Author Correction: Metagenomics of pigmented and cholesterol gallstones: the putative role of bacteria.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Metagenomics of pigmented and cholesterol gallstones: the putative role of bacteria.

There is growing evidence for bacteria playing a role in the pathogenesis and formation of pigmented gallstones from humans. These studies mainly involved cultivation of gallstone-associated bacteria and 16S rRNA profiling, providing an indirect link between processes involved in gallstone formation by the bacteria in-situ. Here, we provide functional metagenomic evidence of a range of genes involved in bile stress response, biofilm formation, and anaerobic energy metabolism by Gram-negative Klebsiella in pigmented gallstones from a 76-year-old male patient. Klebsiella was also present in one cholesterol-type stone in a 30-year-old female patient who had additional cholesterol gallstones characterised by Gram-positive bacteria. Pigmented stones further revealed a predominance of genes involved in carbohydrate metabolism, whilst cholesterol stones indicated a profile dominanted by protein metabolism possibly reflecting known chemical differences between Gram-negative and Gram-positive biofilm matrices. Archaeal genes were not detected. Complementary carbon and hydrogen isotopic analyses of cholesterol within the patients' stones revealed homogeneity, suggesting a common diet or cholesterol biosynthesis pathway that has little influence on microbial composition. This pilot study provides a framework to study microbial processes that play a potential role in gallstone formation across markedly different types of stones and patient backgrounds.

Management of sports injuries of the foot and ankle: An update.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration. In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:1299-1311.

Management of sports injuries of the foot and ankle: an update.

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:874-83.

Lateral ankle and hindfoot instability: a new clinical based classification.

Ankle sprains are one of the most common soft tissue injuries accounting for nearly 40% of sports injuries. There are large number of procedures for its treatment reported in the literature with largely good results. The ankle forms a functional unit with the subtalar joint. We present a new classification for peritalar lateral instability. There are two intents of this classification. Firstly, the classification demonstrates an assessment and treatment guideline for the many causes of peritalar lateral instability. The second use of the classification is for research purposes so that cohorts of patients can be accurately described and the efficacy of different operations in different groups can be properly assessed.

The anatomical footprint of the Achilles tendon: a cadaveric study.

We dissected 12 fresh-frozen leg specimens to identify the insertional footprint of each fascicle of the Achilles tendon on the calcaneum in relation to their corresponding muscles. A further ten embalmed specimens were examined to confirm an observation on the retrocalcaneal bursa. The superficial part of the insertion of the Achilles tendon is represented by fascicles from the medial head of the gastrocnemius muscle, which is inserted over the entire width of the inferior facet of the calcaneal tuberosity. In three specimens this insertion was in continuity with the plantar fascia in the form of periosteum. The deep part of the insertion of the Achilles tendon is made of fascicles from the soleus tendon, which insert on the medial aspect of the middle facet of the calcaneal tuberosity, while the fascicles of the lateral head of the gastrocnemius tendon insert on the lateral aspect of the middle facet of the calcaneal tuberosity. A bicameral retrocalcaneal bursa was present in 15 of the 22 examined specimens. This new observation and description of the insertional footprint of the Achilles tendon and the retrocalcaneal bursa may allow a better understanding of the function of each muscular part of the gastrosoleus complex. This may have clinical relevance in the treatment of Achilles tendinopathies.

Detection of diarrheagenic Escherichia coli by multiplex PCR.

