Systematic review of the effects of bisphosphonates on bone density and fracture incidence in childhood acute lymphoblastic leukaemia.

Skeletal fragility is a common complication of childhood acute lymphoblastic leukaemia (ALL) but the impact of bisphosphonate therapy on bone mass and fracture is unclear. We aim to conduct a systematic review to evaluate the effects of bisphosphonates on bone mineral density (BMD) and fracture incidence in children with ALL. METHODS: EMBASE, Medline and the Cochrane Library were thoroughly searched by two researchers. Inclusion criteria was any child under the age of 18 years with a diagnosis of ALL, who had received any bisphosphonate treatment and had serial measurements of bone density performed thereafter. All primary research studies of any study design, excluding case reports, were included. RESULTS: Ten full text papers were identified with two exclusively meeting the inclusion criteria. Both studies administered bisphosphonates to children receiving maintenance chemotherapy for varying durations. Bone density was assessed at regular intervals by dual x-ray absorptiometry (DXA). The majority of participants had an improvement in bone density at the end of each study. However, no size adjustment of DXA data was performed. Limited information on fracture occurrence was provided by one study but did not include routine screening for vertebral fractures. CONCLUSIONS: This systematic review identified that there is insufficient evidence to support routine use of prophylactic bisphosphonate therapy in childhood ALL for prevention of fracture and improvement of bone mass. Future well-designed clinical trials in those at highest risk of fractures in ALL are now needed.

The at-risk medical student--what more can we do?

Securing a place in medical school is extremely difficult-students who are successful all have similar high levels of academic achievement. So why do some students, and not others, have difficulty with the course, and in some cases, leave the programme? Studies on medical school attrition offer valuable insight into why medical students under-perform. Identification of the 'at-risk' student can trigger additional support and early remediation, helping some students remain in their chosen profession.

Systematic review and meta-analysis of single-incision versus conventional multiport appendicectomy.

BACKGROUND: The aim of this systematic review and meta-analysis was to compare clinical outcomes following single-incision laparoscopic appendicectomy (SILA) and conventional multiport laparoscopic appendicectomy (CLA) for the treatment of acute appendicitis. METHODS: An electronic search of MEDLINE, Embase, Web of Science and Cochrane Library databases was performed. Publications were included if they were clinical trials randomizing patients with appendicitis to SILA or CLA. Outcome measures evaluated included operating time, length of hospital stay, total postoperative complications, and, specifically, wound infection, intra-abdominal collection and ileus. Weighted mean difference was calculated for the effect size of SILA on continuous variables, and pooled odds ratios were calculated for discrete variables. RESULTS: The literature search identified seven randomized clinical trials that met the inclusion criteria for meta-analysis. In total, 1108 appendicectomies were included, 555 SILA and 553 CLA procedures. There were no significant differences between the groups in the incidence of total postoperative complications, wound infection, intra-abdominal collection, ileus or length of hospital stay. However, SILA was associated with a significantly longer operating time compared with CLA (weighted mean difference 6·96 (95 per cent confidence interval 3·79 to 10·12) min; P < 0·001). Insertion of an additional port was required in 7·6 per cent of patients undergoing SILA. CONCLUSION: SILA is a safe procedure for the treatment of acute appendicitis, with comparable clinical outcome to CLA when undertaken by experienced laparoscopic surgeons.

Use of the passive lower lingual arch in the management of anterior mandibular crowding in the mixed dentition.

Leeway space preservation in the mixed dentition is a well-documented method of space management. In the mandibular arch it may be saved for utilisation in the correction of minor anterior crowding by the placement of a passive lower lingual arch (LLA) during the transition from the mixed dentition to the permanent dentition.

Early identification and management of mandibular canine ectopia.

Mandibular canine impaction and transmigration have serious consequences for the patient, as removal of the tooth or teeth in question is often the only solution. The loss of one or both mandibular canines complicates orthodontic treatment. Early warning signs of mandibular canine ectopia are explored in this paper as well as how to assess the potential for displacement, impaction and/or transmigration. This paper highlights the value of interceptive treatment once the early signs of an aberrant mandibular canine have been detected.

Maxillary canine management in the pre-adolescent: a guideline for general practitioners.

This paper focuses on the identification of ectopic eruption patterns of the maxillary canines from the dental ages of approximately 8 to 12 years. The timing and suitability of interceptive treatment in pre-adolescents are discussed.

