Evaluating the role of the diagnostic radiographer in identifying child safeguarding concerns: A knowledge, attitude and practice survey approach

INTRODUCTION

Child safeguarding and the appropriate identification of suspected victims represents a global phenomenon. Diagnostic imaging is acknowledged as a contributory diagnostic service but the role of the radiographer in the identification and escalation process is less well understood.

METHOD

A Knowledge, Attitude and Practice (KAP) survey was constructed to evaluate knowledge base in the context of the patient-radiographer interaction, the shaping of attitude towards child safeguarding and attitudes held towards their role plus the actual practical experiences of managing child safeguarding concerns.

RESULTS

Respondents demonstrated a inconsistent knowledge base with respect to physical, social and radiographic signs and symptoms of child safeguarding concern. A positive attitude towards the role of the radiographer in child safeguarding was demonstrated but one that was shaped more by experience than pre-registration education. Assessment of concerns was chiefly influenced by clinical history and appreciation of aetiology. Practically, radiographers have infrequent involvement with the identification and escalation of concerns. Whilst some statistically significant relationships between responses and demographics did exist, these were either sporadic or argued to be a result of natural variation.

CONCLUSION

Assessment of physical and social signs of child safeguarding concern are argued to be becoming more challenging. Radiological signs continue to be visible to radiographers but with increasing use of other imaging modalities these signs are becoming more varied in nature and are providing new challenges. Radiographers are capable of escalation when required to do so.

IMPLICATIONS FOR PRACTICE

To maximise the contribution of the profession, education needs to account for imaging modality worked with, in combination with an understanding of related aetiology. Previously existing concerns with respect to escalating processes are no longer in evidence and radiographers are both willing and able to contribute to that process.

Deconstructing the evolutionary complexity between rust fungi (Pucciniales) and their plant hosts

The rust fungi (Pucciniales) are the most speciose natural group of plant pathogens, members of which possess the most complex lifecycles in Fungi. How natural selection works on the Pucciniales has been the subject of several hypotheses in mycology. This study uses molecular age estimation using sequence data from multiple loci, and cophylogeny reconciliation analyses to test hypotheses regarding how the aecial and telial stages in the lifecycle of rust fungi may have differentially impacted their diversification. Molecular age estimates show that the timing of diversification in the Pucciniales correlates with the diversification of their gymnosperm and angiosperm hosts. Host reconciliation analyses suggest that systematic relationships of hosts from the aecial stage of the Pucciniales lifecycle better reflect the systematic relationships among the Pucciniales. The results demonstrate the relative importance of this stage on the overall evolution of the Pucciniales and supports hypotheses made by Leppik over half a century ago. This study represents the first evaluation of how different life stages in the Pucciniales shape the evolution of these fungi.

Periaqueductal Grey EP3 Receptors Facilitate Spinal Nociception in Arthritic Secondary Hypersensitivity

Descending controls on spinal nociceptive processing play a pivotal role in shaping the pain experience after tissue injury. Secondary hypersensitivity develops within undamaged tissue adjacent and distant to damaged sites. Spinal neuronal pools innervating regions of secondary hypersensitivity are dominated by descending facilitation that amplifies spinal inputs from unsensitized peripheral nociceptors. Cyclooxygenase-prostaglandin (PG) E2 signaling within the ventrolateral periaqueductal gray (vlPAG) is pronociceptive in naive and acutely inflamed animals, but its contributions in more prolonged inflammation and, importantly, secondary hypersensitivity remain unknown. In naive rats, PG EP3 receptor (EP3R) antagonism in vlPAG modulated noxious withdrawal reflex (EMG) thresholds to preferential C-nociceptor, but not A-nociceptor, activation and raised thermal withdrawal thresholds in awake animals. In rats with inflammatory arthritis, secondary mechanical and thermal hypersensitivity of the hindpaw developed and was associated with spinal sensitization to A-nociceptor inputs alone. In arthritic rats, blockade of vlPAG EP3R raised EMG thresholds to C-nociceptor activation in the area of secondary hypersensitivity to a degree equivalent to that evoked by the same manipulation in naive rats. Importantly, vlPAG EP3R blockade also affected responses to A-nociceptor activation, but only in arthritic animals. We conclude that vlPAG EP3R activity exerts an equivalent facilitation on the spinal processing of C-nociceptor inputs in naive and arthritic animals, but gains in effects on spinal A-nociceptor processing from a region of secondary hypersensitivity. Therefore, the spinal sensitization to A-nociceptor inputs associated with secondary hypersensitivity is likely to be at least partly dependent on descending prostanergic facilitation from the vlPAG.

