IgG4-related disease confined to the laryngopharynx: a case report highlighting the complexities in diagnosis for this rare cause of stridor

This case represents only the 15th reported incidence of IgG4-related disease (IgG4-RD) affecting the laryngopharynx, adding diagnostic and therapeutic data for this rare condition and helping to inform the future management of these patients. A 66-year-old man presented with airway symptoms, and investigations by otolaryngology, cardiology and respiratory teams did not provide a clear diagnosis. Repeat biopsies of the laryngopharynx eventually confirmed a clinicopathological diagnosis of IgG4-RD. Treatment with prednisolone and methotrexate was successful. When infective and malignant causes of adult stridor have been excluded, inflammatory causes should be considered. The diagnosis of IgG4-RD isolated to the laryngopharynx may be delayed when using the widely accepted American College of Rheumatology classification criteria because it excludes upper aerodigestive tract features. IgG4-RD isolated to the laryngopharynx is extremely rare. This means a multidisciplinary approach is vital in ensuring timely diagnosis and treatment. Better diagnostic criteria are also needed.

780 Are E-Scooters Safe for Widespread Public Use? A Case Series Examining Severe Facial Injuries Secondary to E-Scooter Accidents

E-scooter use is becoming commonplace across the UK as an increasing number of towns and cities launch trials with pay-as-you-go e-scooter companies. In addition, e-scooters are cheap method of transport, easily available for an individual to purchase online, without restriction. We present two cases of patients having suffered complex facial injuries secondary to e-scooter accidents.

The first is a 38-year-old male, who was thrown from an e-scooter and had associated loss of consciousness. CT facial bones demonstrated extensive fractures to the bilateral maxillary and frontal sinuses, nasal bones, bilateral orbital floors, and mandible. The Le Fort II and mandibular fractures were fixed in two procedures. The patient has ongoing neuropathic pain around the right mandibular condyle and is receiving input from orthognathic specialists.

The second patient is a 60-year-old male, who collided with the rear of a car and was thrown forward, hitting his face on the tarmac. CT facial bones showed a Le Fort II fracture pattern and a fractured left inferior orbital rim, with extensive surgical emphysema of the face. He underwent plating of the bilateral Le Fort II fractures and application of intermaxillary fixation wires.

With little to no enforcement of personal protective equipment use and safety advice whilst utilising e-scooter services, the number of people suffering serious injuries from using such equipment is set to skyrocket. Increased awareness and education around the danger of e-scooters needs to be addressed and should be prioritised by local authorities and public health services.

58 Introduction of a Basic Trauma Course and an Observational Study of Attitudes to Open Fractures in a Rural Region of Sierra Leone

Introduction

Sierra Leone ranks in the bottom quartile of the ‘Least Developed Countries’ across the world. ‘Injury’ is responsible for an estimated 325,000 deaths per annum. Kambia is a rural district in the northwest of the country with an approximate population of 340,000 people.

We were invited to teach the regions community health care officers (CHO) the first ever trauma skills course. Our secondary aim while in Kambia was to investigate the barriers to safe open fracture care in the region.

Method

A 4day teaching course was created and co-ordinated. Questionnaires examining candidate’s trauma knowledge, were utilised. Feedback sheets were collected to assess the courses local acceptability. Three senior CHOs were invite for a semi-structured interview exploring Open Fractures. This was recorded and a thematic analysis was performed on the results.

Results

The mean pre course questionnaire score was 9.0 (SD 3.45), and post course score 19.7(SD 3.8). This gave a mean difference of 10.7(CI 9.5 – 11.8, p value 0.01). All feedback collected was positive, with 15/23 candidates reports ‘Primary Survey’ the most useful teaching session. The reported boundaries to open fracture care included local beliefs, Lack or resources and services, Lack of finances.

Conclusions

Our basic trauma course provided an effective method of teaching trauma skills to the CHO’s of Kambia. It offered a widely accepted teaching structure and was enjoyed by the local medical community. We also identified barriers to optimal open fracture care in the region of Kambia, which can be targeted for further work.

Accuracy of virtual assessment in hand trauma

A virtual clinic was developed from an existing telemedicine system to manage hand trauma in the Queen Victoria Hospital, East Grinstead, UK, during the first wave of the COVID-19 pandemic. This study evaluates the accuracy of the assessments made and makes comparisons to the traditional face-to-face clinic.

The accuracy of assessment was analysed by comparing diagnosis with findings at surgery. One hundred and eighty-nine virtual assessments conducted by telephone with photographic data or by video were compared to 129 face-to-face assessments conducted prior to the pandemic.

There was no difference in the accuracy of virtual and face-to-face clinics for patients treated surgically (p=0.27); treatment was correctly predicted for 87% of the virtual group and 78% of the face-to-face group. However, fewer virtual assessments led to a surgical outcome (p=0.0064); 68% of the virtual group had surgical outcomes compared to 82% of the face-to-face group. Most face-to-face assessments were done by a specialty trainee compared to a range of clinicians in the virtual clinic. Accuracy of assessment among trainees was significantly associated with experience for the virtual (p=0.045) but not face-to-face clinics (p=0.94). Virtual assessment by video versus telephone plus photographs were similarly accurate.

