Drain tube use in incisional hernia repair: a national survey.

PURPOSE: There is debate regarding the use of drain tubes in incisional hernia repair. This has become topical in Australia, with a court judge suggesting that drain tubes are mandatory. There continues to be a lack of evidence to support generalised decision-making regarding the use of drain tubes. METHODS: The general surgeon membership of General Surgeons Australia (GSA) were surveyed regarding incisional hernia repair, their use of drains, and the decision-making behind their use. RESULTS: A total of 196 surgeons' survey responses were analysed. Most surgeons perform less than 20 incisional hernia repairs per year (78%), prefer an open approach (78%), and preferably perform a pre-peritoneal (sub-lay) repair (53%). There was a variety of approaches to leaving a drain, with the most common answer being "sometimes" (31.28%) and an equal number of surgeons claiming to always or never leaving a drain (11.79% each). There was also no consensus in the duration the drain should stay in, with most surgeons averaging less than 5 days. Interestingly, there was a range of views on the effects of drain tubes, with some surgeons believing drains decreased infections and more believing they increased infections. Most surgeons felt seromas were decreased, but there was increased post-operative pain. The majority of surgeons agreed there was no evidence to support their beliefs. CONCLUSION: Placement of drain tubes is not universally practiced by the general surgeons who participated in the survey. The lack of evidence is reflected by a varied approach to incisional hernia repair and the use of drain tubes.

Association between Bone marrow lesions & synovitis and symptoms in symptomatic knee osteoarthritis.

OBJECTIVE: Bone marrow lesions (BMLs) on MRI are typically subchondral in location, however, a proportion occur at knee ligament attachments and also include a cyst-like component. Our aim was to determine whether the volume of BML subtypes and synovial tissue volume (STV) was associated with symptoms in symptomatic knee OA. METHOD: Images were acquired in a sub-sample who had taken part in a randomised trial of vitamin D therapy in knee OA (UK-VIDEO). Contrast-enhanced (CE) MRI was performed annually. In those who had ≥1 follow-up and a baseline scan (N = 50), STV and BML volume was assessed. BMLs were categorised by location and by the presence/absence of a cyst-like component. WOMAC was assessed annually. We used fixed-effects panel-regression modelling to examine the association between volume and symptoms. RESULTS: There was no association between knee pain and total subchondral BML volume (b = 0.3 WOMAC units, 95% CI -0.3 to 1.0) or total ligament-based BML volume (b = 1.9, 95% CI -1.6 to 5.3). The volume of subchondral BMLs with a cyst-like component was not associated with pain (b = 0.8, 95% CI -0.5 to 2.1) however, the volume of the cyst-like component itself was associated with pain (b = 51.8, 95% CI 14.2 to 89.3). STV was associated with pain (b = 2.2, 95% CI 0.6 to 3.7). CONCLUSION: The volume of the cyst-like component from subchondral BMLs with a cyst-like component was associated with knee pain. BML location, however, did not influence symptoms. STV was also associated with knee symptoms.

Practical approach to a patient with chronic pain of uncertain etiology in primary care.

Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.

A non-randomised single centre cohort study, comparing standard and modified bowel preparations, in adults with cystic fibrosis requiring colonoscopy.

BACKGROUND: Adults with cystic fibrosis (CF) have been reported to be at five to ten-fold risk (25 to 30 fold risk after solid organ transplant) of colorectal cancer (CRC) than the general population. Limited publications to date have reported on practical aspects of achieving adequate colonic cleanse producing good visualisation. In this study, we compared two bowel preparation regimens, standard bowel preparation and a modified CF bowel preparation. METHODS: A non-randomised study of adults with CF attending a single centre, requiring colonoscopy investigation were selected. Between 2001 and 2015, 485 adults with CF attended the clinic; 70 adults with CF had an initial colonoscopy procedure. After five exclusions, standard bowel preparation was prescribed for 27 patients, and modified CF bowel preparation for 38 patients. Demographic and clinical data were collected for all consenting patients. RESULTS: There was a significant difference between modified CF bowel preparation group and standard bowel preparation group in bowel visualisation outcomes, with the modified CF bowel preparation group having a higher proportion of "excellent/good" GI visualisation cleanse (50.0% versus 25.9%) and lower rates of "poor" visualisation cleanse (10.5% versus 44.5%) than standard bowel preparation (p = 0.006). Rates of "fair" GI cleanse visualisation were similar between the two groups (39.4% versus 29.6%) (Additional file 1: Table S1). Detection rates of adenomatous polyps at initial colonoscopy was higher in modified CF bowel preparation cohort than with standard preparation group (50.0% versus 18.5%, p < 0.01). Positive adenomatous polyp detection rate in patient's age > 40 years of age was higher (62.5%) than those < 40 years of age (24.3%) (p = 0.003). Colonic adenocarcinoma diagnosis was similar in both groups. CONCLUSION: This study primarily highlights that standard colonoscopy bowel preparation is often inadequate in patients with CF, and that colonic lavage using modified CF bowel preparation is required to obtain good colonic visualisation. A higher rate of polyps in patients over 40 years of age (versus less than 40 years) was evident. These results support adults with CF considered for colonoscopy screening at 40 years of age, or prior to this if symptomatic; which is earlier than CRC screening in the non-CF Australian population.

