Clinical audit and research in radiography practice: An exploration of the English landscape.

BACKGROUND: Research and clinical audit are central to the quality improvement (QI) process in healthcare; whereas research produces new knowledge, clinical audit establishes if practice is meeting set standards. Thus, radiographers have responsibility to engaging in these QI activities. This study aimed to explore radiographers' understanding, attitudes and level of involvement in clinical research and audit across England. METHODS: A cross-sectional survey using an online questionnaire for data collection over a 6-week period was employed. The questionnaire consisted of open and closed ended questions. Participants were recruited through social media. The quantitative data obtained was analysed using Statistical Package for Social Sciences (SPSS) Version 26 (IBM Inc, Armonk, NY) whilst content analysis was used to analyse the free-response data. RESULTS: A total of 100 valid responses were obtained after exclusion of 45 partial and/or incomplete responses. Radiographers showed a positive attitude towards involvement in research and audit with overall mean score of 3.85 (SD 0.80) and 4.01 (SD 0.80), respectively. Of the respondents, 35.7% (n = 35/98) were currently involved in clinical audit projects whilst 78.6% (n = 77/98) have previously been involved. Radiographers with postgraduate degrees were significantly more likely to have initiated research, 61.5% (n = 16/26) (p = 0.01) and to have previously been involved with research, 80.8% (n = 21/26) (p = 0.02). A significant association between radiographers' role and implementation of changes, following an audit (p = 0.03) was noted. Similarly, a significant association was noted between radiographers' role and initiation of research (p = 0.05). CONCLUSION: Clinical radiographers in England showed a positive attitude towards research and audit. However, this did not translate into actual participation in research and audit activities. IMPLICATIONS FOR PRACTICE: The need to stimulate clinical radiographers' interest in clinical audit and research is highlighted. Additionally, the findings support the rationale for managers to give more support including protected time to radiographers to engage in QI activities.

Non-Ototoxic Local Delivery of Bisphosphonate to the Mammalian Cochlea.

HYPOTHESIS: Local delivery of bisphosphonates results in superior localization of these compounds for the treatment of cochlear otosclerosis, without ototoxicity. BACKGROUND: Otosclerosis is a common disorder of abnormal bone remodeling within the human otic capsule. It is a frequent cause of conductive hearing loss from stapes fixation. Large lesions that penetrate the cochlear endosteum and injure the spiral ligament result in sensorineural hearing loss. Nitrogen-containing bisphosphonates (e.g., zoledronate) are potent inhibitors of bone remodeling with proven efficacy in the treatment of metabolic bone diseases, including otosclerosis. Local delivery to the cochlea may allow for improved drug targeting, higher local concentrations, and the avoidance of systemic complications. In this study, we use a fluorescently labeled bisphosphonate compound (6-FAM-ZOL) to determine drug localization and concentration within the otic capsule. Various methods for delivery are compared. Ototoxicity is evaluated by auditory brainstem responses and distortion product otoacoustic emissions. METHODS: 6-FAM-ZOL was administered to guinea pigs via intraperitoneal injection, placement of alginate beads onto the round window membrane, or microfluidic pump infusion via a cochleostomy. Hearing was evaluated. Specimens were embedded into resin blocks, ground to a mid-modiolar section, and quantitatively imaged using fluorescence microscopy. RESULTS: There was a dose-dependent increase in fluorescent signal after systemic 6-FAM-ZOL treatment. Local delivery via the round window membrane or a cochleostomy increased delivery efficiency. No significant ototoxicity was observed after either systemic or local 6-FAM-ZOL delivery. CONCLUSION: These findings establish important preclinical parameters for the treatment of cochlear otosclerosis in humans.

Newly identified interfibrillar collagen crosslinking suppresses cell proliferation and remodelling.