We conclude that virtual triage serves as a successful alternative to face-to-face appointments. It is robust and succeeds in reducing footfall to the hospital site in line with recent social distancing measures against COVID-19. We have shown that video conferencing triage is no better than telemedicine triage with telephone and photographs.

307 Awareness and Reporting of Needle Stick Injury Amongst Junior Doctors in a General Surgery Department

Introduction

This audit was performed to see if a new cohort of junior doctors in a general surgery department had received legally required sharps injury training, assess knowledge on what to do if a needle stick/splash injury were to occur; and to provide necessary training.

Method

Questionnaires about trust needle stick policy training including current job grade, awareness of general principles, reporting of previous needle stick injuries and barriers to reporting of needle stick injuries were filled in. Training was provided on needle free devices and trust needle stick/splash injury protocol. After training, a second questionnaire was filled in to see if there was better understanding of the trust protocol and the necessary steps after injury. The same group of junior doctors were re-audited at a later date to see if the knowledge gained from training had been retained.

Results

All junior doctors (total of 11) in general surgery reported receiving no formal needle stick/splash training since starting at the trust on the trust policy and no formal induction on needle-free devices and what to do in the event of a needle stick injury since starting at the trust. All doctors felt aware of what to do after training provided with time pressures being identified as a barrier for not reporting all needle stick injuries. Re-audit one month later demonstrated all doctors had awareness of the trusts needle stick/splash injury protocol.

Conclusions

The training provided was effective in providing legally required training and improving staff and patient safety.

312 Retrospective Analysis of Long-Term Scarring Outcomes in Paediatric Burns Patients

Introduction

Paediatric burns are a common presentation to a plastic surgery unit. The long-term scar outcomes in paediatric burns patients are relatively unknown as most are discharged after 6 weeks follow up. We aimed to determine whether the long-term scarring outcomes are significantly different in those who had surgical treatment with Versajetâ debridement and Biobraneâ, versus those treated conservatively with non-adherent dressings, in a cohort of paediatric burns patients.

Method

The parents of all paediatric burns patients admitted to Stoke Mandeville Hospital from October 2014 to September 2017 were contacted by telephone to fill in the Brisbane Burn Scar Impact Profile (BBSIP), a patient reported outcome measure specifically aimed at children. The results from the questionnaires underwent statistical analysis to see if there was a significant difference in questionnaire scores between children treated surgically versus those treated conservatively.

Results

A total of 107 children were admitted in the timeframe, responses were received from 34 patients with 13 having been treated surgically and 21 having been treated conservatively. In all 58 questions that make up the BBSIP, there was no statistically significant difference observed in the scores of those treated surgically versus those treated conservatively. For 31 questions on the BBSIP, the lowest score indicating the best outcome was observed in all patients in both groups.

Conclusions

We found no statistically significant difference in the long-term scar outcomes as assessed by the BBSIP in paediatric burn patients treated with Versajetâ debridement and Biobraneâ, versus those treated conservatively with non-adherent dressings.

1234 Emergency Urology Procedures During COVID-19 Pandemic: A 2 Monthly Prospective Study

Introduction

COVID-19 resulted in Regional tiered restrictions being introduced across the UK with subsequent implications for planned and emergency care. Specific to Merseyside Tier 4 and Tier 2 restrictions were introduced in late 2020. At the onset of the pandemic in the Spring, elective work ceased, and emergency admissions were minimal. The purpose of this study was to examine the volume and nature of all emergency admissions to a Urology unit in Merseyside in the 2nd wave of the pandemic during two different tiers of national restrictions.

Method

A prospective audit examining all emergency urological activity was conducted in Whiston Hospital from October 2020 when the Tier 4 restrictions were introduced to Tier 2 was introduced. Data was obtained by identifying patients using the electronic theatre listing system.

Results

A total of 52 emergency cases were performed (24 in November Tier 4, 28 in December Tier 2). A total of 12 different procedures were performed. The commonest procedure performed was stent insertion (26), followed by scrotal exploration (7). One patient required transfer to a different hospital. In total 4 calls were made by general surgery and 2 by gynaecology for urological assistance in theatre. Two urology patients returned to theatre. Direct Consultant involvement occurred in 19 cases (37%).

Conclusions

Unlike the Spring lockdown acute urology operations presented despite regional restrictions. A total of 52 cases were performed with more occurring in Tier 2. Stent insertion was the commonest procedure with the majority of the cases performed by registrars.

496 The Use of Virtual Trauma Clinics (VTC) In the Assessment of Acute Hand Trauma; A Service Evaluation

As a UK tertiary referral centre for hand trauma the current COVID outbreak has led to the reconfiguration of trauma services. We evaluate the impact of our newly introduced VTC on our hand trauma service, comparing a cohort of patients who were managed pre-COVID, with our current revised pathway.

We carried out a service evaluation of all those patients processed by the VTC over 14 days in April 2020 (n = 184). We collected prospective data on timing of referral to assessment and surgery. This data was compared to a matched period in April 2019 (n = 162).