BACKGROUND: Diarrheagenic E.coli (DEC) are an important cause of childhood diarrhea.Identification of DEC strains needs to detect factors that determine the virulence of these organisms. There is not much data regarding the importance of DEC as a cause of diarrhea in children in India.The prevalence of DEC in children below five years with and without diarrhea was studied using two multiplex PCR assays. MATERIALS AND METHODS: Two multiplex polymerase chain reaction assays were used to detect genes of five types of DEC.The targets selected for each category were eae and bfpA (bundle-forming pilus) for Enteropathogenic E.coli (EPEC), hlyA for Enterohemorrhagic E.coli (EHEC), elt and stla for Enterotoxigenic E.coli (ETEC), CVD432 for Enteroaggregative E.coli (EAEC) and ial for Enteroinvasive E.coli (EIEC). RESULTS: In 200 children with diarrhea 52 (26%) DEC infections were found. Among 100 controls 8 (8%) DEC infections were found. EAEC was the most common DEC by multiplex PCR both in cases (26, 13%)and controls (5,5%), followed by EPEC seen in 16% cases and 3% controls. ETEC and EIEC were found in 7 (3.5%) and 3 (1.5%) of the diarrheal cases. EIEC and ETEC were not detected in the control cases. EHEC was not isolated from either the diarrheal or control cases. CONCLUSION: DEC strains are a significant cause of diarrhea in children. The two Multiplex PCR assays can be used for the detection of DEC in routine diagnostic laboratories. These assays are specific and sensitive for the rapid detection of DEC. EAEC was the most frequent pathotype in the population under study.

Entrapment of the sciatic nerve following closed reduction of a dislocated revision total hip replacement.

Injury to the sciatic nerve following closed manipulation of a dislocated total hip replacement is rare. We present such a case in an elderly patient with partial recovery following exploration and release of the nerve.

Correcting genu varum and genu valgum in children by guided growth: temporary hemiepiphysiodesis using tension band plates.

A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3 degrees and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7 degrees per month in the femur (0.3 degrees to 1.5 degrees ), 0.5 degrees per month in the tibia (0.1 degrees to 0.9 degrees ) and 1.2 degrees per month (0.1 degrees to 2.2 degrees ) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered. The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.

Use of a patient consultation questionnaire and weighted numerical scoring system for the prediction of colorectal cancer and other colorectal pathology in symptomatic patients: a prospective cohort validation study of a Welsh population.

OBJECTIVE: There is currently no system in widespread use that accurately prioritizes colorectal referrals in symptomatic patients with an acceptable degree of sensitivity and specificity. We have validated a weighted numerical scoring system for the prioritization of such colorectal referrals in an attempt to rectify this, with detection of colorectal cancer (CRC) the primary outcome. METHOD: We conducted a prospective study of symptomatic patients referred by primary care to the colorectal service in a district general hospital. A computer-generated weighted numerical score (WNS) was derived from the primary symptoms and symptom combinations. Patients underwent colorectal investigations and a final diagnosis was established. Sensitivity, specificity and accuracy of CRC detection as determined by the WNS, Department of Health (DOH) and National Institute for Health and Clinical Excellence guidelines was determined. Primary Care compliance with guidelines was analysed. RESULTS: A definitive diagnosis was established in 3457 patients. One hundred and eighty-six (5.4%) had CRC. The mean score for the cancer patients (76.9, 95%CI 72-81) was significantly higher than that of non-cancer patients (52, 95%CI 52-53) P < 0.001. Receiver Operator Curve analysis demonstrates a high discriminatory power for the Patient Consultation Questionnaire (PCQ) with an area under curve of 0.76. Compliance by primary care with the nationally recommended referral guidelines was poor with only 55% and 58% compliance with DOH and National Institute for Clinical Excellence referral guidelines for suspected cancer respectively. CONCLUSION: The PCQ and the WNS is an efficient, objective system that allows the accurate prioritization of colorectal referrals with a high sensitivity for cancer and other serious colorectal pathologies.

Susceptibility of Candida albicans and Enterococcus faecalis to Chitosan, Chlorhexidine gluconate and their combination in vitro.