The mixed dentition pantomogram: a valuable dental development assessment tool for the dentist.

The mixed dentition pantomogram is routinely used in paediatric patients. This paper discusses the value of the pantomogram for early identification of problems in dental development during the mixed dentition stage. Aspects regarding dental maturity, leeway space, the sequence of eruption of the permanent teeth, anomalies and the development of the canines will be reviewed.

Antifungal effect of gaseous nitric oxide on mycelium growth, sporulation and spore germination of the postharvest horticulture pathogens, Aspergillus niger, Monilinia fructicola and Penicillium italicum.

AIM: To evaluate the antifungal activity of nitric oxide (NO) against the growth of the postharvest horticulture pathogens Aspergillus niger, Monilinia fructicola and Penicillium italicum under in vitro conditions. METHODS AND RESULTS: Different volumes of NO gas were injected into the Petri dish headspace to obtain the desired concentrations of 50-500 microl l(-1). The growth of the fungi was measured for 8 days of incubation in air at 25 degrees C. All concentrations of NO were found to produce an antifungal effect on spore germination, sporulation and mycelial growth of the three fungi, with the most effective concentration for A. niger and P. italicum being 100 and 500 microl l(-1) for M. fructicola. CONCLUSIONS: Short-term exposure to a low concentration of NO gas was able to inhibit the subsequent growth of A. niger, M. fructicola and P. italicum. SIGNIFICANCE AND IMPACT OF THE STUDY: NO gas has potential use as a natural fungicide to inhibit microbial growth on postharvest fruit and vegetables.

'True Day Case' Laparoscopic Cholecystectomy in a High-Volume Specialist Unit and Review of Factors Contributing to Unexpected Overnight Stay.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the gold standard treatment for gallstones. British Association of Day Case Surgery recommends at least 60% of LCs be performed as day cases. The aim of this study was to assess our rate of true day case LCs and review factors preventing same-day discharge. METHODS: We prospectively collected data of all elective LCs performed in a district general hospital over 32 months. RESULTS: 500 patients underwent LC during this period; 438 (88.2%) patients were planned day cases and 59 patients (11.8%) planned overnight stays. Of the planned day cases, 75.8% (n=332) were discharged on the same day and 106 (24.2%) had unexpected overnight stay (UOS). Most patients with BMI >35 and ASA3 planned day case patients were successfully discharged. Drain insertion, longer operations, and late recovery departure were the main reasons for UOS. There were more complications in this group compared to day cases. CONCLUSIONS: This unit has a high 'true day case' rate of 75.8%. High BMI and ASA3 should not be absolute contraindications to day case surgery. The majority of unexpected overnight stays are unavoidable but may be reduced by patient selection, stringent preoperative assessment, operation scheduling, and reduction in unnecessary drain insertion.

Elective "True Day Case" Laparoscopic Inguinal Hernia Repair in a District General Hospital: Lessons Learned from 1000 Consecutive Cases.

INTRODUCTION: Laparoscopic inguinal hernia repair (LIHR) is ideal for day case surgery. It is recommended that at least 70% should be day cases as a measure of cost-effectiveness. The aims of this study were to (i) assess the rate of true day case (TDC) surgery and (ii) identify predictors associated with unexpected overnight stay (UOS). METHODS: Data was collected prospectively on 1000 consecutive elective LIHR performed in a District General Hospital (DGH) over a 7-year period. Data was collected on baseline patient demographics, ASA grade, and intraoperative details. A multivariate analysis was performed in order to identify predictors of UOS. RESULTS: 1000 patients (927 males) underwent elective LIHR. Mean age was 57.3±15.2 years. 915 patients were planned as day case procedures. 822/915 day cases (89.8%) were discharged on the same day and 93 (10.2%) stayed overnight unexpectedly. Patient age, duration of procedure, and patient slot in the operating list were found to be independent predictors (p<0.05) of UOS. CONCLUSION: Our results demonstrate that LIHR is a "true" day case procedure in a DGH. Although some factors associated with UOS cannot be altered, careful patient selection and operating list planning are of paramount importance in order to minimise the burden on healthcare resources.

Evaluation in volunteers of a candidate live oral attenuated Salmonella typhi vector vaccine.