Post VTC there has been a significant reduction in time to clerking and time to surgery (p = < 0.001), with 98.1% being clerked within 1 day of referral. Post VTC 12.9% of patients were discharged directly from VTC, all other patients had definitive treatment in a single trip.

VTC has shown a clear benefit to patients with definitive management provided in a single trip in all cases. Whilst we have been able to clerk patients earlier any improvement in time to surgery depends on theatre staffing and availability, which differed in the two cohorts and certainly will as we move forward into normal services.

162 An Examination of Scar Modelling and Assessment Methods for the Evaluation of Scar Treatments

Introduction

Scarring is the final common pathway for healing within the skin. Scars can be itchy, painful, tight, and disfiguring. Despite advances in surgery there is currently no reliably effective treatment for reducing or preventing scarring. The primary aim of this research is to assess the currently available models for scarring and evaluate/further develop the utility of current assessment tools, in an effort to design a pilot randomised control trial (RCT) for silicone gel treatment of scars.

Method

A systematic review of scar models in humans and animals. Examination of currently used subjective and objective scar assessment tools in a plastic surgery scar clinic. A retrospective cohort study assessing long-term scar outcomes in paediatric burn patients.

Results

Limitations and drawbacks of many existing methods to assess scar treatments were found. No statistically significant difference in long-term scarring outcomes was found between paediatric burns patients treated surgically versus conservatively. A RCT for silicone gel sheeting in the treatment of scars was set up and successful in recruitment.

Conclusions

Here, we have demonstrated difficulties in establishing a scientific scar treatment model; and created a pilot study that will help to provide high-quality evidence for the efficacy of silicone gel sheeting as a treatment for scars.

923 Accuracy of Assessment in Hand Trauma; Pre COVID-19 Face to Face Assessment Compared to Virtual Assessment During COVID-19 Lockdown

Introduction

The Queen Victoria Hospital (QVH) was designated a cancer and trauma hub during the COVID-19 pandemic. With this, a new virtual hand trauma clinic was set up.

We assess accuracy of assessment within this virtual set-up with comparison to pre COVID-19 face-to-face assessment.

Method

Two weeks of clinic sessions during and pre lockdown were analysed. Initial assessment was compared with the patient's operation note.

Results

In the pre COVID-19 two-week period 129 face-to-face appointments were analysed. Of 99 patients that required surgery 77 (78%) had an accurate assessment. 6 were overestimated, 12 were underestimated.

189 patients were seen over two weeks during lockdown via telephone or video call. Accuracy of assessment increased with seniority of the clinician. Of 126 patients that required an operation 109 (87%) had an accurate assessment; all structures injured were correctly predicted. 12 were overestimated, 5 had their injury underestimated.

Conclusions

The new virtual clinic allowed patients to be remotely assessed during lockdown, reducing footfall and unnecessary journeys.

We found that virtual clinic assessments are accurate, and no patient underwent an unnecessary procedure. Using a telephone call plus photo gave similar accuracy as a video call.

Virtual assessment was more accurate than face-to-face assessment.

The single-use rhinolaryngoscope: an evaluation and cost comparison

BACKGROUND

This study investigated whether the single-use rhinolaryngoscope is clinically and economically comparable to the conventional reusable rhinolaryngoscope within a tertiary otolaryngology centre in the UK.

METHODS

A non-blinded, prospective and single-arm evaluation was carried out over a 5-day period, in which micro-costing was used to compare single-use rhinolaryngoscopes with reusable rhinolaryngoscopes.

RESULTS

Overall, 68 per cent of the investigators perceived the single-use rhinolaryngoscope to be 'good' or 'very good', while 85 per cent believed the single-use rhinolaryngoscope could replace the reusable rhinolaryngoscope (n = 59). The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the out-patient clinic, when compared to single-use rhinolaryngoscopes, were £30 and £11, respectively. The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the acute surgical assessment unit, when compared to single-use rhinolaryngoscopes, were -£4 and -£73, respectively.

CONCLUSION

The single-use rhinolaryngoscope provides a clinically comparable, and potentially cost-minimising, alternative to the reusable rhinolaryngoscope for use in the acute surgical assessment unit of our hospital.

Transoral robotic surgery for the benefit of patients with head and neck cancer of unknown primary: our experience at St George's University Hospital, London

INTRODUCTION

Head and neck carcinoma of unknown primary represents 1-5% of all head and neck cancers and presents a diagnostic and therapeutic dilemma. In approximately 40% of cases, a primary tumour location remains unknown despite investigation. With advancements in our understanding of the role of high-risk human papilloma virus in head and neck cancer, transoral robotic surgery presents an option for diagnosis and therapy.

MATERIALS AND METHODS

This is a retrospective case series from a single centre. Case notes were reviewed for 28 patients who had transoral robotic surgery for head and neck carcinoma of unknown primary between May 2015 and July 2019.