A Review of Issues Affecting the Efficiency of Decision Making in the NICE Single Technology Appraisal Process.

BACKGROUND: Escalating demands upon the National Institute for Health and Care Excellence's (NICE's) Single Technology Appraisal (STA) programme require a 2.5-times increase upon 2015 capacity by 2020. This additional strain on committee resources threatens to compromise the rigour of the STA process. In 2018, NICE introduced changes to the appraisal process, aiming to expedite final decisions, including consultation opportunities prior to the company's evidence submission, a 'Technical Engagement' stage prior to the first committee meeting, and powers for committee chairs to recommend technologies without a second formal meeting. OBJECTIVE: This study reviews recent STAs and aims to understand why appraisals require multiple meetings, and whether recent reforms can address the underlying issues. METHODS: NICE STAs published between January 2010 and January 2018 were reviewed, excluding updates or re-considerations. Data on cost, clinical, and decision-making outcomes from 146 appraisals were extracted and analysed thematically. RESULTS: Drugs for advanced cancers were least likely to be recommended (28/43 [65.1%] vs 71/74 [96%] for non-cancer) and took longer (2.36 meetings for a final decision vs 1.97 for non-cancer). The academic review increased upon the company's base-case incremental cost-effectiveness ratio by a median of 32.7%. Eighty-four technologies (57.5%) received a negative preliminary recommendation, deferring a final decision by an average of 142 days. Of these, 85.1% were not considered cost-effective. Uncertainty in economic (34.3%) and clinical (22.3%) data also prevented a positive decision. The majority (72.6% [61/84]) of negative preliminary decisions were overturned following further committee discussion; important considerations were Patient Access Schemes, decision optimisation, and the Cancer Drugs Fund. CONCLUSIONS: Value considerations are the primary driver of negative preliminary recommendations. It is unclear if new opportunities for additional interaction between NICE, review groups, and manufacturers will meaningfully improve the efficiency of the appraisal process, particularly given the proportion of technologies requiring further committee discussion for decision optimisation or admission into the CDF.

Effect of palpable vs. impalpable cricothyroid membranes in a simulated emergency front-of-neck access scenario.

The Difficult Airway Society 2015 guidelines recommend and describe in detail a surgical cricothyroidotomy technique for the can't intubate, can't oxygenate (CICO) scenario, but this can be technically challenging for anaesthetists with no surgical training. Following a structured training session, 104 anaesthetists took part individually in a simulated can't intubate, can't oxygenate event using simulation and airway models to evaluate how well they could perform these front-of-neck access techniques. Main outcomes measures were: ability to correctly perform the technical steps; procedural time; and success rate. Outcomes were compared between palpable and impalpable cricothyroid membrane scenarios. Anaesthetists' technical abilities were good, as assessed by a video analysis checklist score. Mean (SD) procedural time was 44 (16) s and 65 (17) s for the palpable and impalpable cricothyroid membrane models, respectively (p ≤ 0.001). First-pass tracheal tube placement was obtained in 103 out of the 104 palpable cricothyroidotomies and in 101 out of the 104 impalpable cricothyroidotomies (p = 0.31). We conclude that anaesthetists can be trained to perform surgical front-of-neck access to an acceptable level of competence and speed when assessed using a simulator.

Comparative reliability and diagnostic performance of conventional 3T magnetic resonance imaging and 1.5T magnetic resonance arthrography for the evaluation of internal derangement of the hip.