The aim of the present study was to analyse the sustain release of Chlorhexidine with Chitosan and to investigate the antimicrobial activity of 2% Chlorhexidine gel, 2% Chitosan gel and their combination against Candida albicans and Enterococcus faecalis. Sustain release of Chlorhexidine with Chitosan was determined using UV spectrophotometer. Then the inoculae of these organisms were used to make the lawn culture on sabouraud's dextrose agar and blood agar plates. Wells were prepared in these lawn cultures and filled with 2% Chlorhexidine gel, 2% Chitosan gel and their combination. The agar plates were incubated overnight at 37 degrees C and the zone of inhibition was examined after 48 h. Release of Chlorhexidine with Chitosan was better than plain Chlorhexidine release. Combination of Chlorhexidine and Chitosan showed maximum inhibitory zone for C. albicans (25.2 mm) and E. faecalis (26.0 mm). Plain Chlorhexidine gel showed intermediate inhibitory zone for C. albicans (20.6 mm) and E. faecalis (21.4 mm) and plain Chitosan gel showed minimum inhibitory zone for C. albicans (16.6 mm) and E. faecalis (11.0 mm). Carbopol which served as control did not have any antimicrobial effect. The present study suggests that 2% Chlorhexidine gel in combination with 2% Chitosan gel has the highest antimicrobial effect against C. albicans and E. faecalis compared with 2% Chlorhexidine gel or 2% Chitosan gel alone.

Conversion after laparoscopic cholecystectomy in England.

BACKGROUND: Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstones. Conversion to open surgery is reported to be necessary in 5-10% of cases. This study aimed to define those factors associated in English hospitals with the need to convert a laparoscopic cholecystectomy to an open procedure. These included patient-related and particularly nonpatient-related factors. METHODS: Using data derived from a national administrative database, Hospital Episode Statistics, patients undergoing cholecystectomy in acute National Health Service (NHS) hospitals in England during the financial years 2004-2006 were studied. The individual surgeon caseload and the hospital conversion rate were calculated using data from the first (baseline) year. Factors affecting the need for conversion were analyzed using data from the second (index) year. RESULTS: The study included 43,821 laparoscopic cholecystectomies undertaken from 2005 to 2006 in English hospitals. The overall conversion rate was 5.2%: 4.6% for elective procedures and 9.4% for emergency procedures. Patient-related factors that were good predictors of conversion included male sex, emergency admission, old age, and complicated gallstone disease (p < 0.001). Nonpatient-related factors that were good predictors of conversion included the laparoscopic cholecystectomy caseload of individual consultant surgeons and the overall hospital conversion rate in the previous year (all p < 0.001). CONCLUSIONS: Conversion after laparoscopic cholecystectomy is less common as consultant caseload increases. This suggests that operation should be undertaken only by surgeons with an adequate caseload. There is a wide variation in conversion rates among hospitals. This has important implications for training as well as for the organization and accreditation of cholecystectomy services on a national basis.

Proximal femoral nail failures in extracapsular fractures of the hip.

PURPOSE: To review patients with proximal femoral nails (PFNs) in our hospital that developed complications and needed revision. METHODS: Between January 2000 and June 2006, records of 216 patients with PFN fixations for traumatic extracapsular trochanteric fractures (n=160), pathological fractures (n=23), and as a prophylactic measure for metastasis (n=33) were retrospectively reviewed. The injury mechanism, reduction technique and quality, and time to and cause of implant failure were recorded. RESULTS: 12 PFNs failed: 8 in the trauma group, 3 in the pathological group, and one in the prophylactic nailing group. Two PFNs broke at the proximal lag screw level at a later stage secondary to non-union of the pathological fractures. One broke at the level of the distal locking screw at an early stage, as the locking holes were too close to the fracture. CONCLUSION: Poorly reduced fractures tend to fail early, whereas late failures are due to non-union. Good reduction with minimal dissection, the use of appropriate nail length, and proper positioning of the nail and screws are necessary to avoid failure or revision.

Traumatic transepiphyseal separation of the upper femoral epiphysis following seizures in two children with cerebral palsy.

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

The Oncosurge strategy for the management of colorectal liver metastases - an external validation study.