RESULTS

Transoral robotic surgery identified an oropharyngeal primary tumour in 19 of 28 (67.8%) patients. All oropharyngeal primaries were p16 positive. The base of tongue identification rate was 63.2%. Median length of inpatient stay postoperatively was 1.0 day. Normal oral intake resumed within 48 hours in 96% (27/28) of patients. Three patients (10.3%) suffered minor postoperative bleeds that were all managed conservatively.

DISCUSSION

The base of tongue primary identification rate (63.2%) in this series is consistent with that previously reported (43-63%; 95% confidence interval). Primary tumour identification rate if a patient is p16 positive is 86.3% (19/22), with 100% of these being oropharyngeal. We suggest future investigation into p16 status as a means of stratifying patients with head and neck carcinoma of unknown primary for transoral robotic surgery.

CONCLUSION

Transoral robotic base of tongue mucosectomy (or lingual tonsillectomy) is a promising technique that offers a high yield of positive identification for the primary tumour. It is well tolerated with minimal associated morbidity. Our findings are comparable with those in the current literature.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

IL-1 induces p62/SQSTM1 and autophagy in ERα+ /PR+ BCa cell lines concomitant with ERα and PR repression, conferring an ERα- /PR- BCa-like phenotype

Estrogen receptor α (ERα)^low/- tumors are associated with breast cancer (BCa) endocrine resistance, where ERα low tumors show a poor prognosis and a molecular profile similar to triple negative BCa tumors. Interleukin-1 (IL-1) downregulates ERα accumulation in BCa cell lines, yet the cells can remain viable. In kind, IL-1 and ERα show inverse accumulation in BCa patient tumors and IL-1 is implicated in BCa progression. IL-1 represses the androgen receptor hormone receptor in prostate cancer cells concomitant with the upregulation of the prosurvival, autophagy-related protein, Sequestome-1 (p62/SQSTM1; hereinafter, p62); and given their similar etiology, we hypothesized that IL-1 also upregulates p62 in BCa cells concomitant with hormone receptor repression. To test our hypothesis, BCa cell lines were exposed to conditioned medium from IL-1-secreting bone marrow stromal cells (BMSCs), IL-1, or IL-1 receptor antagonist. Cells were analyzed for the accumulation of ERα, progesterone receptor (PR), p62, or the autophagosome membrane protein, microtubule-associated protein 1 light chain 3 (LC3), and for p62-LC3 interaction. We found that IL-1 is sufficient to mediate BMSC-induced ERα and PR repression, p62 and autophagy upregulation, and p62-LC3 interaction in ERα⁺ /PR⁺ BCa cell lines. However, IL-1 does not significantly elevate the high basal p62 accumulation or high basal autophagy in the ERα^- /PR^- BCa cell lines. Thus, our observations imply that IL-1 confers a prosurvival ERα^- /PR^- molecular phenotype in ERα⁺ /PR⁺ BCa cells that may be dependent on p62 function and autophagy and may underlie endocrine resistance.

125I-Fibrinogen Binding to Platelets in Myeloproliferative Disease

Recent reports have suggested a variation in the density and affinity of fibrinogen binding sites in platelets from patients with myeloproliferative disorders (MPD) which may reflect platelet functional abnormalities in these subjects. We have investigated the binding of 125I-fibrinogen (125I-Fb) to gel-filtered platelets from a large relatively homogeneous group of patients with MPD compared to normal age matched controls. Twenty-two of the patients investigated had polycythaemia vera and four essential thrombocythaemia.

The maximal density and affinity (Kd) of 125I-Fb binding was assessed by saturation analysis in gel-filtered platelets (GFP) stimulated with either 10 εM ADP or 150 mU thrombin. In addition the functional significance of the binding sites was studied by evaluating the response of GFP from the two experimental groups by assessing the effects of increasing concentrations of added fibrinogen on the response to 10 εM ADP using standard light transmission aggregometry.

In both groups the density of fibrinogen binding sites expressed in response to thrombin stimulation was significantly higher (approximately 2-3 fold) than that found in response to ADP. However, fewer binding sites were detected in the MPD group as compared with the control group in response to both ADP and thrombin. The Kd for 125I-Fb was similar for both agonists in normal controls and was significantly lower than that found in the MPD subjects.

Although the 125I-Fb binding study results indicate a significant reduction in both the number and affinity of fibrinogen binding sites in patients with myeloproliferative disorders, the clinical and functional significance of these findings remain uncertain.

Guide Field Reconnection: Exhaust Structure and Heating

Magnetospheric Multiscale observations are used to probe the structure and temperature profile of a guide field reconnection exhaust ~100 ion inertial lengths downstream from the X-line in the Earth's magnetosheath. Asymmetric Hall electric and magnetic field signatures were detected, together with a density cavity confined near 1 edge of the exhaust and containing electron flow toward the X-line. Electron holes were also detected both on the cavity edge and at the Hall magnetic field reversal. Predominantly parallel ion and electron heating was observed in the main exhaust, but within the cavity, electron cooling and enhanced parallel ion heating were found. This is explained in terms of the parallel electric field, which inhibits electron mixing within the cavity on newly reconnected field lines but accelerates ions. Consequently, guide field reconnection causes inhomogeneous changes in ion and electron temperature across the exhaust.