OBJECTIVE: To compare the diagnostic accuracy of conventional 3T MRI against 1.5T MR arthrography (MRA) in patients with clinical femoroacetabular impingement (FAI). METHODS: Sixty-eight consecutive patients with clinical FAI underwent both 1.5T MRA and 3T MRI. Imaging was prospectively analysed by two musculoskeletal radiologists, blinded to patient outcomes and scored for internal derangement including labral and cartilage abnormality. Interobserver variation was assessed by kappa analysis. Thirty-nine patients subsequently underwent hip arthroscopy and surgical results and radiology findings were analysed. RESULTS: Both readers had higher sensitivities for detecting labral tears with 3T MRI compared to 1.5T MRA (not statistically significant p=0.07). For acetabular cartilage defect both readers had higher statistically significant sensitivities using 3T MRI compared to 1.5T MRA (p=0.02). Both readers had a slightly higher sensitivity for detecting delamination with 1.5T MRA compared to 3T MRI, but these differences were not statistically significant (p=0.66). Interobserver agreement was substantial to perfect agreement for all parameters except the identification of delamination (3T MRI showed moderate agreement and 1.5T MRA substantial agreement). CONCLUSION: Conventional 3T MRI may be at least equivalent to 1.5T MRA in detecting acetabular labrum and possibly superior to 1.5T MRA in detecting cartilage defects in patients with suspected FAI. KEY POINTS: • Conventional 3T MRI is equivalent to 1.5T MRA for diagnosing labral tears. • Conventional 3T MRI is superior to 1.5T MRA for diagnosing acetabular cartilage defect. • Conventional 3T MRI is equivalent to 1.5T MRA for diagnosing cartilage delamination. • Symptom severity score was significantly higher (p<0.05) in group proceeding to surgery.

Impact of a National Controlled Donation After Circulatory Death (DCD) Program on Organ Donation in the United Kingdom: A 10-Year Study.

Organ transplantation is the most successful treatment for some forms of organ failure, yet a lack of organs means many die on the waiting list. In the United Kingdom, the Organ Donation Taskforce was set up to identify barriers to organ donation and in 2008 released its first report (Organ Donation Taskforce Report; ODTR). This study assesses the success since the ODTR and examines the impact of the United Kingdom's controlled donation after circulatory death (DCD) program and the controversies surrounding it. There were 12 864 intended donation after brain death (DBD) or DCD donors from April 2004 to March 2014. When the 5 years preceding the ODTR was compared to the 5 years following, intended DCD donors increased 292% (1187 to 4652), and intended DBD donors increased 11% (3327 to 3698). Organs retrieved per intended DBD donor remained static (3.30 to 3.26), whereas there was a decrease in DCD (1.54 to 0.99) due to a large rise in donors who did not proceed to donation (325 to 2464). The majority of DCD donors who proceeded did so within 30 min from time of withdrawal. Our study suggests further work on converting eligible referrals to organ donation and exploring methods of converting DCD to DBD donors.

Predicting drinking outcomes: Evidence from the United Kingdom Alcohol Treatment Trial (UKATT).

AIMS: To explore client characteristics that predict drinking outcomes using data from the UK Alcohol Treatment Trial (UKATT). METHODS: Multiple linear regression was used to determine if there were any characteristics, measured before the start of treatment, that could predict drinking outcomes at three and 12months, as measured by percent day abstinent (PDA) and drinks per drinking day (DDD) over the preceding 90days. RESULTS: Lower baseline DDD score and greater confidence to resist drinking predicted lower DDD at both three and twelve months following entry to treatment. In addition to baseline PDA and having greater confidence to resist heavy drinking, female gender, aiming for abstinence, more satisfaction with family life and a social network that included less support for drinking were predictors of percent days abstinent. CONCLUSIONS: Overall the strongest and most consistent predictors of outcome were confidence to avoid heavy drinking and social support for drinking. More predictors were identified for percent of days abstinent than for drinks per drinking day. For percent of days abstinent, a number of client characteristics at baseline consistently predicted outcome at both month three and month twelve.

A knee brace alters patella position in patellofemoral osteoarthritis: a study using weight bearing magnetic resonance imaging.

