A randomised controlled trial of transforaminal endoscopic discectomy vs microdiscectomy.

PURPOSE: Transforaminal endoscopic discectomy (TED) minimises paraspinal muscle damage. The aim of this trial was to compare clinical outcomes of TED to Microdiscectomy (Micro). METHODS: 143 patients, age 25-70 years and <115 kg, with single level lumbar prolapse and radiculopathy, were recruited and randomised. 70 received TED under conscious sedation and 70 Micro under general anaesthesia. Oswestry Disability Index (ODI), visual analogue scores (VAS) of back and leg pain, and Short Form Health Survey indices (SF-36) were measured preoperatively and at 3, 12 and 24 months. RESULTS: All outcome measures improved significantly in both groups (p < 0.001). Affected side leg pain was lower in the TED group at 2 years (1.9 ± 2.6 vs 3.5 ± 3.1, p = 0.002). Hospital stay was shorter following TED (0.7 ± 0.7 vs 1.4 ± 1.3 days, p < 0.001). Two Micro patients and five TED patients required revision giving a relative risk of revision for TED of 2.62 (95% CI 0.49-14.0). CONCLUSIONS: Functional improvements were maintained at 2 years in both groups with less ongoing sciatica after TED. A greater revision rate after TED was offset by a more rapid recovery.

The Role of Magnetic Resonance Imaging in the Investigation and Management of Invasive Lobular Carcinoma-A 3-Year Retrospective Study in Two District General Hospitals.

Invasive lobular carcinoma (ILC) accounts for 5-15% of breast cancers. In comparison to other types of breast cancer, ILC is more likely to be associated with multifocal and contralateral breast involvement as well as a tendency to a diffuse infiltrative growth pattern which can represent a diagnostic challenge. The National Institute of Clinical Excellence guidelines in 2009 recommended the use of magnetic resonance imaging (MRI) in the preoperative assessment of ILC. This study aims to assess compliance with the guidelines in two District General Hospitals and the utility of MRI in the investigation of ILC. All cases of ILC between 2011 and 2013 were retrospectively identified from the pathology database and their breast imaging findings, pathology report, and operative intervention were reviewed. A total of 126 patients were identified with ILC, of these 46 had MRI preoperatively (36.5%). MRI upgraded mammography/ultrasound diagnoses in 10 patients (21.7%). MRI showed multicentric unilateral disease in 17 patients (37.0%) occult on ultrasound/mammogram, with these patients undergoing mastectomy and 16/17 (94.1%) confirmed multifocality on pathology. MRI showed a contralateral lesion in 9 patients (19.6%), four (8.7%) of which were malignant and had bilateral surgery, and five (10.9%) were benign on further imaging/biopsy. MRI also downgraded three patients (6.5%) to unifocal disease with reported multifocal appearances on mammography/ultrasound, and these patients underwent breast-conserving surgery. MRI adds significant additional information to mammograms/ultrasound in ILC and should be undertaken in all such cases preoperatively assuming no contraindication.

Smartphone apps for spinal surgery: is technology good or evil?

PURPOSE: The increased utilization of smartphones together with their downloadable applications (apps) provides opportunity for doctors, including spinal surgeons, to integrate such technology into clinical practice. However, the clinical reliability of the medical app sector remains questionable. We reviewed available apps themed specifically towards spinal surgery and related conditions and assessed the level of medical professional involvement in their design and content. METHOD: The most popular smartphone app stores (Android, Apple, Blackberry, Windows, Samsung, Nokia) were searched for spinal surgery-themed apps, using the disease terms Spinal Surgery, Back Surgery, Spine, Disc Prolapse, Sciatica, Radiculopathy, Spinal Stenosis, Scoliosis, Spinal Fracture and Spondylolisthesis. RESULTS: A total of 78 individual spinal surgery themed apps were identified, of which there were six duplicates (N = 72). According to app store classifications, there were 57 (79 %) medical themed apps, 11 (15 %) health and fitness themed apps, 1 (1 %) business and 3 (4 %) education themed apps. Forty-five (63 %) apps were available for download free of charge. For those that charged access, the prices ranged from £0.62 to £47.99. Only 44 % of spinal surgery apps had customer satisfaction ratings and 56 % had named medical professional involvement in their development or content. CONCLUSIONS: This is the first study to specifically address the characteristics of apps related to spinal surgery. We found that nearly half of spinal surgery apps had no named medical professional involvement, raising concerns over app content and evidence base for their use. We recommend increased regulation of spinal surgical apps to improve the accountability of app content.