Observations of Hall Reconnection Physics Far Downstream of the X Line

Observations made using the Wind spacecraft of Hall magnetic fields in solar wind reconnection exhausts are presented. These observations are consistent with the generation of Hall fields by a narrow ion inertial scale current layer near the separatrix, which is confirmed with an appropriately scaled particle-in-cell simulation that shows excellent agreement with observations. The Hall fields are observed thousands of ion inertial lengths downstream from the reconnection X line, indicating that narrow regions of kinetic dynamics can persist extremely far downstream.

Ion-scale secondary flux ropes generated by magnetopause reconnection as resolved by MMS

New Magnetospheric Multiscale (MMS) observations of small-scale (~7 ion inertial length radius) flux transfer events (FTEs) at the dayside magnetopause are reported. The 10 km MMS tetrahedron size enables their structure and properties to be calculated using a variety of multispacecraft techniques, allowing them to be identified as flux ropes, whose flux content is small (~22 kWb). The current density, calculated using plasma and magnetic field measurements independently, is found to be filamentary. Intercomparison of the plasma moments with electric and magnetic field measurements reveals structured non-frozen-in ion behavior. The data are further compared with a particle-in-cell simulation. It is concluded that these small-scale flux ropes, which are not seen to be growing, represent a distinct class of FTE which is generated on the magnetopause by secondary reconnection.

A phase 1 study of intermittently administered pazopanib in combination with continuous daily dosing of lapatinib in patients with solid tumors

PURPOSE

Preclinically, pazopanib/lapatinib combination acted synergistically to suppress the activity of multiple tyrosine kinases, including VEGFR-1, 2, 3, PDGFR and c-kit (pazopanib), HER1/EGFR and HER2 (lapatinib), and several other tyrosine kinases including c-Met through, plausibly, network inhibition effects. Clinically, continuous dosing of pazopanib/lapatinib combination was associated with a higher response rate than with lapatinib monotherapy, with poor tolerance. We explored multiple intermittent dose levels of pazopanib combined with continuous daily dosing of lapatinib in patients with solid tumors.

METHODS

The present study used a phase 1, modified 3 + 3, dose-escalation design to evaluate the safety and tolerability of the combination of orally received pazopanib once every other day with continuous daily dosing of lapatinib for 28 days. In the expansion phase, tumor response was evaluated in patients with specific genetic alterations (HER2 amplification, HER2 mutation, c-Met amplification, c-Met mutation, and EGFR mutation).

RESULTS

Twenty-four patients were treated. The most common drug-related adverse events were fatigue 7/24 (29%), skin rash 5/21 (21%), and diarrhea 3/24 (17%), with 4/24 (16%) patients experiencing grade ≥3 drug-related adverse events. Escalation to the FDA-approved dose (800 mg daily for pazopanib and 1500 mg every day for lapatinib) was not feasible due to toxicities. Pazopanib 200 mg every other day + lapatinib 500 mg daily was considered the maximum tolerated dose (MTD). No tumor response was observed, including in patients with the specific molecular genetic alterations tested.

CONCLUSION

Every other day dosing of pazopanib combined with daily lapatinib was tolerated at the established MTD, but no complete or partial tumor responses were observed at these dose levels.

Ventilated post-mortem computed tomography through the use of a definitive airway

Ventilated post-mortem computed tomography (VPMCT) has been shown to achieve lung expansion in cadavers and has been proposed to enhance the diagnosis of lung pathology. Two key problems of the method of ventilation have been identified: firstly, the presence of head and neck rigor making airway insertion challenging and, secondly, air leak, if there is not a good seal around the airway, which diminishes lung expansion and causes inflation of the stomach. Simple procedures to insert a 'definitive' cuffed airway, which has a balloon inflated within the trachea, are therefore desirable. This study aims to test different procedures for inserting cuffed airways in cadavers and compare their ventilation efficacy and to propose a decision algorithm to select the most appropriate method. We prospectively tested variations on two ways of inserting a cuffed airway into the trachea: firstly, using an endotracheal tube (ET) approach, either blind or by direct visualisation, and, secondly, using a tracheostomy incision, either using a standard tracheostomy tube or shortened ET tube. We compare these approaches with a retrospective analysis of a previously reported series using supraglottic airways. All techniques, except 'blind' insertion of ET tubes, were possible with adequate placement of the airway in most cases. However, achieving both adequate insertion and a complete tracheal seal was better for definitive airways with 56 successful cases from 59 (95 %), compared with 9 cases from 18 (50 %) using supraglottic airways (p < 0.0001). Good lung expansion was achieved using all techniques if the airway was adequately positioned and achieved a good seal, and there was no significant chest pathology. We prefer inserting a shortened ET tube via a tracheostomy incision, as we find this the easiest technique to perform and train. Based on our experience, we have developed a decision algorithm to select the most appropriate method for VPMCT.