Copper is becoming recognised as a key cation in a variety of biological processes. Copper chelation has been studied as a potential anti-angiogenic strategy for arresting tumour growth. Conversely the delivery of copper ions and complexes in vivo can elicit a pro-angiogenic effect. Previously we unexpectedly found that copper-stimulated intraperitoneal angiogenesis was accompanied by collagen deposition. Here, in hard tissue, not only was healing accelerated by copper, but again enhanced deposition of collagen was detected at 2 weeks. Experiments with reconstituted collagen showed that addition of copper ions post-fibrillogenesis rendered plastically-compressed gels resistant to collagenases, enhanced their mechanical properties and increased the denaturation temperature of the protein. Unexpectedly, this apparently interfibrillar crosslinking was not affected by addition of glucose or ascorbic acid, which are required for crosslinking by advanced glycation end products (AGEs). Fibroblasts cultured on copper-crosslinked gels did not proliferate, whereas those cultured with an equivalent quantity of copper on either tissue culture plastic or collagen showed no effect compared with controls. Although non-proliferative, fibroblasts grown on copper-cross-linked collagen could migrate, remained metabolically active for at least 14 days and displayed a 6-fold increase in Mmps 1 and 3 mRNA expression compared with copper-free controls. The ability of copper ions to crosslink collagen fibrils during densification and independently of AGEs or Fenton type reactions is previously unreported. The effect on MMP susceptibility of collagen and the dramatic change in cell behaviour on this crosslinked ECM may contribute to shedding some light on unexplained phenomena as the apparent benefit of copper complexation in fibrotic disorders or the enhanced collagen deposition in response to localised copper delivery.

The potential utility of high-intensity ultrasound to treat osteoarthritis.

Osteoarthritis (OA) is a widespread musculoskeletal disease that reduces quality of life and for which there is no cure. The treatment of OA is challenging since cartilage impedes the local and systemic delivery of therapeutic compounds (TCs). This review identifies high-intensity ultrasound (HIU) as a non-contact technique to modify articular cartilage and subchondral bone. HIU enables new approaches to overcome challenges associated with drug delivery to cartilage and new non-invasive approaches for the treatment of joint disease. Specifically, HIU has the potential to facilitate targeted drug delivery and release deep within cartilage, to repair soft tissue damage, and to physically alter tissue structures including cartilage and bone. The localized, non-invasive ultrasonic delivery of TCs to articular cartilage and subchondral bone appears to be a promising technique in the immediate future.

Surface roughness enhances the osseointegration of titanium headposts in non-human primates.

It is well recognized that micrometer and nanometer sized surface features enhance the skeletal attachment of implants within bone. However, little is known regarding the integration of implants placed outside the bone but in contact with the surface. Loosening of chronic skull anchored headposts in non-human primate based experiments can be a factor. The purpose of this study was to evaluate the effect of a simple and easily applied surface texture on bone apposition to titanium implants fixed to the periosteal surface of the skull. Implants possessed either a polished surface or a textured surface created by grit-basting followed by acid etching. The percent of bone in contact with the implant surface (bone apposition) to three polished and three textured implants was evaluated in one adult female monkey after 14 weeks. Upon harvest, implants were processed for undecalcified histology and regions of bone apposition were quantified using backscatter electron microscopy and digital image analysis. The bone apposition to textured implants was 62±20% and to polished implants was 42±21%. The application of a peak-and-pit like texture to the surface of titanium implants significantly increased bone apposition to titanium implants placed on the periosteal surface of the skull. This study demonstrates that titanium headposts can easily be modified to improve osseointegration using equipment and supplies available to most neurophysiological laboratories. In addition, implant texturing may have utility in areas including skeletal trauma and reconstruction where devices are placed in contact with the bone surface.

Recent progress in interfacial tissue engineering approaches for osteochondral defects.

This review provides a brief synopsis of the anatomy and physiology of the osteochondral interface, scaffold-based and non-scaffold based approaches for engineering both tissues independently as well as recent developments in the manufacture of gradient constructs. Novel manufacturing techniques and nanotechnology will be discussed with potential application in osteochondral interfacial tissue engineering.

An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals.

Adults with anorexia are an under-researched group because the usual focus is on adolescents. The relationships that occur between healthcare professionals and adults with anorexia are often challenging, because they do not necessarily agree on the goals of treatment. The therapeutic relationship is widely recognized as crucial to care, even healing and restorative in its own right but problematic in this setting. This is a phenomenological study of how therapeutic relationships are negotiated and maintained in a day care service. Six women with anorexia nervosa and seven of their healthcare professionals were interviewed in the care setting to explore their lived experience of their relationships. Six important themes emerged from the interviews: the authenticity of the relationship, safety, the externalization of the eating disorder, recovery measured in kilos, the power of hope and optimism and the use and acceptance of maternalism in the care setting. Findings suggest that patients appreciated the safety and security of care, but some were using the service as respite rather than recovery. Patients saw goals and tasks related directly to weight gain as irrelevant to their main concerns, but engagement with people who provided a secure, nurturing and maternalistic context for safety and optimism was seen as supportive.