SIGNIFICANCE STATEMENT

After tissue damage, sensitivity to painful stimulation develops in undamaged areas (secondary hypersensitivity). This is found in many painful conditions, particularly arthritis. The periaqueductal gray (PAG) is an important center that controls spinal nociceptive processing, on which secondary hypersensitivity depends. Prostaglandins (PGs) are mediators of inflammation with pronociceptive actions within the PAG under normal conditions. We find that secondary hindpaw hypersensitivity in arthritic rats results from spinal sensitization to peripheral A-nociceptor inputs. In the PAG of arthritic, but not naive, rats, there is enhanced control of spinal A-nociceptor processing through PG EP3 receptors. The descending facilitatory actions of intra-PAG PGs play a direct and central role in the maintenance of inflammatory secondary hypersensitivity, particularly relating to the processing of A-fiber nociceptive information.

Periaqueductal grey cyclooxygenase-dependent facilitation of C-nociceptive drive and encoding in dorsal horn neurons in the rat

The experience of pain is strongly affected by descending control systems originating in the brainstem ventrolateral periaqueductal grey (VL-PAG), which control the spinal processing of nociceptive information. A- and C-fibre nociceptors detect noxious stimulation, and have distinct and independent contributions to both the perception of pain quality (fast and slow pain, respectively) and the development of chronic pain. Evidence suggests a separation in the central processing of information arising from A- vs. C-nociceptors; for example, inhibition of the cyclooxygenase-1 (COX-1)-prostaglandin system within the VL-PAG alters spinal nociceptive reflexes evoked by C-nociceptor input in vivo via descending pathways, leaving A-nociceptor-evoked reflexes largely unaffected. As the spinal neuronal mechanisms underlying these different responses remain unknown, we determined the effect of inhibition of VL-PAG COX-1 on dorsal horn wide dynamic-range neurons evoked by C- vs. A-nociceptor activation. Inhibition of VL-PAG COX-1 in anaesthetised rats increased firing thresholds of lamina IV-V wide dynamic-range dorsal horn neurons in response to both A- and C-nociceptor stimulation. Importantly, wide dynamic-range dorsal horn neurons continued to faithfully encode A-nociceptive information, even after VL-PAG COX-1 inhibition, whereas the encoding of C-nociceptor information by wide dynamic-range spinal neurons was significantly disrupted. Dorsal horn neurons with stronger C-nociceptor input were affected by COX-1 inhibition to a greater extent than those with weak C-fibre input. These data show that the gain and contrast of C-nociceptive information processed in individual wide dynamic-range dorsal horn neurons is modulated by prostanergic descending control mechanisms in the VL-PAG.

The Rose Rust Fungus, Phragmidium tuberculatum, is Widespread in the Americas: First Reports from California, Oregon, Massachusetts, and Honduras