Distributed and dynamic modelling of hydrology, phosphorus and ecology in the Hampshire Avon and Blashford Lakes: evaluating alternative strategies to meet WFD standards

The issues of diffuse and point source phosphorus (P) pollution in the Hampshire Avon and Blashford Lakes are explored using a catchment model of the river system. A multibranch, process based, dynamic water quality model (INCA-P) has been applied to the whole river system to simulate water fluxes, total phosphorus (TP) and soluble reactive phosphorus (SRP) concentrations and ecology. The model has been used to assess impacts of both agricultural runoff and point sources from waste water treatment plants (WWTPs) on water quality. The results show that agriculture contributes approximately 40% of the phosphorus load and point sources the other 60% of the load in this catchment. A set of scenarios have been investigated to assess the impacts of alternative phosphorus reduction strategies and it is shown that a combined strategy of agricultural phosphorus reduction through either fertiliser reductions or better phosphorus management together with improved treatment at WWTPs would reduce the SRP concentrations in the river to acceptable levels to meet the EU Water Framework Directive (WFD) requirements. A seasonal strategy for WWTP phosphorus reductions would achieve significant benefits at reduced cost.

Determinants of exposure to second-hand smoke at home and outside the home among students aged 11-17 years: results from the Mumbai Student Tobacco Survey 2010

BACKGROUND

While no level of exposure to Second-hand smoke (SHS) is free of risk, 37% of students from South-East Asia region were exposed to SHS.

AIMS

To estimate the prevalence of exposure to SHS and identify predictors of exposure to SHS at home and outside the home among 1,511 school students aged 11-17 years.

SETTING

The City of Mumbai.

STUDY DESIGN

This study used a two-stage cluster sampling design.

MATERIALS AND METHODS

Mumbai Student Tobacco Survey (MSTS) was a cross-sectional study, using anonymous self-administered structured questionnaire among students. The probability of schools being selected was proportional to the enrolment into grades 8 to 10. The study aimed to sample around 60 students from selected classes in each chosen school.

STATISTICAL ANALYSIS

Proportions, 95% confidence interval and adjusted odds ratios (AOR) were used.

RESULTS

About 79.9% students were aware about the current smoking ban at public places and 88.1% were knowledgeable about the deleterious influence of SHS on them. Overall, 16.5% of students were exposed to SHS at home, and 39.9% outside of the home. Students from families where at least one parent used tobacco were at the greatest risk of SHS exposure at home in addition to outside the home exposure. Those students who were not aware about the smoking ban in public places were at a significantly higher risk of SHS exposure outside the home.

CONCLUSION

Self-reported tobacco use status, age, parents' tobacco use, close friends' smoking, and the route they take to school were significant determinants of exposure to SHS at home and outside the home.

Design and construction of a single tube, quantitative endpoint, LATE-PCR multiplex assay for ventilator-associated pneumonia

AIMS

The goal of this study was to develop a molecular diagnostic multiplex assay for the quantitative detection of microbial pathogens commonly responsible for ventilator-associated pneumonia (VAP) and their antibiotic resistance using linear-after-the-exponential polymerase chain reaction (LATE-PCR).

METHOD AND RESULTS

This multiplex assay was designed for the quantitative detection and identification of pathogen genomic DNA of methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter baumannii, Pseudomonas aeruginosa, plus a control target from Lactococcus lactis. After amplification, the single-stranded amplicons were detected simultaneously in the same closed tube by hybridization to low-temperature molecular beacon probes labelled with four differently coloured fluorophores. The resulting hybrids were then analysed by determining the fluorescence intensity of each of the four fluorophores as a function of temperature.

CONCLUSIONS

This LATE-PCR single tube multiplex assay generated endpoint fluorescent contours that allowed identification of all microbial pathogens commonly responsible for VAP, including MRSA. The assay was quantitative, identifying the pathogens present in the sample, no matter whether there were as few as 10 or as many 100 000 target genomes.

SIGNIFICANCE AND IMPACT OF THE STUDY

This assay is rapid, reliable and sensitive and is ready for preclinical testing using samples recovered from patients suffering from ventilator-associated pneumonia.

A phase I study of ISIS 481464 (AZD9150), a first-in-human, first-in-class, antisense oligonucleotide inhibitor of STAT3, in patients with advanced cancers

