965 Complication Rates in Operatively Managed Ankle Fracture/Dislocations - The Effect of Pre-Reduction Imaging and Compliance with BOAST 12 Guidance

Aim

The BOAST-12 guidelines for the management of ankle fractures aims to optimise functional recovery and reduce complications. They advise against having radiographs prior to urgent reduction of clinically deformed ankles as it could cause an unacceptable delay to subsequent management. Our study aimed to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction.

Method

This was a retrospective observational study of patients with ankle fracture-dislocations between 2013 to 2017 at the Northern General Hospital’s Emergency Department (ED). Information collected from 2 patient groups (with and without pre-reduction radiographs), included patient demographics, time to accepted reduction, number of manipulations, operations, and subsequent complications.

Results

242 patients were identified. Time from arrival in ED to acceptable reduction was significantly longer in patients with pre-reduction radiographs versus patients without (184.5 vs 82 minutes, p < 0.00), but did not increase the overall risk of complications (p = 0.62). Pre-reduction radiographs were associated with insignificantly higher rates of post-traumatic osteoarthritis (p = 0.17) and slightly longer wait time for definitive intervention (1 vs 2 days, p = 0.72). However, this had no relationship with the number of manipulations (p = 0.53).

Conclusions

The use of pre-reduction radiographs significantly increased time to acceptable reduction of ankle fracture-dislocations. However, this was not associated with increased risk of complications or time to definitive management.

Metastatic Breast Care E-Learning Modules

Background and context: The McGrath Foundation has created an e-Learning course to upskill breast care nurses in current metastatic breast cancer practice. The e-Learning course has supported better specialist knowledge and helped close the gap in metastatic cancer support services across Australia. Aim: The project aimed to deliver specialist training to breast care nurses on current trends in care and treatment of individuals with metastatic breast cancer, via an e-Learning platform to enable a cost effective delivery across Australia to 119 nurses. Strategy/Tactics: Key learning outcomes were developed to ensure specific information could be delivered via an online platform. Industry experts, clinicians and experienced breast care nurses/nurse practitioners were consulted to develop the content and an outline of what would be delivered. An experienced online content development company was also engaged to ensure that the content would be presented in an engaging way. Program/Policy process: The metastatic e-Learning course was available for McGrath Breast Care Nurses in June 2017 and accredited for professional development hours by the Australian College of Nursing to contribute to registration under the Nursing and Midwifery Board of Australia. Certificates of completion are given to all participants who successfully complete the course once they achieve competency in all areas of assessment. Outcomes: The e-Learning course has had reach across all areas of the country and allowed easy dissemination of information on current trends in metastatic breast cancer to nurses. This is seen to have great reach with almost all McGrath Breast Care Nurses also caring for a proportion of patients with metastatic disease. Additional qualitative and quantitative analysis will be available during the presentation after analysis is completed. What was learned: Some key learnings from this project have been the scalability of e-Learning as a technology enabled professional development solution. The need for good design to enable engagement with content was consistent theme during feedback sessions. As well as using competency based testing to enable participants to gain professional development in a technology enabled platform has reduced nurse down time.

Retinal disease in the C3 glomerulopathies and the risk of impaired vision

BACKGROUND

Dense deposit disease and atypical hemolytic uremic syndrome are often caused by Complement Factor H (CFH) mutations. This study describes the retinal abnormalities in dense deposit disease and, for the first time, atypical haemolytic uremic syndrome. It also reviews our understanding of drusen pathogenesis and their relevance for glomerular disease.

METHODS

Six individuals with dense deposit disease and one with atypical haemolytic uremic syndrome were studied from 2 to 40 years after presentation. Five had renal transplants. All four who had genetic testing had CFH mutations. Individuals underwent ophthalmological review and retinal photography, and in some cases, optical coherence tomography, and further tests of retinal function.

RESULTS

All subjects with dense deposit disease had impaired night vision and retinal drusen or whitish-yellow deposits. Retinal atrophy, pigmentation, and hemorrhage were common. In late disease, peripheral vision was restricted, central vision was distorted, and there were scotoma from sub-retinal choroidal neovascular membranes and atypical serous retinopathy. Drusen were present but less prominent in the young person with atypical uremic syndrome due to a heterozygous CFH mutation.

CONCLUSIONS

Drusen are common in forms of C3 glomerulopathy caused by compound heterozygous or heterozygous CFH mutations. They are useful diagnostically but also impair vision. Drusen have an identical composition to glomerular deposits. They are also identical to the drusen of age-related macular degeneration, and may respond to the same treatments. Individuals with a C3 glomerulopathy should be assessed ophthalmologically at diagnosis, and monitored regularly for vision-threatening complications.

Modification of Copper Surfaces: Effect on Adhesion at the Copper Polyimide Interface

Copper surfaces were derivatized resulting in the formation of Mx[Cu(II)(CN)Fe(II/III)(CN)5] at the interface. Polyimides were spin coated onto the modified metal surfaces and the degree of adhesion measured by the tape pull test. Effects of mechanical interlocking were evident in the case of modified copper samples, due to derivatization by ferricyanide. The chemical bonding and elemental analyses of the interfaces were studied by XPS and SEM.