The rust fungus Phragmidium tuberculatum Jul. Müll. is a common pathogen on Rosa spp., on which all life cycle stages are formed. Symptoms occur in spring and may include distorted stems, yellow spots on the upper leaf surface, and a bright orange spore mass formed on the abaxial leaf surface. In late summer, sori become speckled with black as fascicles of teliospores develop. The current known distribution of P. tuberculatum is mostly limited to Europe with some occurrence in Asia and into Australasia (2). There is some documented occurrence in North America (Alaska, Connecticut, and Canada [2]), where most rose rust disease is attributed to P. mucronatum (Pers.) Schltdl. This study used a combination of molecular and morphological analyses on newly collected material from across North America (California: BPI877978, PURN7783; Oregon: BPI877980; Massachusetts: BPI877977; and Quebec: BPI877979) and herbarium material from South and Central America (Honduras: BPI864186; and Argentina: BPI843677; both previously identified as P. mucronatum) to document a much broader distribution of P. tuberculatum. Collectively, teliospores from these collections are 4 to 6 celled, dark to black-brown, warted, elongated to cylindrical, 64.7 to 92.4 μm in length by 23.1 to 39.3 μm in width (average 77.6 × 30.0 μm) (30 teliospores from 2 leaves), with 2 to 3 pores/cell and a pronounced hyaline apiculus 4.6 to 18.5 μm long (average 8.3 μm). P. tuberculatum is similar morphologically to P. mucronatum, but sensu Gäumann (3) differs in having wider (30 to 36 μm) and longer (65 to 110 μm) teliospores with an average of 6 to 8 cells/spore. However, the two are easily distinguished by DNA analyses (4). The 28S sequences were amplified using the protocols described in Aime (1) and compared phylogenetically to 28S sequences available in the GenBank database for P. tuberculatum, P. mucronatum, and other Phragmidium spp. (4). In a maximum likelihood analysis, all isolates formed a 99% bootstrap supported clade with P. tuberculatum sequences from Germany, and shared 100% sequence identity with JF907675 P. tuberculatum. In contrast, comparison with HQ421646 P. mucronatum produced only 92% identity (e.g., 836/911 bp for PURN7783). This information indicates that P. tuberculatum is likely to be widespread in the Americas but simply misidentified as P. mucronatum, as was found to be the case for the two herbarium specimens sampled. Detailed examination of historical herbarium material may help to pinpoint how long the fungus has been present and the current extent of its distribution. The rose rust fungus is not considered to be a problem economically, but its spread within North America may be an indicator of commercial practices that serve as a vector for other diseases on ornamental plants. Voucher specimens have been deposited in the U.S. National Fungus Collections (BPI) and Arthur Fungarium (PUR); voucher sequences are deposited in GenBank (Accession Nos. KJ841917 to 23). References: (1) M. C. Aime. Mycoscience 47:112, 2006. (2) J. F. Arthur. Manual of the rusts in United States and Canada. Purdue Research Foundation, 1934. (3) E. Gäumann. Die Rostpilze Mitteleuropas mit besonderer Berücksichtigung der Schweiz. Büchler, Bern, 1959. (4) C. M. Ritz et al. Mycol. Res. 109:603, 2005.

First Report of the White Pine Blister Rust Fungus, Cronartium ribicola, on Ribes odoratum in Indiana

Cronartium ribicola J. C. Fisch., causal agent of white pine blister rust (WPBR), is one of the most damaging pathogens of five-needle pines, forming aecial states on the trunk and branches and causing cankering, topkill, and branch dieback. Infection can predispose hosts to attack by other pests such as bark beetles, and can result in host mortality. Various species of Ribes, Pedicularis, and Castilleja are alternate hosts on which C. ribicola forms its uredinial and telial states during the mid-summer to fall. In an effort to mitigate the damage caused by white pine blister rust, the planting of ornamental species of Ribes, such as R. occidentalis, is prohibited in 14 states. Indiana currently has no restrictions on the planting of Ribes spp. Since 2010, a Cronartium sp. has been observed producing uredinia and telia on R. odoratum 'Crandall' H.L. Wendl. leaves in an urban environment in West Lafayette, Indiana. Symptoms include yellow-orange lesions on the leaf upper surface with uredinia on the underside. These persist from late summer until leaf drop. Telia were collected in 2011 to establish the identity of the causal agent using morphological and molecular analyses. Morphological comparisons between this specimen and other Cronartium species were made using Arthur (2). Filiform telial columns ranged from 0.5 to 1.5 mm in length. Teliospores were cylindrical to sub-ventricose, truncate on either end with one end generally tapering more than the other, and measured 9.0 to 18.6 × 37.2 to 60.0 μm (average 11.9 × 47.4 μm from 30 spores across 4 leaves). These teliospore measurements overlap those of C. ribicola and C. occidentale, but are more consistent with C. ribicola, in which the spores are wider and longer (8 to 12 × 30 to 60 μm) than in C. occidentale (9 to 10 × 27 to 56 μm). For molecular analyses, two nuclear ribosomal loci were sequenced: the internal transcribed spacer regions 1, 2, and 5.8S (ITS) and the 5' end of the large subunit (28S) (1). The ITS sequence was 665 bp long (KF387533) and the 28S was 892 bp (KC876675). These sequences were queried to GenBank using a BLASTn search. The 28S shared 99% identity (891/892 bp) and the ITS shared 100% identity (663/663 bp) to other published C. ribicola sequences with no close matches to any other species with either locus. Both morphological and molecular methods indicate this species to be C ribicola, making this a first report of white pine blister rust on R. odoratum in Indiana. This fungus has been observed previously on R. odoratum in the northeastern United States (Connecticut, Massachusetts, Rhode Island, Vermont, and New Hampshire), the Rockies (Colorado), northwestern United States (Washington), and Canada (3). In Indiana, C. ribicola has also been reported on R. cysnobati. There are no other reports of this fungus on any other host within the state. However, the aecial host, Pinus strobus, does grow within the state, and within West Lafayette. To our knowledge, WPBR has only been observed (not reported) once in Indiana in the past 30 years (Paul Pecknold, personal communication). Further monitoring of C. ribicola hosts is needed in Indiana to determine the extent of the disease. The specimen has been vouchered in the Arthur Herbarium (PUR N6734). References: (1) M. C. Aime. Mycoscience 47:112. 2006. (2) J. F. Arthur. Manual of the Rusts in United States and Canada. Purdue Research Foundation, 1934. (3) D. F. Farr and A. Y. Rossman. Fungal Databases Systematic Mycology and Microbiology Laboratory, ARS, USDA. Retrieved from http://nt.ars-grin.gov/fungaldatabases/ April 23, 2013.