Titanium-tethered vancomycin prevents resistance to rifampicin in Staphylococcus aureus in vitro.

Rifampicin is currently recognized as the most potent drug against Gram positive implant related infections. The use of rifampicin is limited by the emergence of bacterial resistance, which is often managed by coadministration of a second antibiotic. The purpose of this study was to determine the effectiveness of soluble rifampicin in combination with vancomycin tethered to titanium metal as a means to control bacterial growth and resistance in vitro. Bacterial growth was inhibited when the vancomycin-tethered titanium discs were treated with Staphylococcus aureus inocula of ≤2×106 CFU, however inocula greater than 2×106 CFU/disc adhered and survived. The combination of surface-tethered vancomycin with soluble rifampicin enhanced the inhibitory effect of rifampicin for an inoculum of 106 CFU/cm² by one dilution (combination MIC of 0.008 mg/L versus 0.015 mg/L for rifampicin alone). Moreover, surface tethered vancomycin prevented the emergence of a rifampicin resistant population in an inoculum of 2×108 CFU.

Direct visualization and quantification of bone growth into porous titanium implants using micro computed tomography.

The utility of porous metals for the integration of orthopaedic implants with host bone has been well established. Quantification of the tissue response to cementless implants is laborious and time consuming process requiring tissue processing, embedding, sectioning, polishing, imaging and image analysis. Micro-computed tomography (µCT) is a promising three dimensional (3D) imaging technique to quantify the tissue response to porous metals. However, the suitability and effectiveness of µCT for the quantification of bone ingrowth remains unknown. The purpose of this study was to evaluate and compare bone growth within porous titanium implants using both µCT and traditional hard-tissue histology techniques. Cylindrical implants were implanted in the distal femora and proximal tibiae of a rabbit. After 6 weeks, bone ingrowth was quantified and compared by µCT, light microscopy and backscattered electron microscopy. Quantification of bone volume and implant porosity as determined by µCT compared well with data obtained by traditional histology techniques. Analysis of the 3D dataset showed that bone was present in the pores connected with openings larger 9.4 µm. For pore openings greater than 28.2 µm, the size of the interconnection had little impact on the bone density within the porosity for the titanium foams.

A droplet-based building block approach for bladder smooth muscle cell (SMC) proliferation.

Tissue engineering based on building blocks is an emerging method to fabricate 3D tissue constructs. This method requires depositing and assembling building blocks (cell-laden microgels) at high throughput. The current technologies (e.g., molding and photolithography) to fabricate microgels have throughput challenges and provide limited control over building block properties (e.g., cell density). The cell-encapsulating droplet generation technique has potential to address these challenges. In this study, we monitored individual building blocks for viability, proliferation and cell density. The results showed that (i) SMCs can be encapsulated in collagen droplets with high viability (>94.2 +/- 3.2%) for four cases of initial number of cells per building block (i.e. 7 +/- 2, 16 +/- 2, 26 +/- 3 and 37 +/- 3 cells/building block). (ii) Encapsulated SMCs can proliferate in building blocks at rates that are consistent (1.49 +/- 0.29) across all four cases, compared to that of the controls. (iii) By assembling these building blocks, we created an SMC patch (5 mm x 5 mm x 20 microm), which was cultured for 51 days forming a 3D tissue-like construct. The histology of the cultured patch was compared to that of a native rat bladder. These results indicate the potential of creating 3D tissue models at high throughput in vitro using building blocks.

Tissue response to the components of a hydroxyapatite-coated composite femoral implant.

Bone loss around femoral implants used for THA is a persistent clinical concern. It may be caused by stress shielding, generally attributed to a mismatch in stiffness between the implants and host bone. In this regard, a fatigue resistant, carbon fiber (CF) composite femoral implant with bone-matching stiffness has been developed. This study evaluated the tissue response to the three material components of this implant in normal and textured (blasted with 24 grit alumina) surfaces: the hydroxyapatite (HA) coating, the CF composite and the intermediate crystalline HA particulate composite layer to bond to the HA coating (blended). Sprague-Dawley rats underwent bilateral femoral implantation each receiving two rod-like implants. Bone apposition to the HA (37%) and textured Ti (41%) implants was not significantly different. Bone apposition to the untextured CF (14%) and blended (19%) implants and polished Ti (8%) implants was significantly lower. Bone apposition to the textured CF (9%) and blended (11%) implants was lower (but not statistically from the as received or untextured counterparts). Nearly all sections from femurs containing CF implants presented CF debris. There was no evidence of localized bone loss or any strong immune response associated with any of the implant materials. All materials were well tolerated with minimal inflammation despite the presence of particulate debris. The high degree of bone apposition to the HA-coated composite implants and the lack of short-term inflammation and adverse tissue response to the three material implant component support continued evaluation of this composite technology for use in THA.

