recommended energy intakes, and more than 50% of these patients were also consuming less than recommended vitamin D, selenium and zinc intakes. Nutrient intake (energy, vitamin B6, D, E, iron, folate and riboflavin) was lower in CHF patients than in the comparison group, with vitamin B6 and folate intake and antioxidant status decreasing, and isoprostane status increasing as NYHA functional class increased. CONCLUSION: The majority of CHF patients do not meet dietary reference values for energy and a range of nutrients, and nutrient intake is lower in CHF patients than in healthy individuals. Dietary inadequacy tends to be increased in those with more severe disease.

Summary of prior grain entrapment rescue strategies.

Entrapment in flowable agricultural material continues to be a relevant problem facing both farmers and employees of commercial grain storage and handling operations. While considerable work has been done previously on the causes of entrapment in grain and possible preventative measures, there is little research on the efficacy of current first response or extrication techniques. With the recent introduction of new grain rescue equipment and training programs, it was determined that the need exists to document and summarize prior grain rescue strategies with a view to develop evidence-based recommendations that would enhance the efficacy of the techniques used and reduce the risks to both victims and first responders. Utilizing the Purdue University Agricultural Entrapment Database, all data were queried for information related to extrication of victims from grain entrapments documented over the period 1964-2006. Also analyzed were data from other sources, including public records related to entrapments and information from onsite investigations. Significant findings of this study include the following: (1) between 1964 and 2006, the number of entrapments averaged 16 per year, with the frequency increasing over the last decade; (2) of all cases documented, about 45% resulted in fatality; (3) no less than 44% of entrapments occurred in shelled corn; (4) fatality was the result in 82% of cases where victims were submerged beneath the grain surface, while fatality occurred in 10% of cases where victims were only partially engulfed; (5) the majority of rescues were reported to have been conducted by untrained personnel who were at the scene at the time of entrapment; and (6) in those cases where the rescue strategies were known, 56% involved cutting or punching holes in the side walls of the storage structure, 19% involved utilizing onsite fabricated grain retaining walls to extricate partially entrapped victims, and the use of grain vacuum machines as a rescue strategy was on the increase. Among the recommendations growing out of the study are these: (1) conduct further tests on the efficacy of grain rescue strategies, including the use of recently introduced grain rescue tubes and grain vacuum machines; (2) incorporate the findings into future first responder training programs; and (3) enhance the first response skills of personnel working at grain storage facilities, both on-farm and at commercial operations.