An animal model of chronic inflammatory pain: Pharmacological and temporal differentiation from acute models

Clinically, inflammatory pain is far more persistent than that typically modelled pre-clinically, with the majority of animal models focussing on short-term effects of the inflammatory pain response. The large attrition rate of compounds in the clinic which show pre-clinical efficacy suggests the need for novel models of, or approaches to, chronic inflammatory pain if novel mechanisms are to make it to the market. A model in which a more chronic inflammatory hypersensitivity phenotype is profiled may allow for a more clinically predictive tool. The aims of these studies were to characterise and validate a chronic model of inflammatory pain. We have shown that injection of a large volume of adjuvant to the intra-articular space of the rat knee results in a prolonged inflammatory pain response, compared to the response in an acute adjuvant model. Additionally, this model also results in a hypersensitive state in the presence and absence of inflammation. A range of clinically effective analgesics demonstrate activity in this chronic model, including morphine (3mg/kg, t.i.d.), dexamethasone (1mg/kg, b.i.d.), ibuprofen (30mg/kg, t.i.d.), etoricoxib (5mg/kg, b.i.d.) and rofecoxib (0.3-10mg/kg, b.i.d.). A further aim was to exemplify the utility of this chronic model over the more acute intra-plantar adjuvant model using two novel therapeutic approaches; NR2B selective NMDA receptor antagonism and iNOS inhibition. Our data shows that different effects were observed with these therapies when comparing the acute model with the model of chronic inflammatory joint pain. These data suggest that the chronic model may be more relevant to identifying mechanisms for the treatment of chronic inflammatory pain states in the clinic.

Discovery of 1-[4-(3-chlorophenylamino)-1-methyl-1H-pyrrolo[3,2-c]pyridin-7-yl]-1-morpholin-4-ylmethanone (GSK554418A), a brain penetrant 5-azaindole CB2 agonist for the treatment of chronic pain

We report the synthesis and SAR of a series of novel azaindole CB(2) agonists. 6-Azaindole 18 showed activity in an acute pain model but was inactive in a chronic model. 18 is a Pgp substrate with low brain penetration. The template was redesigned, and the resulting 5-azaindole 36 was a potent CB(2) agonist with high CNS penetration. This compound was efficacious in the acute model and the chronic joint pain model.

Pyridine-3-carboxamides as novel CB(2) agonists for analgesia

We describe herein the medicinal chemistry approach which led to the discovery of a novel pyridine-3-carboxamide series of CB(2) receptor agonists. The SAR of this new template was evaluated and culminated in the identification of analogue 14a which demonstrated efficacy in an in vivo model of inflammatory pain.