OBJECTIVE: To assess using weight bearing magnetic resonance imaging (MRIs), whether a patellar brace altered patellar position and alignment in patellofemoral joint (PFJ) osteoarthritis (OA). DESIGN: Subjects age 40-70 years old with symptomatic and a radiographic Kellgren-Lawrence (K-L) evidence of PFJOA. Weight bearing knee MRIs with and without a patellar brace were obtained using an upright open 0.25 T scanner (G-Scan, Easote Biomedica, Italy). Five aspects of patellar position were measured: mediolateral alignment by the bisect offset index, angulation by patellar tilt, patellar height by patellar height ratio (patellar length/patellar tendon length), lateral patellofemoral (PF) contact area and finally a measurement of PF bony separation of the lateral patellar facet and the adjacent surface on the femoral trochlea (Fig. 1). RESULTS: Thirty participants were recruited (mean age 57 SD 27.8; body mass index (BMI) 27.8 SD 4.2); 17 were females. Four patients had non-usable data. Main analysis used paired t tests comparing within subject patellar position with and without brace. For bisect offset index, patellar tilt and patellar height ratio there were no significant differences between the brace and no brace conditions. However, the brace increased lateral facet contact area (P = .04) and decreased lateral PF separation (P = .03). CONCLUSION: A patellar brace alters patellar position and increases contact area between the patella and femoral trochlea. These changes would lower contact stress at the PFJ. Such changes in patella position in weight bearing provide a possible biomechanical explanation for the success of the PFJ brace in clinical trials on PFJOA.

Synovial volume vs synovial measurements from dynamic contrast enhanced MRI as measures of response in osteoarthritis.

OBJECTIVE: Synovium is increasingly a target of osteoarthritis (OA) treatment, yet its optimal measurement is unclear. Using dynamic contrast enhanced (DCE) MRI in knee OA patients before and after intraarticular steroid injection, we compared the responsiveness of static synovial volume measures to measures of dynamic changes in synovial enhancement, changes that are strongly related to synovial vascularity. METHODS: Ninety three patients underwent DCE-MRI before and 1-2 weeks after intra-articular injection of 80 mg methylprednisolone. Synovium was segmented and volume, relative enhancement rate (RER), maximum relative enhancement (REmax), late relative enhancement (RElate) and pharmacokinetic parameters (K(trans), ve) were calculated. KOOS (​knee injury and osteoarthritis outcome score) pain score was recorded before and after injection. Standardized change scores were calculated for each parameter. Linear regression and Pearson's correlations were used to investigate the relationship between change in MRI parameters and change in pain. RESULTS: The change in standardized score for the measures of synovial enhancement, RElate and REmax were -0.58 (95% CI -0.79 to -0.37) and -0.62 (95% CI -0.83 to -0.41) respectively, whereas the score for synovial volume was -0.30 (-0.52 to -0.09). Further, change in knee pain correlated more strongly with changes in enhancement (for both REmax and RElate, r = -0.27 (95% CI -0.45 to -0.07)) than with changes in synovial volume -0.15 (-0.35 to 0.05). CONCLUSION: This study suggests DCE-MRI derived measures of synovial enhancement may be more sensitive to the response to treatment and more strongly associated with changes in pain than synovial volume and may be better outcomes for assessment of structural effects of treatment in OA.

Ultrasound and magnetic resonance imaging assessment of joint disease in symptomatic patients with cystic fibrosis arthropathy.

OBJECTIVES: Cystic fibrosis arthropathy (CFA) is a term commonly used for joint pain with and without swelling seen in some patients with CF. Early studies into CFA focused on the presence of rheumatoid factor and immunological changes on synovial biopsy, with parallels drawn between respiratory and joint activity. Identification of anti-cyclic citrullinated peptide antibodies (anti-CCP) as a marker of rheumatoid arthritis (RA), along with increased access to sensitive imaging techniques including ultrasound (US) and magnetic resonance imaging (MRI), offer great potential to investigate and more accurately understand the type(s) of inflammatory arthritis that may underlie CFA. The aim of this study was to phenotype an active CFA cohort using serology and imaging, as a basis for further work in this understudied area. METHODS: This was a prospective observational cohort study of symptomatic CFA patients presenting with joint pain. Participants underwent serological testing, clinical and US joint and entheseal assessment, as well as MRI of the most symptomatic joint/joint area. RESULTS: Ten symptomatic patients were studied with 9/10 having positive clinical findings. Inflammatory changes on US were seen in 8/10 cases. Five patients had positive findings on MRI (3 of whom had received IV gadolinium contrast). This included patients with significant erosive changes. One patient was anti-CCP positive suggestive of RA, and two were anti-nuclear antibody positive. CONCLUSION: Imaging, and to a lesser extent serology, identified inflammatory joint pathology in a proportion of cases, providing important data to explore in a large CFA cohort examining the clinical and imaging phenotype of this group.