Future approaches to organ regeneration: microscale environments, stem cell engineering, and self-assembly of living tissues.

A promising means to address the limited supply of donor tissue is through the generation of artificial organs consisting of cells and materials. Progress towards this goal is limited by three main obstacles namely the generation of a sufficient number of cells specific to the organ, the arrangement of these cells in a functional tissue architecture and the delivery of nutrients and removal of waste from the tissue mass. This chapter describes the emerging approaches that may be achieved by the control of stem cell differentiation, control of the local tissue environment on the microscale, and the generation of complex structures containing multiple cell types.

Applications of microscale technologies for regenerative dentistry.

While widespread advances in tissue engineering have occurred over the past decade, many challenges remain in the context of tissue engineering and regeneration of the tooth. For example, although tooth development is the result of repeated temporal and spatial interactions between cells of ectoderm and mesoderm origin, most current tooth engineering systems cannot recreate such developmental processes. In this regard, microscale approaches that spatially pattern and support the development of different cell types in close proximity can be used to regulate the cellular microenvironment and, as such, are promising approaches for tooth development. Microscale technologies also present alternatives to conventional tissue engineering approaches in terms of scaffolds and the ability to direct stem cells. Furthermore, microscale techniques can be used to miniaturize many in vitro techniques and to facilitate high-throughput experimentation. In this review, we discuss the emerging microscale technologies for the in vitro evaluation of dental cells, dental tissue engineering, and tooth regeneration.

Novel carbon fiber composite for hip replacement with improved in vitro and in vivo osseointegration.

A novel composite femoral stem has been developed to match cortical stiffness and achieve fixation by osseointegration with the primary goal to reduce cortical bone loss associated with stress shielding. The femoral stem consists of three distinct material layers: the first is a long carbon fiber (CF) in a polyamide 12 (PA12) polymer matrix (PA12/CF); the second is a PA12/HA (hydroxyapatite) interface; and the third is a plasma-sprayed coating of HA. In vitro studies with MG63 cells indicated that the HA surface supported improved proliferation and differentiation of osteoblast-like cells as determined by alkaline phosphatase activity and osteocalcin production when compared with Ti-6Al-4V (Ti64). In vivo studies comparing the composite and Ti64 rods in the rabbit femur demonstrated significantly higher bone apposition to the composite than Ti64 rods. The results of this study indicate that the invasion of surrounding bone cells and thus osteointegration together with its bone-matching mechanical properties make the PA12/CF/HA stem a promising hip replacement candidate.

The use of RANKL-coated brushite cement to stimulate bone remodelling.

Calcium phosphate cements were first proposed as synthetic bone substitutes over two decades ago, however, they are characterised by slow chemical or cellular resorption and a slow osteointegration. In contrast, bone autograft has been shown to stimulate osteoclastogenesis and angiogenesis resulting in active bone remodelling and rapid graft incorporation. Therefore, we aimed to develop a biomaterial able to release a key stimulator of the bone remodelling process, cytokine RANKL. Cylinders of brushite cement, hydroxyapatite cement and sodium alginate were loaded with RANKL either by incorporation into the cement or by coating the material with soluble RANKL. To test the biological activity of these formulations, we assessed their effectiveness in inducing osteoclast formation from RAW 264.7 monocytic cell line. Only brushite and hydroxyapatite cements coated with RANKL allowed for retaining sufficient biological activity to induce osteoclast formation. Most efficient was coating 40 mg cylinder of brushite cement with 800 ng RANKL. We have found that RANKL-coated brushite cement exhibits osteoclastogenic activity for at least 1 month at 37 degrees C. Thus, we developed a formulation of brushite cement with RANKL - a synthetic bone graft that is similar to autografts in its ability to actively induce osteoclastogenesis.

The response of mineralizing culture systems to microtextured and polished titanium surfaces.