24-Month Outcomes of Indirect Decompression Using a Minimally Invasive Interspinous Fixation Device versus Standard Open Direct Decompression for Lumbar Spinal Stenosis: A Prospective Comparison.

Purpose: An early-stage, multi-centre, prospective, randomised control trial with five-year follow-up was approved by Health Research Authority to compare the efficacy of a minimally invasive, laterally implanted interspinous fixation device (IFD) to open direct surgical decompression in treating lumbar spinal stenosis (LSS). Two-year results are presented. Patients and Methods: Forty-eight participants were randomly assigned to IFD or decompression. Primary study endpoints included changes from baseline at 8-weeks, 6, 12 and 24-months follow-ups for leg pain (visual analogue scale, VAS), back pain (VAS), disability (Oswestry Disability Index, ODI), LSS physical function (Zurich Claudication Questionnaire), distance walked in five minutes and number of repetitions of sitting-to-standing in one minute. Secondary study endpoints included patient and clinician global impression of change, adverse events, reoperations, operating parameters, and fusion rate. Results: Both treatment groups demonstrated statistically significant improvements in mean leg pain, back pain, ODI disability, LSS physical function, walking distance and sitting-to-standing repetitions compared to baseline over 24 months. Mean reduction of ODI from baseline levels was between 35% and 56% for IFD (p<0.002), and 49% to 55% for decompression (p<0.001) for all follow-up time points. Mean reduction of IFD group leg pain was between 57% and 78% for all time points (p<0.001), with 72% to 94% of participants having at least 30% reduction of leg pain from 8-weeks through 24-months. Walking distance for the IFD group increased from 66% to 94% and sitting-to-standing repetitions increased from 44% to 64% for all follow-up time points. Blood loss was 88% less in the IFD group (p=0.024) and operating time parameters strongly favoured IFD compared to decompression (p<0.001). An 89% fusion rate was assessed in a subset of IFD participants. There were no intraoperative device issues or re-operations in the IFD group, and only one healed and non-symptomatic spinous process fracture observed within 24 months. Conclusion: Despite a low number of participants in the IFD group, the study demonstrated successful two-year safety and clinical outcomes for the IFD with significant operation-related advantages compared to surgical decompression.

The prognostic significance of the insulin-like growth factor-1 ligand and receptor expression in breast cancer tissue.

BACKGROUND AND OBJECTIVES: Previous in vitro studies have suggested that IGF-1 stimulation can lead a more aggressive breast cancers and subsequent poor prognosis in breast cancer patients. We aim to how IGF-1 and IGF-1R mRNA levels in breast cancer are associated with disease-free survival (DFS) and other clinicopathological factors. METHODS: IGF-1 and IGF-1R mRNA levels were measured in breast cancer tissue from 132 patients using real-time PCR. DFS and clinicopathological information were obtained from patient case notes. RESULTS: IGF-1 and IGF-1R mRNA levels did not correlate with any clinicopathological factors. Patients who relapsed had lower IGF-1 mRNA levels in their tumour tissue compared to those who remained disease-free during the 5-year follow-up period. Patients who had ER-positive breast cancers with high IGF-1 mRNA levels had longer DFS compared to those with low IGF-1 mRNA levels. IGF-1 mRNA levels was not associated with DFS in patients with ER-negative cancers. IGF-1R mRNA levels was not associated with DFS in any subgroup analysis. Multivariate analysis showed that IGF-1 mRNA levels and histopathological grade were independent predictors of DFS. CONCLUSIONS: Breast cancer tissue IGF-1 expression is a favourable prognostic indicator and could be used in clinical setting in planning for adjuvant treatment.

Lumbar spine radiographs - is it time for widespread adoption of posteroanterior projection?