Dose-response effects of sotalol on cardiovascular function in conscious, freely moving cynomolgus monkeys

BACKGROUND AND PURPOSE

The non-selective beta-adrenoceptor antagonist, D,L-sotalol (sotalol) is commonly employed as a positive control during preclinical cardiovascular safety pharmacology testing, mainly because of its ability to prolong QT interval duration. However, no information appears in the literature, except in abstract form, regarding the dose-response effects of sotalol in unanesthetized monkeys. The current study was conducted to determine the dose- and plasma-response effects of orally administered sotalol on cardiovascular function in conscious non-human primates.

EXPERIMENTAL APPROACH

Male cynomolgus monkeys were implanted with telemetry devices and the effects of sotalol hydrochloride (5, 10 and 30 mg kg(-1) of body weight, p.o.) on arterial blood pressure, heart rate, body temperature and electrocardiogram waveform were continuously monitored for 6 h after dosing. Blood was sampled for the measurement of plasma concentrations of sotalol.

KEY RESULTS

Sotalol dose dependently decreased heart rate and prolonged RR, PR, QT and corrected QT intervals, while having little or no effects on the QRS complex, arterial pressure or body temperature, over the dose range tested. When the data were related to plasma concentrations of sotalol, it was clear that the cardiovascular effects occurred in a similar pattern and to a comparable degree as those reported in human studies.

CONCLUSIONS AND IMPLICATIONS

The current study helps demonstrate the validity of utilizing telemetry-instrumented non-human primates for the cardiovascular safety pharmacology assessment of drugs prior to first-in-human testing, and its findings may serve as a reference source for the dose- and plasma-response effects of orally administered sotalol in conscious monkeys.

Pressure application measurement (PAM): A novel behavioural technique for measuring hypersensitivity in a rat model of joint pain

Chronic joint pain affects physical well being and can lead to severe psychological and social problems, therefore successful long-term management is highly sought-after. No current behavioural measures of pain used in pre-clinical models mimic the clinical dolorimeter, which provides an objective measure of joint hypersensitivity. In this study we aim to use a novel behavioural readout alongside an established measure to mimic the multifactorial measurements taken in the clinic. Using the pressure application measurement (PAM) device a gradually increasing squeeze was applied across the knee joint of rats until the animal gave an indication of pain or discomfort. PAM and the incapacitance tester were used to detect joint hypersensitivity in a well-established rodent model of adjuvant-induced arthritis. Subsequently, the analgesic effects of prednisolone (1, 3 or 10 mg kg(-1)), morphine (3 mg kg(-1)) and celecoxib (15 mg kg(-1)) were assessed. Both PAM and the incapacitance tester detected a reversal of hypersensitivity 1h post-drug administration. Furthermore, the two readouts were highly correlated, and power analysis indicated that PAM was highly reproducible. In conclusion, PAM provides a novel, accurate behavioural tool for detecting a primary mechanical hypersensitivity in a rat model of chronic inflammatory joint pain.

Discovery of 2-[(2,4-Dichlorophenyl)amino]-N-[(tetrahydro- 2H-pyran-4-yl)methyl]-4-(trifluoromethyl)- 5-pyrimidinecarboxamide, a Selective CB2 Receptor Agonist for the Treatment of Inflammatory Pain

Selective CB2 receptor agonists are promising potential therapeutic agents for the treatment of inflammatory and neuropathic pain. A focused screen identified a pyrimidine ester as a partial agonist at the CB2 receptor with micromolar potency. Subsequent lead optimization identified 35, GW842166X, as the optimal compound in the series. 35 has an oral ED50 of 0.1 mg/kg in the rat FCA model of inflammatory pain and was selected as a clinical candidate for this indication.