The surface texture of titanium has a predictable effect on peri-implant tissue formation in vivo. When implanted in an osseous environment, smooth surfaces (R(a) < 0.5 mm) are generally apposed by fibrous tissue and textured surfaces (R(a) > 1.0 mm) are generally apposed by osseous tissue. Thus in vitro study assessed the mineralization and proliferation response of TF274, MC3T3-E1, murine femoral stromal cells and canine stromal cells to tissue culture plastic (R(a) = 0.001 mm), polished (R(a) = 0.01 mm) and irregularly textured (R(a) = 3.26 mm) titanium surfaces. Amongst all culture systems, proliferation was significantly decreased on textured vs. smooth surfaces. Midway through the culture of the canine marrow cells, the cell layer detached from the tissue culture plastic and polished titanium surfaces. The TF274, MC3T3-E1, murine femoral stromal cell systems formed a mineralized matrix on the tissue culture plastic and polished titanium surfaces which was not observed with the canine stromal cell system. Compared to the tissue culture plastic and polished titanium surfaces, matrix mineralization was significantly reduced on the textured titanium surfaces for the TF274, MC3T3-E1, murine femoral stromal systems, a result which was differed significantly in comparison to the canine stromal system. These results were surprising given the large number of reports concerning the in vivo response to titanium in clinical and pre-clinical studies. Further work is required to determine if the TF274, MC3T3-E1 and murine femoral stromal systems are suitable for the in vitro investigation of the effects of titanium surface texture on osteoblast activity.

Catching life: the contribution of arts initiatives to recovery approaches in mental health.

This paper draws on a qualitative study that was undertaken as part of a national research study to assess the impact of participatory arts provision for people with mental health needs. It explores how arts and mental health projects may facilitate some of the key elements of what has been termed a 'recovery approach' in mental health. It is argued that it is precisely these elements--the fostering of hope, creating a sense of meaning and purpose, developing new coping mechanisms and rebuilding identities--which are hard to standardize and measure, yet may be the most profound and significant outcomes of participation in such projects. Therefore, in the context of a growing emphasis on recovery-orientated mental health services, while not necessarily being appropriate for all service users, arts and mental health initiatives could make an essential contribution to the future of mental health and social care provision.

A physical vapor deposition method for controlled evaluation of biological response to biomaterial chemistry and topography.

The purpose of this study was to characterize a technique to effectively mask surface chemistry without modifying surface topography. A thin layer of titanium was deposited by physical vapor deposition (PVD) onto different biomaterial surfaces. Commercially pure titanium disks were equally divided into three groups. Disks were either polished to a mirror finish, grit blasted with alumina particles, or grit blasted and subsequently plasma sprayed with a commercial grade of hydroxyapatite (HA). A subgroup of each of these treatment types was further treated by masking the entire disk surface with a thin layer of commercially pure titanium deposited by PVD. A comparison of surface topography and chemical composition was carried out between disks within each treatment group. Canine marrow cells were seeded on all disk surfaces to determine the stability of the PVD Ti mask under culture conditions. The PVD process did not significantly alter the surface topography of any samples. The thin titanium layer completely masked the underlying chemistry of the plasma sprayed HA surface and the chemistry of the plasma vapor deposited titanium layer did not differ from that of the commercially pure titanium disks. Aliquots obtained from the media during culture did not indicate any significant differences in Ti concentration amongst the Ti and Ti-masked surfaces. The PVD application of a Ti layer on HA coatings formed a stable, durable, and homogenous layer that effectively masked the underlying surface chemistry without altering the surface topography.

Spontaneous bilateral Achilles tendon rupture in a patient treated with oral levofloxacin.

A case of bilateral rupture of the Achilles tendon in a patient treated with levofloxacin for cystitis is reported. A 76-year-old woman suddenly developed painful ankles one day after levofloxacin treatment. Drug therapy was switched to amoxicillin/clavulanate on the fourth day. Sonography revealed a serious condition of tendinosis with complete bilateral full-thickness rupture on day 6. Tendons were both repaired in the same surgical session. Pathological anatomy of the specimens reported fatty tissue lobules with panniculitis and histiocytosis. Ankles were immobilized postoperatively with a plaster cast. Achilles tendon rupture may occur as an adverse side effect of short-term use of levofloxacin, a fluoroquinolone antibiotic. This adverse effect is a rare and poorly understood complication of this antibiotic therapy. A review of the literature is provided.