OBJECTIVE: Phantom studies and a prior patient study have shown up to 53% effective dose reduction when lumbar spine radiographs are acquired posteroanterior (PA) instead of anteroposterior (AP). Since November 2017, Taunton and Somerset NHS Foundation Trust has acquired all standing lumbar spine radiographs PA. The aim of this study was to locally evaluate dose and image quality in both projections and survey current UK practice. METHODS: 80 outpatients having a standing lumbar spine radiograph (40 AP; 40 PA) had their dose-area product recorded at a constant KV and focus film distance. Effective dose was calculated using PCXMC software. Each blinded radiograph was scored against an optimal reference image using European Guidelines criteria. The data were analyzed using Mann-Whitney U tests and linear regression. Eighty radiologists nationally were sent an anonymous survey to establish their current practice. RESULTS: A lumbar spine radiograph acquired PA instead of AP reduced effective dose by 41% (p < 0.001) with no difference in image quality (p = 0.9). 21 radiologists completed our survey and only 1 NHS Trust is currently using PA. CONCLUSION: PA lumbar spine radiography reduces patient radiation exposure with no affect on image quality, acquisition time or cost. The majority of NHS Trusts nationally are still using AP and it is time to standardize to PA. ADVANCES IN KNOWLEDGE: This patient study provides further good evidence of how reduction in exposure to ionizing radiation can be achieved in lumbar spine radiography and more widespread adoption of PA protocol could improve patient safety.

Lymphangiogenesis and lymph node metastasis in breast cancer.

INTRODUCTION: There have been few studies on lymphangiogenesis in the past due to the lack of specific lymphatic endothelial markers, and lymphatic-specific growth factors. Recently, these limitations have been relieved by the discovery of a small number of potential lymphatic-specific markers. The relationship between lymphangiogenesis and regional or distant metastasis has not previously been investigated in humans. Using these lymphatic markers, it is possible to explore the relationship between lymphangiogenesis and tumour metastasis. This study indirectly quantified lymphangiogenesis by measuring mRNA expression of all seven lymphatic markers described above in breast cancers and correlated these markers with lymphatic involvement and survival. The cDNA from 153 frozen archived breast samples were analysed with Q-PCR for all seven lymphangiogenic markers. This was correlated with various prognostic factors as well as patient survival. RESULTS: There was significantly greater expression of all 7 markers in malignant compared to benign breast tissue. In addition, there was greater expression in lymph node positive/grade 3 tumours when compared to lymph node negative/grade 1 tumours. In 5 of the markers, there was a greater expression in poor NPI prognostic tumours when compared to favourable prognostic tumours which was not statistically significant. There was no association between recurrence risk and lymphangiogenic marker expression. CONCLUSION: In summary, the findings from this study show that lymphangiogenesis, measured by specific lymphatic marker expression, is higher in breast cancers than in normal breast tissue. Secondly, breast cancers which have metastasised to the regional lymphatics show higher expression compared to those which have not, although the individual differences for all five markers were not statistically significant.

The role of Herceptin in early breast cancer.

Herceptin is widely regarded as the most important development in the treatment of breast cancer since Tamoxifen and the development of the multidisciplinary team (MDT). It is particularly exciting from an oncological polint of view as it represents success in the emerging field of specific targeted therapies to specific molecular abnormalities in tumour cells. This review will focus on the nature of the Her2 overexpression and the role of herceptin in the treatment of early breast cancer.

Isolated fracture of the coracoid process associated with unstable shoulder.

We report on an unusual case where a seemingly trivial injury in a patient on immunosupressant therapy led to fracture of the coracoid and an unstable shoulder with a subscapularis tear. This was managed with open reduction and internal fixation. One year postoperatively, the patient had regained full function and range of motion.

An unusual cause of chest pain:case report.

BACKGROUND: Sarcomas form a heterogenous group of relatively uncommon malignant tumours which are derived from connective tissue components. In total they comprise approximately 1% of all new cancers diagnosed per year in the United Kingdom (UK). As subset of this, the 'Unclassified' Sarcoma forms approximately 4% of the total 1. They often present with as relatively slow growing, asymptomatic masses and as such may often be misdiagnosed as in this case. CASE PRESENTATION: A 52 year old man presented to his general practitioner (GP) with left sided chest pain. A strong family history of ischaemic heart disease prompted hospital referral and further investigations which all proved negative for coronary artery disease. Following weight loss and ongoing chest pain, he represented to his GP with a hard mass arising from the left pectoralis major muscle at the site of the previous pain. Surgical excision followed by later compartectomy revealed an unclassified low grade Sarcoma with lymphoma like features. CONCLUSION: In this case, chest pain masquerading as ischaemia, may have been caused by peri-neural infiltration or compression of adjacent muscle bulk by tumour, with eventual surgical resection providing a good long term prognosis.