Bacterial ancestry of actin and tubulin

The structural and functional resemblance between the bacterial cell-division protein FtsZ and eukaryotic tubulin was the first indication that the eukaryotic cytoskeleton may have a prokaryotic origin. The bacterial ancestry is made even more obvious by the findings that the bacterial cell-shape-determining proteins Mreb and Mbl form large spirals inside non-spherical cells, and that MreB polymerises in vitro into protofilaments very similar to actin. Recent advances in research on two proteins involved in prokaryotic cytokinesis and cell shape determination that have similar properties to the key components of the eukaryotic cytoskeleton are discussed.

Third degree anal sphincter tears: risk factors and outcome

The aim of this retrospective study was to determine the incidence, risk factors and anal symptoms related to third degree tears after vaginal delivery. There were 9,631 vaginal deliveries during the 5-year period studied, with 116 (1.2%) having a third degree tear. Statistically significant risk factors for a third degree tear were primiparity, forceps delivery, episiotomy, fetal birth-weight greater than 4,000 g and increased duration of the second stage of labour. Eighty four of the 116 women were able to be interviewed, and 21 (25%) had anal symptoms related to the tear. Only 3 women had sought help for their symptoms. Twelve women experienced anal incontinence and 2 more required delayed repair of the anal sphincter for incontinence. Third degree tears are a major cause of perinatal and postnatal morbidity. Attention needs to be directed to the prevention of such tears by awareness of the women at risk and to better follow-up and counselling of the women sustaining a tear.

Hepatitis B and C markers among alcoholics in Israel: high incidence of HCV infection

Patients with alcoholic liver disease have an increased prevalence of viral hepatitis. However, the role of demographic characteristics has not been adequately delineated. Therefore, we examined and compared the seroprevalences of hepatitis B and C in Israeli alcoholic patients to that of blood donors control group by their country of birth and origin. Hepatitis B surface antigen, hepatitis B core antibody and hepatitis C virus antibody testing (second generation ELISA) and a confirmatory recombinant immunoblot assay was performed on 496 alcoholic attending an alcoholic abstinence program and compared to 193,806 randomly non-alcoholic blood donors on the basis of their country of birth. Three hundred twenty-eight alcoholic patients (66%) were immigrants and Israeli born Jews and 168 (34%) were Israeli Arabs. Of the 496 alcoholic patients, 24 (4.8%) were HBsAg positive, 38 (7.6%) were anti HCV positive, and 2 (North African Jews) were positive for both markers. HBsAg was detected in 13 (3.9%) immigrant and Israeli Jews and 11 (6.5%) Israeli Arabs, significantly higher than in the adjusted non alcoholic blood donors (p < 0.01). Anti-HCV was detected in 33 (10%) immigrants and Israeli Jews and 5 (2.9%) Israeli Arabs, significantly higher than in the control group (p < 0.005). In the subgroup alcoholic Jews there was no significant difference in hepatitis B seropositivity among alcoholic that were native Israeli, Eastern Europe and former USSR, and Western Europe and American immigrants comparing to the control group. In contrast, anti-HCV recombinant immunoblot assay seropositivity in alcoholic Jews from all subgroups was significantly greater than in non alcoholic blood donors (p < 0.001). Odds analysis of all ethnic groups revealed that alcoholism requiring detoxification have a significant risk factor for hepatitis C more than hepatitis B (p < 0.001). The increased seroprevalence of hepatitis C among Israeli alcoholic patients, regardless their country of birth and origin, suggest that alcoholism is likely to have a predisposing factor for HCV infection.

Atrial sounds and endocardial electrograms recorded during coarse atrial fibrillation

Hearing atrial sounds is unusual during atrial flutter and rare during atrial fibrillation. We report a patient with hypertrophic cardiomyopathy and coarse atrial fibrillation in whom atrial sounds were recorded phonocardiographically during endocardial atrial electrography. The atrial sounds were recorded phonocardiographically at the same periodicity as the atrial electrograms, and both had beat-to-beat variability in morphology, amplitude, and cycle length. These observations suggest that atrial sounds originate from the atrium and that organized electrical and mechanical activity occur in some types of atrial fibrillation.

Arrangement of subunits in flagellar microtubules

Electron micrographs of outer doublet tubules from flagella have been analysed by methods which make use of the computed diffraction patterns of electron-microscope images. Analysis of singlet A-tubules in the tips of flagella has led to a determination of the helical surface lattice of the A-subfibre, confirming that there are 13 longitudinal protofilaments in the tubule wall and that dimers in neighbouring protofilaments form a staggered arrangement, equivalent to the lattice with an axial periodicity of 8.0 nm predicted in earlier work. A low-resolution 3-dimensional image of the A-tubule has been reconstructed, which supports the evidence for an 8.0-nm-long heterodimer oriented along the protofilaments. The heterodimer is identified as a pair of 4.0-nm morphological units, which appear to be globular at this resolution.

Filtered images have been obtained from doublet tubules which show that the B-subfibre is also made up of 8.0-nm dimers, but it differs from the A-tubule in that dimers in adjacent filaments are not in a staggered arrangement but are lined up obliquely at a shallow angle. Using the additional information about the hands of the lattices in the 2 subfibres which is presented in the accompanying paper, a model for the whole doublet has been proposed.