Who gets Hartmann's reversed in a regional centre?

BACKGROUND: Many patients who undergo a Hartmann's procedure do not have their stoma reversed. We analysed parameters and co-morbidity scales to assess their accuracy in predicting likelihood of undergoing reversal. MATERIAL AND METHODS: Retrospective analysis of 165 patients from a prospective colorectal database who were discharged home following a Hartmann's procedure at Barwon Health (Geelong, Australia), a regional centre, between 2002 and 2010. Parameters measured included age, sex, time to reversal, ICU admission and pathology results were recorded. Patients' ASA, POSSUM and Elixhauser co-morbidity scales were retrospectively analysed. RESULTS: Reversal of Hartmann's was performed in 74/165 (45%) patients after a median of 294 days (range 70-902). Age (mean 58.5 vs 72.9 years, p < 0.001), ICU stay (34/74 vs 66/91, p < 0.001), ASA (p < 0.002), Elixhauser co-morbidity count (mean 1.14 vs 1.92, p < 0.002) and a malignant diagnosis (9/74 vs 31/91, p < 0.002) were all associated with a decreased reversal rate on univariate analysis. Age was the only parameter found to be significant on multivariate analysis. The complication rate was 23/74, with 7/74 noted to have major complications (Clavian-Dindo III-IV). Reasons for not reversing patients included age and co-morbidities, patient refusal, and malignant disease progression. CONCLUSIONS: More than half the patients undergoing a Hartmann's procedure did not proceed to a closure of their stoma. Age was the only parameter significant in predicting those patients undergoing reversal.

Can a single isotropic 3D fast spin echo sequence replace three-plane standard proton density fat-saturated knee MRI at 1.5 T?

OBJECTIVE: To assess whether a single isotropic three-dimensional (3D) fast spin echo (FSE) proton density fat-saturated (PD FS) sequence reconstructed in three planes could replace the three PD (FS) sequences in our standard protocol at 1.5 T (Siemens Avanto, Erlangen, Germany). METHODS: A 3D FSE PD water excitation sequence was included in the protocol for 95 consecutive patients referred for routine knee MRI. This was used to produce offline reconstructions in axial, sagittal and coronal planes. Two radiologists independently assessed each case twice, once using the standard MRI protocol and once replacing the standard PD (FS) sequences with reconstructions from the 3D data set. Following scoring, the observer reviewed the 3D data set and performed multiplanar reformats to see if this altered confidence. The menisci, ligaments and cartilage were assessed, and statistical analysis was performed using the standard sequence as the reference standard. RESULTS: The reporting accuracy was as follows: medial meniscus (MM) = 90.9%, lateral meniscus (LM) = 93.7%, anterior cruciate ligament (ACL) = 98.9% and cartilage surfaces = 85.8%. Agreement among the readers was for the standard protocol: MM kappa = 0.91, LM = 0.89, ACL = 0.98 and cartilage = 0.84; and for the 3D protocol: MM = 0.86, LM = 0.77, ACL = 0.94 and cartilage = 0.64. CONCLUSION: A 3D PD FSE sequence reconstructed in three planes gives reduced accuracy and decreased concordance among readers compared with conventional sequences when evaluating the menisci and cartilage with a 1.5-T MRI scanner. ADVANCES IN KNOWLEDGE: Using the existing 1.5-T MR systems, a 3D FSE sequence should not replace two-dimensional sequences.

Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal symptoms: a prospective observational cohort study.

OBJECTIVES: To monitor progression to inflammatory arthritis (IA) in individuals with non-specific musculoskeletal (MSK) symptoms and positive anticyclic citrullinated peptide (anti-CCP) antibodies. To develop a pragmatic model to predict development of IA in this patient group. METHODS: In this prospective observational cohort, patients with new non-specific MSK symptoms and positive anti-CCP were recruited from regional primary care and secondary care referrals. Clinical, imaging and serological parameters were assessed at baseline. Cox regression analysis was performed to identify predictors of progression to IA and develop a risk score to stratify patients at presentation. FINDINGS: 100 consecutive patients (73 women, mean age 51 years) were followed up for median 19.8 months (range 0.1-69.0); 50 developed IA after a median 7.9 months (range 0.1-52.4), 34 within 12 months. The majority (43/50) fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism criteria for rheumatoid arthritis. A model for progression to IA was devised using four variables: tenderness of hand or foot joints, early morning stiffness ≥30 min, high-positive autoantibodies, and positive ultrasonographic power Doppler signal. None of the five individuals at low risk (score 0) progressed to IA, compared with 31% of 29 at moderate risk (1-2) and 62% of 66 at high risk (≥3). Adding shared epitope increased the number at low risk (score 0-1; 0/11 progressed). CONCLUSIONS: In patients presenting with non-specific MSK symptoms and anti-CCP, the risk of progression to IA could be quantified using data available in clinical practice. The proposed risk score may be used to stratify patients for early therapeutic intervention. TRIAL REGISTRATION NUMBER: NCT02012764 at ClinicalTrials.gov.