Pagets disease of uncertain origin: case report.

BACKGROUND: Pagets disease of the nipple presents as an eczematous lesion, occurs in 1 - 4% of all female breast carcinoma cases and is invariably associated with underlying malignancy either overt or occult. The majority of these cases are invasive disease although 40-45% are associated with DCIS. CASE PRESENTATION: A 39 year old lady presented to our unit with a palpable lump in the right breast. Radiological and histological investigation proved this to be an extensive area of Ductal Carcinoma in Situ (DCIS) for which she underwent a simple mastectomy and immediate latissimus dorsi flap reconstruction. Histology revealed high grade DCIS with 2 small foci of invasive carcinoma. At 1 year the patient represented with a nodule adjacent to the reconstruction scar which was proved on biopsy to be consistent with Paget's disease. This was proved on formal excision. CONCLUSION: In the absence of underlying breast or apocrine tissue this case details a case of Paget's disease of uncertain origin.

"About a cupful"--a prospective study into accuracy of volume estimation by medical and nursing staff.

In this prospective study, medical and nursing health care professionals were asked to visually estimate various fluid volumes. The aims were to assess overall accuracy, and to identify factors that caused error. The effects of fluid volume, colour and clinical experience were analysed. 152 doctors and nurses were shown a selection of containers filled with five different volumes of fluid, each presented in three different colours. Subjects recorded their estimates of volume by filling in a questionnaire. There was considerable variation in accuracy between subjects. Very large standard deviations were noted, and some subjects were found to over-report, to a maximum of 700%. Nurses were more accurate than doctors (p=0.0003). Nurses' accuracy was influenced by fluid colour but not volume, whereas the opposite was true for doctors. Doctors with more than 20 years' clinical experience significantly overestimated volumes compared to their younger colleagues. This effect was not seen with the nursing group. We conclude that visual estimation is unreliable, and recommend against using visual estimation in clinical practice.

Endoscopic transnasal surgery as a replacement for maxillotomy techniques to approach the central skull base: fewer complications and more acceptable to patients?

Objectives To compare the complication rates of endoscopic transnasal and open maxillotomy approaches for the central skull base. Design Retrospective review. Setting Single-center study, London, United Kingdom. Participants From 1992 to 2012, 81 patients underwent surgery for skull base lesions, 59 by maxillotomy and 22 by endoscopy. Main Outcome Measures Total time of surgical anesthesia, blood loss, complications, duration of tracheal intubation, duration of hospital stay, myelopathy score, and mortality rate. Results The surgical time, blood loss, and duration of the postoperative intubation period were significantly less with endoscopy (p < 0.001). Requirements for intensive care, ward stay, and total hospital stay were also significantly less in the endoscopic group (p = 0.01, p < 0.001, and p < 0.001, respectively). The complication rate was lower with transnasal endoscopic surgery. Conclusion In patients for whom open maxillotomy or endoscopic surgery are both feasible, the preference should be to perform endoscopic surgery, with better visualization and fewer complications.

Septic shock after posterior spinal arthrodesis on a patient with Scheuermann kyphosis and multiple body piercings.

STUDY DESIGN: A case report. OBJECTIVE: We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed. SUMMARY OF BACKGROUND DATA: Body piercing has become increasingly more common because of change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following orthopedic or spinal procedures associated with body piercing have not been reported. METHODS: We reviewed the medical notes and radiographs of an adolescent patient with Scheuermann kyphosis and multiple body piercings who underwent a posterior spinal arthrodesis and developed septic shock. RESULTS: Septic shock developed on postoperative day 2 after reinsertion of all piercings following the patient's request. The patient became systemically very unwell and required intensive medical management, as well as a total course of antibiotics of 3 months. The piercings remained in situ. She did not develop a wound infection despite the presence of bacteremia and spinal instrumentation. The patient had no new piercings subsequent to her deformity procedure. Two and a half years after spinal surgery she reported no medical problems, had a balanced spine with no loss of kyphosis correction and no evidence of nonunion or recurrence of deformity. CONCLUSION: The development of septic shock as a result of piercing reinsertion in the postoperative period has not been previously reported. This is an important consideration to prevent potentially life-threatening complications following major spinal surgery.