Candidate vector vaccine strain CVD 906 (aroC- and aroD- derivative of virulent Salmonella typhi strain ISP1820) was evaluated in phase 1 clinical trials. The first nine volunteers ingested a single dose of 5 x 10(7) CVD 906 bacilli. At this dose CVD 906 stimulates remarkable systemic and mucosal immune responses, inasmuch as 89% of volunteers developed marked serum antibody levels to S. typhi antigens and high numbers of antigen-specific gut-derived antibody-secreting cells. Four (44%) volunteers developed asymptomatic vaccinemia 4-10 d after immunization and all volunteers excreted CVD 906 on at least one occasion. However, two volunteers developed febrile adverse reactions, one on the day of vaccination and the other on day 4. Of 11 volunteers who ingested a single dose of 5 x 10(3) CVD 906 bacilli, none displayed side effects but 27% developed significant serum responses to S. typhi LPS. In vitro, CVD 906 replicates for only nine generations in pooled human serum, indicating that CVD 906 growth is limited in this physiologically relevant medium. In phorbol myristate acetate-induced U937 human macrophage-like cells, CVD 906 replicates intracellularly to a lesser extent than parent strain ISP1820. Although, strain CVD 906 is attenuated and highly immunogenic, the occasional febrile reactions at high doses indicate that further attenuation of this strain is necessary.

Infraocclusion of primary molars: a review of the literature.

Infraocclusion of primary molar teeth is a relatively common clinical finding and decision-making concerning the successful management of such cases can present a challenge to the general dental practitioner. This paper reviews the epidemiology, aetiology, diagnosis, treatment rationale and includes flow charts for easy reference to the various treatment options for infraoccluded primary molar teeth.

Laparoscopic Common Bile Duct Exploration for Retrieval of Impacted Dormia Basket following Endoscopic Retrograde Cholangiopancreatography with Mechanical Failure: Case Report with Literature Review.

Dormia baskets are commonly used during endoscopic retrograde cholangiopancreatography (ERCP). One complication is basket retention, through impaction with a gallstone or wire fracture. We describe a case where the external handle of the basket snapped causing retained basket plus large gallstone impacted in the common bile duct (CBD). Following laparoscopic cholecystectomy, laparoscopic CBD exploration allowed direct stone fragmentation under vision with the choledochoscope. Fragments were removed using a choledochoscopic basket and Fogarty catheter, and the basket was withdrawn. Literature search identified 114 cases of retained baskets with management including shockwave lithotripsy (27%), papillary balloon dilatation (22%), open CBD exploration (11%), and one laparoscopic case.

Dentoskeletal and soft-tissue changes in growing class II malocclusion patients during nonextraction orthodontic treatment.

An investigation was conducted to determine the outcome of nonextraction edgewise orthodontic treatment of thirty-five caucasian patients with Class II molar relationships (13 division 1 and 22 division 2 cases). Twenty-three females and 12 males aged between 10 and 16 years old were treated using Class II intermaxillary elastics worn with 0.016" x 0.022" stainless steel archwires and without extra-oral traction. Thirty cephalometric landmarks were identified and digitized, and used to calculate 41 parameters. Space analyses were conducted on pretreatment study models. Most of the cases had between 0-4 mm space shortage in both maxillary and mandibular dentitions. Results of this study indicated that the mean SNA angle decreased by 1.580 degrees, and that this change was largely due to posterior movement of point A. The mean pre-treatment ANB value was 4.490 degrees which decreased to a mean posttreatment value of 2.810 degrees (p<0.05). No significant changes in the growth direction of the jaws were found, showing that the use of Class II intermaxillary elastics in this sample had no detrimental effect on this parameter (p<0.05). The SNB angle increased by a mean of 0.110 degrees, which can be attributed to anterior mandibular growth. The dentoalveolar changes included a mean overjet reduction of 3.816mm (mean posttreatment overjet was 2.2mm) and proclination of the lower incisors relative to the APo line and the mandibular plane, probably caused by the use of Class II intermaxillary elastics. The lower lip advanced relatively more than the upper lip, and this contributed to an improvement of the lip relationship. The amount of nose growth observed during the study was normal for this age group, and compared favourably with other data in the literature.

Variability in response to a low-fat, low-cholesterol diet in children with elevated low-density lipoprotein cholesterol levels.