8523

Background: ISIS 481464 is a synthetic bicyclic nucleic acid-containing antisense oligonucleotide that is complementary to the mRNA for signal transducer and activator of transcription 3 (STAT3). Methods: Primary objective of the dose-escalation study (3+3 design) was to establish the maximum tolerated dose (MTD) and recommended phase II dose (RP2D). Secondary objectives included safety, tumor response, pharmacokinetics (PK), and pharmacodynamics (PD) using IL-6 and tumor markers. Patient (pt) eligibility included : >18 yrs old, solid tumors or lymphomas refractory to at least 1 prior systemic therapy. ISIS 481464 was administered IV as a loading dose on Days 1, 3, and 5 and then weekly. Results: 15 pts were dosed (4 at 2 mg/kg and 11 at 4 mg/kg). 6 pts had advanced lymphoma (3 DLBCL, 2 Hodgkin’s lymphoma, 1 mantle cell lymphoma) and 9 pts solid tumors. There was one dose limiting toxicity (DLT), a possibly related thrombotic microangiopathy at 4 mg/kg. Treatment emergent thrombocytopenia was observed with an average reduction of approximately 70% from baseline. Three pts, 1 at 2 mg/kg and 2 at 4 mg/kg, experienced nadirs in platelet count below 50x109/L (range 16 to 33x109/L). MTD was not reached; however, given the thrombocytopenia at 4mg/kg, the RP2D was 2mg/kg. Partial responses were observed in 2/3 DLBCL pts. The 1st DLBCL pt (2 mg/kg) with 10 prior treatments had a durable 55% reduction in tumor size and is ongoing treatment at 11 months. This pt had a 76% reduction in IL-6. The 2nd DLBCL pt (4 mg/kg) with 2 prior treatments had a 65% reduction for 4 months and was able to undergo autologous stem cell transplantation. There were no responses in the solid tumor pts. PKs revealed increased plasma trough levels (indicative of tissue concentrations) with increased dose. Conclusions: ISIS 481462 was well-tolerated and the RP2D was determined to be 2 mg/kg. Initial tumor activity was observed in DLBCL pts and a dose expansion in advanced lymphomas is ongoing. Clinical trial information: NCT01563302.

Urology on the inside: managing the needs of the incarcerated

Objective:

Despite a substantial body of literature on prisoner health and the management of specific conditions that affect incarcerated persons, there remains a paucity of data pertaining to the specific urological needs of prisoners. Additionally, no study has documented the impact of prison referrals on a department of urology.

Materials and methods:

A year-long prospective study was performed in a university hospital recording all contact made by detained persons with the department of urology.

Results:

A total of 77 clinical encounters were made by 47 detained patients from seven different institutions over 12 months. All patients were male. The most common reason for urological consultation was investigation of lower tract symptoms, but a total of 18 separate complaints were recorded, including acute trauma.

Conclusions:

The presence of several places of detention impacts significantly on a department’s workload. Management of persons detained under Home Office Licence in a general hospital poses several challenges, including confidentiality and security issues, privacy and patient concerns and prison personnel secondments. The transient nature of the prisoner population can pose difficulties for planned admissions and outpatient follow-up.

An advanced pharmacy practice experience in a student-staffed medication therapy management call center

OBJECTIVE

To describe the implementation of an advanced pharmacy practice experience (APPE) in medication therapy management (MTM) designed to contribute to student pharmacists' confidence and abilities in providing MTM.

DESIGN

Sixty-four student pharmacists provided MTM services during an APPE in a communication and care center.

ASSESSMENT

Students conducted 1,495 comprehensive medication reviews (CMRs) identifying 6,056 medication-related problems. Ninety-eight percent of the students who completed a survey instrument (52 of 53) following the APPE expressed that they had the necessary knowledge and skills to provide MTM services. Most respondents felt that pharmacist participation in providing Medicare MTM could move the profession of pharmacy forward and that pharmacists will have some role in deciding the specific provisions of the Medicare MTM program (92% and 91%, respectively).

CONCLUSION

Students completing the MTM APPE received patient-centered experiences that supplemented their confidence, knowledge, and skill in providing MTM services in the future.

Transition towards health promoting hospitals: adapting a global framework to Pakistan

The World Health Organization encourages hospitals to become Health Promoting Hospitals (HPH) but adapting this concept to Pakistan has not been investigated. We explore perceptions of healthcare stakeholders about strategies and a priority action-plan to encourage HPHs in Pakistan. We conducted a qualitative study in 2007 where key-informant interviews and focus group discussions were held with healthcare stakeholders in Karachi. Thematic analysis was done and emerging themes were categorized. The HPH core components were perceived as the "standard framework"; however more emphasis was placed on priority actions as to satisfy "basic needs" of patients, staff and the community. This included basic facilities of comfort, health, hygiene, safety, security and emotional support. A change in the traditional mindset from cure to care and identification of key personnel, awareness-raising and cooperation would strengthen advocacy efforts for HPH in Pakistan.

Single-aliquot EPR dosimetry of wallboard (drywall)

Electron paramagnetic resonance spectra and dose-response curves are presented for a variety of wallboard samples obtained from different manufacturing facilities, as well as for source gypsum and anhydrite. The intensity of the CO(3)(-) paramagnetic centre (G2) is enhanced with gamma radiation. Isothermal decay curves are used to propose annealing methods for the removal of the radiosensitive CO(3)(-) radical without affecting the unirradiated baseline. Post-irradiation annealing of wallboard prevents recuperation of the radiosensitive CO(3)(-) radical with additional irradiation. A single-aliquot additive dose procedure is developed that successfully measures test doses as low as 0.76 Gy.

Capacity development for community health nurses in Pakistan: the assistant manager role

BACKGROUND

Community health nurses (CHNs), as leaders in developing countries, can promote successful outcomes in meeting the targets of the Millennium Development Goals. A community-based organization in Pakistan is striving to achieve the goals of maternal and child health through the development of the assistant manager role for community health nursing.