Chronic secondary hypersensitivity of dorsal horn neurones following inflammation of the knee joint

Intra-articular injection of Freund's complete adjuvant (FCA) into the rat knee joint produces a swelling of the joint and long lasting hypersensitivity. In this study we have used this model and in vivo electrophysiology to investigate the time course of spinal changes underlying chronic secondary hypersensitivity, by stimulating the ankle joint (an area outside the site of primary hypersensitivity), and have compared the results with behavioural data from the same population of animals at 4-8, 13-17 and 55-59 days following FCA injection. The magnitude of responses and the proportion of dorsal horn neurones receiving inputs from A beta- A delta- and C-fibre afferents were monitored. At all time points, there was a significant increase in the ongoing activity of deep dorsal horn neurones when compared to nai ve rats, correlating well with the behavioural hypersensitivity. Both the magnitude of neuronal responses, and the proportion of neurones responding to electrical or mechanical stimulation in an area of secondary hypersensitivity, were significantly increased 4-8 and 13-17 days following FCA injection. However, while there was still behavioural hypersensitivity at 55-59 days there was a substantial decline in the responses to mechanical stimulation and A-fibre responses to electrical stimulation, although the proportion of neurones responding in the C-fibre latency remained elevated. These results suggest that the behavioural hypersensitivity is due to hyperexcitability at the level of the dorsal horn reflected as an increase of both C-fibre responses and spontaneous activity.

The discovery of 6-[2-(5-chloro-2-{[(2,4-difluorophenyl)methyl]oxy}phenyl)-1-cyclopenten-1-yl]-2-pyridinecarboxylic acid, GW848687X, a potent and selective prostaglandin EP1 receptor antagonist for the treatment of inflammatory pain

The discovery of a series of selective EP1 receptor antagonists based on a 1,2-diarylcyclopentene template is described. After defining the structural requirements for EP1 potency and selectivity, heterocyclic rings were incorporated to reduce logD and improve in vitro pharmacokinetic properties. The 2,6-substituted pyridines and pyridazines gave an appropriate balance of potency, in vivo pharmacokinetic properties and a low potential for inhibiting a range of CYP450 enzymes. From this series, GW848687X was shown to have an excellent profile in models of inflammatory pain and was selected as a development candidate.

Multiple synchronous and metachronous neoplasms of the parotid gland: The Chichester experience

Parotid neoplasms are usually solitary and multiple tumours occurring in an individual are uncommon. The incidence and implications of multiple synchronous and metachronous tumours remains relatively unknown. We reviewed the case notes of 606 patients who had parotidectomies for neoplastic lesions over a 30 year period and identified 30 patients (5%) with multiple primary tumours. There were 24 patients with synchronous tumours and 6 with metachronous tumours. Sixteen of the synchronous tumours (67%) were ipsilateral, whereas all six metachronous tumours were contralateral. Preoperative examination was effective at detecting bilateral tumours but poor at detecting multiple ipsilateral tumours. Multiple tumours were likely to be of the same histology (n=24, 80%) and Warthin's was by far the most common multiple tumour. Ipsilateral tumours of differing histological types and identical tumours other than Wartin's were uncommon. All but one patient had superficial parotidectomies and there were no recurrences.

Changes in dorsal root ganglion CGRP expression in a chronic inflammatory model of the rat knee joint: differential modulation by rofecoxib and paracetamol

Neuropeptide-expressing small diameter sensory neurones are thought to be vital in generating inflammatory hyperalgesic responses. Within the dorsal root ganglion (DRG), both the levels of the neuropeptide calcitonin gene-related peptide (CGRP) and the numbers of CGRP-immunoreactive (CGRP-IR) DRG neurones have been shown to increase in a number of acute adjuvant-induced inflammatory pain models. The aim of this study was to look specifically at changes in numbers of CGRP-IR DRG neurones in a chronic model of inflammatory joint pain following complete Freund's adjuvant (CFA) injection into the rat knee. In this model, there were significant increases in the number of ipsilateral CGRP-IR small DRG neurones at days 1, 16 and 35 following intra-articular CFA, compared to saline-injected sham animals. This correlated with the behavioural readouts of hypersensitivity and knee joint inflammation at the same time points. There was also a significant increase in the number of ipsilateral CGRP-IR medium DRG neurones and contralateral CGRP-IR small DRG neurones at day 1. Following dosing of CFA-injected rats with rofecoxib (Vioxx) or paracetamol, there was a significant decrease in the number of ipsilateral CGRP-IR small and medium DRG neurones in rofecoxib- but not paracetamol-treated rats. These data also correlated with behavioural readouts where hypersensitivity and knee joint inflammation were significantly reduced by rofecoxib but not paracetamol treatment. In conclusion, these data show that changes in ipsilateral CGRP expression within small DRG neurones are consistent with behavioural readouts in both time course, rofecoxib and paracetamol studies in this model of chronic inflammatory pain.