Role of vascular channels as a novel mechanism for subchondral bone damage at cruciate ligament entheses in osteoarthritis and inflammatory arthritis.

OBJECTIVES: The purpose of this work was to test whether normal peri-entheseal vascular anatomy at anterior and posterior cruciate ligaments (ACL and PCL) was associated with distribution of peri-entheseal bone erosion/bone marrow lesions (BMLs) in inflammatory arthritis (IA) and osteoarthritis (OA). METHODS: Normal microanatomy was defined histologically in mice and by 3 T MRI and histology in 21 cadaveric knees. MRI of 89 patients from the Osteoarthritis Initiative and 27 patients with IA was evaluated for BMLs at ACL and PCL entheses. Antigen-induced arthritis (AIA) in mice was evaluated to ascertain whether putative peri-entheseal vascular regions influenced osteitis and bone erosion. RESULTS: Vascular channels penetrating cortical bone were identified in knees of non-arthritic mice adjacent to the cruciate ligaments. On MRI of normal cadavers, vascular channels adjacent to the ACL (64% of cases) and PCL (71%) entheses were observed. Histology of 10 macroscopically normal cadaveric specimens confirmed the location of vascular channels and associated subclinical changes including subchondral bone damage (80% of cases) and micro-cyst formation (50%). In the AIA model, vascular channels clearly provided a site for inflammatory tissue entry and osteoclast activation. MRI showed BMLs in the same topographic locations in both patients with early OA (41% ACL, 59% PCL) and IA (44%, 33%). CONCLUSION: The findings show that normal ACL and PCL entheses have immediately adjacent vascular channels which are common sites of subtle bone marrow pathology in non-arthritic joints. These channels appear to be key determinants in bone damage in inflammatory and degenerative arthritis.

The responsiveness of novel, dynamic, contrast-enhanced magnetic resonance measures of total knee synovitis after intra-articular corticosteroid for painful osteoarthritis.

OBJECTIVE: Sensitive biomarkers are needed to understand synovial response to therapy in osteoarthritis (OA). Dynamic, contrast-enhanced magnetic resonance imaging (DCE MRI) provides quantitative, novel measures of synovial inflammation. This exploratory study examined DCE-assessed synovial response to intra-articular corticosteroid (IACS). METHODS: People with ACR clinical criteria OA knee underwent 3 T MRI pre- and 2 weeks post-IACS. Five MRI variables were assessed blindly: total synovial volume (semi-automated computer program), early enhancement rate (EER) and late enhancement ratio of the entire knee, synovial volume × late enhancement and a semi-quantitative (SQ) score (six sites scored 0-3). Clinical symptoms were assessed using pain visual analogue score (VAS) and WOMAC. RESULTS: 13 participants (5 male, mean age 63, mean pain VAS 66 mm mean body mass index (BMI) 31.3 kg/m(2)) were included. The majority of MRIs demonstrated no change in SQ score although the DCE variables changed to some extent in all. There was generally a reduction in synovial volume ((Wilcoxon test) median (interquartile range (IQR)) reduction 14 cm(3) (-1, 29)), EER (0.2% (-0.3, 0.6)) and late enhancement ratio (8% (-0.5, 41)). Synovial volume × late enhancement ratio demonstrated a substantive reduction (2250 (-930, 5630)) as well as the largest effect size, r = 0.45. There was a median 26% reduction in EER in participants with good symptomatic response to IACS, contrasting with a 23% increase in those who responded poorly. CONCLUSIONS: DCE MRI may be more sensitive than a SQ score at detecting post-therapy synovial changes. The association between EER and symptomatic response to IACS may reflect a closer relation of this biomarker to synovial inflammation than with volumetric assessment.

The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments.

INTRODUCTION: Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. METHODS: Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared. RESULTS: Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent. CONCLUSIONS: Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.