INTRODUCTION: Because most patients with colorectal liver metastases (CRLM) present to general surgeons and oncologists without a specialist interest in their management, a computer program (OncoSurge) has been created that identifies individual patient resectability and recommends optimal treatment strategies. The aim of this study was to validate the Oncosurge strategy by comparing its recommendations with the decisions made by a multidisciplinary (MDT) meeting, in a supra-regional hepatobiliary referral centre, using real cases with known outcomes. METHODS: We reviewed the records and imaging of 98 consecutive patients with CRLM, who had been referred for decision making to our MDT meeting between January 1, 2004 and December 31, 2004. All patient and tumour characteristics were entered onto the Oncosurge decision model, which was accessed at www.evidis.com/oncosurge/ RESULTS: There was concordance between Oncosurge and MDT decisions in 93/98 cases. The observed kappa (kappa) was 0.850 (95% CI: 0.728-0.972). In descriptive terms, a kappa score greater than 0.8 equates to "almost perfect agreement". CONCLUSIONS: Our results demonstrate the validity of the Oncosurge system when compared to one year of decision making in an established hepatobiliary MDT meeting. This confirms the utility of the Oncosurge system for decision making, audit and educational purposes.

Assessment of a patient consultation questionnaire-based scoring system for stratification of outpatient risk of colorectal cancer.

BACKGROUND: The UK government's fast-track 2-week wait (2WW) rule and colorectal cancer guidelines aimed to detect patients at high risk of having colorectal cancer, but the yield has been poor. A patient consultation questionnaire (PCQ)-based scoring system may be an effective tool for prioritizing colorectal referrals. The aim of this study was to validate the system in a large and ethnically diverse population and to compare it with 2WW referrals. METHODS: Over a 1-year period, all colorectal referrals (2WW and traditional letters) at nine hospitals in Leicestershire were sent a PCQ to complete and return. A weighted numerical score (WNS), which reflects the patient's risk of having colorectal cancer, was calculated and compared with the hospital diagnosis. RESULTS: Of a total of 1422 PCQs returned, 83 patients were diagnosed with colorectal cancer. The 2WW referrals constituted 35.7 per cent of all referrals. The mean WNS of patients with colorectal cancer was significantly higher than that of the other patients (mean 76.3 versus 48.9 respectively; P < 0.001). For similar cancer detection rates (or sensitivity), the specificity of a WNS cut-off of 70 was significantly better than that of the 2WW system (82.7 versus 66.1 per cent; P < 0.001). CONCLUSION: The PCQ-based WNS system improves specificity for detecting colorectal cancer, particularly when the WNS exceeds 70.

Antimicrobial action of calcium hydroxide, chlorhexidine and their combination on endodontic pathogens.

BACKGROUND: The common recovery of Candida albicans and Enterococcus faecalis from failed root canals of teeth in which previous treatment has failed is notable. These organisms have been shown to be resistant to antimicrobial action of calcium hydroxide but are sensitive to chlorhexidine gluconate. The aim of the present in vitro study was to investigate the antimicrobial efficacy of calcium hydroxide paste, 2% chlorhexidine gel and their combination against Candida albicans and Enterococcus faecalis. METHODS: Inoculae of these organisms were used to make lawn cultures on Sabouraud's dextrose agar and blood agar plates. Wells were prepared with these lawn cultures and filled with calcium hydroxide paste, 2% chlorhexidine gel and their combination. The agar plates were kept overnight for incubation at 37 degrees C and the zone of inhibition was examined after 24 and 72 hours. RESULTS: The results suggest that 2% chlorhexidine gel alone is more effective at 72 hours than calcium hydroxide paste alone or in combination with 2% chlorhexidine gel against both the organisms, even though calcium hydroxide showed better antifungal efficacy against Candida albicans at 24 hours. CONCLUSION: In failed root canal treatments, 2% chlorhexidine gel may be a more effective intracanal medicament than calcium hydroxide paste or their combination against Candida albicans and Enterococcus faecalis.

Rhys-davies exsanguinator: a haven for bacteria.

Serial swabs were taken from the inner and outer surfaces of a new Rhys-Davies exsanguinator before and after use on the limbs of patients to exsanguinate limbs prior to tourniquet inflation and surgery. Both surfaces of the exsanguinator showed increasing levels of contamination with bacterial colonisation with use starting from the first use. The organisms grown included potentially harmful bacteria such as Pseudomonas sp. The Rhys-Davies exsanguinator can harbour potentially harmful organisms and, thus, may raise the risk of infection transmission between patients when used without cleaning between uses. Methods of effective cleaning of the exsanguinator between uses are discussed.