The reduction of dietary cholesterol and fat lowers low-density lipoprotein cholesterol (LDL-C) and reduces risk of coronary heart disease in adults. The purpose of this study was to determine the individual variability of response of serum lipid and lipoprotein levels to a low-fat, low-cholesterol diet in children with elevated LDL-C levels. Thirty-two children (2 to 16 years of age) enrolled in a diet modification program, who had LDL-C levels of at least 110 mg/dL but normal triglyceride levels for their ages, were studied. Lipid levels and dietary nutrients were analyzed at the time of admission, and final assessments were made at least 3 months after entry. There was a significant correlation, for the group as a whole, between change in LDL-C concentration and change in grams of dietary saturated fat; however, there was marked individual variability in LDL-C response. There were no significant correlations between changes in LDL-C levels and changes in either total fat, polyunsaturated fat, or cholesterol intake. It is concluded that modest decreases in dietary saturated fat coincide with a lowering of LDL-C concentration, over a short term, in many children, but the degree of lowering varies considerably from one child to another. This variability is consistent with the concept that response of serum lipid levels to dietary changes is modified by genetic, metabolic, and other, as of yet, undefined variables.

The Mayo three-community hypertension control program. V. Cost-effectiveness of intervention.

This paper compares the costs of a categorical clinic model for community hypertension intervention with the costs of two less resource-intensive hypertension programs. Three categories of costs are measured for each program: program costs, patient costs, and time costs. Total costs are expressed in terms of costs per hypertensive patient controlled under each program. When adjusted for differences in hypertension prevalence and screening costs in the three community programs, the cost-effectiveness of the categorical clinic model is questionable. These results suggest that careful analyses of the categorical clinic model in other communities should be conducted before public resources are committed to the establishment of such models on a widespread basis.

Outcome of women with inadequate cervical smears followed up for five years.

BACKGROUND: The clinical and prognostic significance of "inadequate" cervical smear is unknown, even though women with repeated inadequate smears are referred for colposcopy in the National Health Service (NHS) Cervical Screening Programme. AIM: To follow up a cohort of women with inadequate cervical smears over the following five years to examine outcomes, including detection of high grade cervical intraepithelial neoplasia (CIN). METHODS: The study comprised 1972 women with an inadequate cervical smear reported at Walsall Hospitals NHS Trust between 1 April 1995 and 31 March 1996. Results of cervical smears and biopsies taken over the following five years were reviewed to confirm the outcome. FINDINGS: Within five years, 2.2% of women with an inadequate cervical smear developed histologically confirmed high grade CIN, which was higher than the 1.3% seen among all women with cervical smear tests reported at the same laboratory over the same period, although the difference was not significant at the 95% level of confidence. Where inadequacy resulted from or was contributed to by "polymorphs obscuring", the risk of subsequent development/detection of high grade CIN was 2.6%. CONCLUSIONS: Women with inadequate cervical smears had an increased risk of detection of high grade CIN in the following five years compared with "all women". This increased risk was not significant, although if a larger number of women had been studied significance may have been reached, so that further studies are needed. The increased risk appeared to be at least partially dependent on the reason for inadequacy.

Atrial fibrillation and interatrial septal aneurysm in a patient with Marfan's syndrome.

A 25-year-old male, with Marfan's syndrome, had asymptomatic atrial fibrillation. Echocardiography revealed an interatrial septal aneurysm. Electrical cardioversion restored sinus rhythm. Relevant aspects of interatrial septal aneurysm are reviewed.

Spectrographic determination of gold and platinum metals in geological and other materials by fire-assay preconcentration.

A method is described for the determination of gold, platinum, palladium, rhodium and iridium at microgram levels in geological and other materials by a combination of fire-assay preconcentration and emission spectrography. The noble metals are collected into 4-mg silver or platinum prills by a normal fire-assay technique. These prills are arced between graphite electrodes at 12 A d.c. No buffer is required to prevent ejection of the prill. Gold, platinum and palladium are determined in the silver prills and gold, palladium, rhodium and iridium in the platinum prills. Low, but reproducible, results are found for iridium. At the 0.08 ppm level an overall coefficient of variation of 11% is found. This technique is simple and rapid for the determination of the precious metals.

The structural failure of a multi-hole collimator.

During measurements of the extrinsic spatial resolution of a gamma camera, it was noted that there was a variation with the position in the field of view. The problem was traced to the collimator, and this was confirmed by inspection of the parallel hole structure. Removal of the cover showed that the lead foil honeycomb had become detached from its surround. The fault could have had serious implications for the quality of patient investigations and could also have caused damage to the crystal if it had gone undetected. As a result of this investigation, the quality assurance procedures within this department have been updated to include a visual check of all collimator cores.