PURPOSE

The purpose of this study was to assess the perception of the role of the CHN assistant manager, with the goal of strengthening that role.

METHODS

This interpretive, qualitative study included 13 participants already familiar with CHNs in Pakistan. Interviewing was utilized to explore perceptions of the assistant manager role and to uncover challenges currently existing within this new role.

FINDINGS

Content analysis revealed the following themes: 'role perceptions', 'expectations of the role' and 'collaboration with other community healthcare providers'.

CONCLUSION

Changes to the role are necessary including increased education of the assistant manager CHNs and preparing administration to work with the assistant mangers for effective leadership.

Lateral spine radiographs before androgen deprivation treatment detect a high incidence of undiagnosed vertebral fragility fractures in men with advanced prostate cancer

PURPOSE

Baseline bone mineral density scanning in patients about to commence long-term androgen deprivation therapy for advanced/metastatic prostate cancer is reported to show a high incidence of osteoporosis and osteopenia. We investigated the incidence of existing spinal osteoporotic fractures in this population as this is known to be a risk factor for the development of treatment induced fractures.

MATERIALS AND METHODS

Since 2003 we performed lateral thoracolumbar x-rays on all patients before androgen deprivation therapy for prostate cancer. The heights of T4-L5 vertebral bodies were measured, then reanalyzed by the Eastell method to define grade 1 or worse grade 2 vertebral crush fractures. We used a morphometric algorithm including an age stratified random sample of men with normal thoracolumbar x-rays to quantitatively assess fractures.

RESULTS

A total of 202 patients with prostate cancer underwent thoracolumbar x-rays before androgen deprivation therapy. Of the patients 61.9% had 1 or more grade 1 and 60.9% had 1 or more grade 2 wedge fractures. In addition, 46.5% of patients had 1 or more grade 1 and 44.6% had greater than 1 grade 2 biconcavity fractures. Finally 63.9% of patients had 1 or more grade 1 and 47.8% had 1 or more grade 2 compression fractures. With conventional reporting 72.4% of patients had no bony abnormality, 14.9% had 1 and 12.7% multiple vertebral crush fractures. Bone mineral density was significantly less in patients with fracture(s) vs those with no abnormality (p<0.001).

CONCLUSIONS

Routine reporting identifies a high incidence of spinal fractures before commencing androgen deprivation therapy, but this is much greater when quantitative assessment is applied. Thoracolumbar x-rays identify the risk of treatment induced fracture and allow baseline comparison in individuals who experience back pain on androgen deprivation therapy. We advocate more routine adoption of baseline thoracolumbar x-rays in patients with prostate cancer.

Design and optimization of a novel reverse transcription linear-after-the-exponential PCR for the detection of foot-and-mouth disease virus

AIMS

A novel molecular assay for the detection of foot-and-mouth disease virus (FMDV) was developed using linear-after-the-exponential polymerase chain reaction (LATE-PCR).

METHODS AND RESULTS

Pilot experiments using synthetic DNA targets demonstrated the ability of LATE-PCR to quantify initial target concentration through endpoint detection. A two-step protocol involving reverse transcription (RT) followed by LATE-PCR was then used to confirm the ability of the assay to detect FMDV RNA. Finally, RT and LATE-PCR were combined in a one-step duplex assay for co-amplification of an FMDV RNA segment and an internal control comprised of an Armored RNA. In that form, each of the excess primers in the reaction mixture hybridize to their respective RNA targets during a short pre-incubation, then generate cDNA strands during a 3-min RT step at 60°C, and the resulting cDNA is amplified by LATE-PCR without intervening sample processing.

CONCLUSIONS

The RT-LATE-PCR assay generates fluorescent signals at endpoint that are proportional to the starting number of RNA targets and can detect a range of sequence variants using a single mismatch-tolerant probe.

SIGNIFICANCE AND IMPACT OF THE STUDY

In addition to offering improvements over current laboratory-based molecular diagnostic assays for FMDV, this new assay is compatible with a novel portable ('point-of-care') device, the BioSeeq II, designed for the rapid diagnosis of FMD in the field.

Processing of Electric Arc Furnace Dust using Deep Eutectic Solvents

The present paper describes the design and operation of the first large-scale extraction and separation of metals from a complex matrix using an ionic liquid. The liquid was a deep eutectic solvent based on choline chloride. The hydrogen-bond donors were mixed to optimize solubility and fluid viscosity. It was found that the incorporation of a fine particulate dust actually decreased the viscosity of the fluid. The present paper shows that selective extraction of zinc and lead can be achieved through judicious choice of the hydrogen-bond donor and it is also shown that metals in solution can be separated using cementation with zinc powder. Electrowinning of pure zinc is demonstrated but scale-up tests suggest that the process is relatively slow and has poor current efficiency. An alternative methodology was developed to rapidly recover the zinc from solution using dilute ammonia solution. It is also shown for the first time that cementation can be efficiently carried out in ionic liquids because the recovered metal is porous and allows thick layers to be deposited.