Measuring IGF-1, ER-α and EGFR expression can predict tamoxifen-resistance in ER-positive breast cancer.

In vitro studies have suggested that tamoxifen resistance may be due to altered expression and downstream signalling of insulin-like growth factor-1 (IGF-1) receptor (IGF-1l), oestrogen receptor-alpha (ERα), epidermal growth factor receptor (EGFR) and HER-2. We investigated which gene expressions could predict tamoxifen resistant breast cancer. Expression of IGF-1R, IGF-1 ligand (IGF-1), ERα, EGFR and HER-2 in 91 ER-positive breast cancer tumours were measured using real-time PCR and correlated with clinical outcome. The tamoxifen resistant group (n=20) consisted of: i) tumours which were resistant to neoadjuvant tamoxifen treatment and ii) tumours which were excised from patients who later developed recurrence or metastasis during adjuvant tamoxifen treatment. These were compared with tamoxifen sensitive tumours which were surgical excision specimens from patients who did not develop recurrence/metastasis during adjuvant tamoxifen treatment. Tumours with higher IGF-1 ligand and ERα expression took longer to develop tamoxifen resistance. Tamoxifen resistant tumours had lower IGF-1 and ERα expression compared to tamoxifen-sensitive tumours. IGF-1 expression strongly correlated with ERα expression in the tamoxifen sensitive group only. ERα inversely correlated with EGFR expression in the tamoxifen resistant group only. We conclude that IGF-1 ligand and ERα expression in breast carcinomas can be measured to predict tamoxifen resistance. Measuring ERα expression using RT-PCR may be more sensitive than immunohistochemistry in determining anti-oestrogen sensitivity.

The use of abbreviations in medical records in a multidisciplinary world--an imminent disaster.

Abbreviations are commonly used in the medical world to save time and space whilst writing in the patients' medical records. As various specialties have evolved, each has developed a collection of commonly used abbreviations within its practice, which may not be recognizable to those not working within the same field. The purpose of this study was to assess whether we, the multidisciplinary team members, correctly interpret the abbreviations used in the medical records. We analysed one week of orthopaedic surgical medical records for the use of abbreviations and assessed their appreciation by other members of the multidisciplinary team by means of a standardized questionnaire. We found great variability in the understanding of these abbreviations by different groups of health care professionals. As expected, the orthopaedic surgeons produced significantly more right answers when compared to the other groups, but even they could correctly interpret just over half (57.24 per cent) of the abbreviations. There were many misinterpretations of the abbreviations across the specialties posing imminent clinical risk. Whilst abbreviations may indeed save time, the observed inter-group variation in correct interpretation of these abbreviations is unacceptable. We recommend that the abbreviations have no place in the multidisciplinary world and their continued use will only lead to eventual clinical error.

Oestrogen producing enzymes and mammary carcinogenesis: a review.

There is a large and compelling body of epidemiological and experimental evidence that oestrogens are instrumental in the aetiology of breast cancer. Their mechanisms of action are varied, including stimulation of cellular proliferation through receptor-mediated hormonal activity, increasing genetic mutation rates through cytochrome P450-mediated metabolic activation, and induction of aneuploidy. The local biosynthesis of oestrogens especially in postmenopausal women is believed to play a very important role in the pathogenesis and development of hormone dependent breast carcinoma and the over-expression of regulatory enzymes seems to be associated with the development of a more aggressive disease and associated with poor outcome and increased local and distant recurrences. In this article we highlight the role of CYP19 gene expression and aromatase activity in mammary carcinogenesis. Other oestrogen producing (17-beta-hydroxysteroid dehydrogenase and steroid sulphatase) and catalyzing enzymes (3-beta-hydroxysteroid dehydrogenase, Oestrogen sulfotransferase, CYP1A1, CYP1B1, and CYP3A4) are also discussed in some detail. Understanding the mechanisms that regulate these enzymes is crucial to the development of new endocrine therapies in post-menopausal females with hormone dependant breast cancer. Currently, third generation aromatase inhibitors has revolutionized the treatment of oestrogen dependant breast cancer. However, the important role of both STS and 17-beta-HSD type 1 in local oestrogen production provides novel potential targets for endocrine therapy. Such endocrine therapy is currently being explored and the development of STS inhibitors, combined aromatase/steroid sulfatase inhibitors and 17-beta-HSD type 1 inhibitors is underway with promising initial results.