Prostanoid receptor EP1 and Cox-2 in injured human nerves and a rat model of nerve injury: a time-course study

Background

Recent studies show that inflammatory processes may contribute to neuropathic pain. Cyclooxygenase-2 (Cox-2) is an inducible enzyme responsible for production of prostanoids, which may sensitise sensory neurones via the EP1 receptor. We have recently reported that while macrophages infiltrate injured nerves within days of injury, they express increased Cox-2-immunoreactivity (Cox-2-IR) from 2 to 3 weeks after injury. We have now investigated the time course of EP1 and Cox-2 changes in injured human nerves and dorsal root ganglia (DRG), and the chronic constriction nerve injury (CCI) model in the rat.

Methods

Tissue sections were immunostained with specific antibodies to EP1, Cox-2, CD68 (human macrophage marker) or OX42 (rat microglial marker), and neurofilaments (NF), prior to image analysis, from the following: human brachial plexus nerves (21 to 196 days post-injury), painful neuromas (9 days to 12 years post-injury), avulsion injured DRG, control nerves and DRG, and rat CCI model tissues. EP1 and NF-immunoreactive nerve fibres were quantified by image analysis.

Results

EP1:NF ratio was significantly increased in human brachial plexus nerve fibres, both proximal and distal to injury, in comparison with uninjured nerves. Sensory neurones in injured human DRG showed a significant acute increase of EP1-IR intensity. While there was a rapid increase in EP1-fibres and CD-68 positive macrophages, Cox-2 increase was apparent later, but was persistent in human painful neuromas for years. A similar time-course of changes was found in the rat CCI model with the above markers, both in the injured nerves and ipsilateral dorsal spinal cord.

Conclusion

Different stages of infiltration and activation of macrophages may be observed in the peripheral and central nervous system following peripheral nerve injury. EP1 receptor level increase in sensory neurones, and macrophage infiltration, appears to precede increased Cox-2 expression by macrophages. However, other methods for detecting Cox-2 levels and activity are required. EP1 antagonists may show therapeutic effects in acute and chronic neuropathic pain, in addition to inflammatory pain.

A predictive tool for the self-management of diabetes (Librae): evaluation using a continuous glucose monitoring system

AIMS

Diabetes self-management involves a difficult balancing act between insulin, food and exercise. The challenge is to develop innovative, validated algorithms to aid patient decision-making and optimize glycaemic control. 'Librae' is a computerized diabetes simulator in diary format, developed as an educational predictive tool for patients, reducing 'trial and error' by allowing patients to simulate and experiment with dietary or insulin adjustments on a 'body double'. We have evaluated the predictive ability of Librae using continuous blood glucose monitoring (CGMS).

METHODS

Patients with Type 1 Diabetes attending the Paediatric Clinic were invited to use 'Librae' for 1 week and were then fitted with a CGMS for 72 h. The predictive ability of 'Librae' was compared with concurrent data obtained from the CGMS.

RESULTS

Seven thousand nine hundred and sixty paired blood glucose values were obtained from the 11 patients who completed the study. 'Librae' underestimated the measured CGMS values, the error having a positive mean of 0.35 mmol/l (95% confidence interval 0.22-0.48 mmol/l). However, Librae tended to overestimate at low levels of blood glucose readings, and underestimate at high levels of blood glucose readings.

CONCLUSION

The modelled values of 'Librae' correlated well with the CGMS data, but clinically unacceptable errors occurred at extremes of blood glucose levels. Concurrent CGMS recordings have provided a large data set to modify and improve the existing Librae model and patient feedback has led to improvements in its usability. Librae may provide a useful tool to improve diabetes self-management education and optimize glycaemic control.

Activation of CB1 and CB2 receptors attenuates the induction and maintenance of inflammatory pain in the rat

The aim of the present study was to investigate the effects of cannabinoid agonists on established inflammatory hyperalgesia. We have compared the effects of pre-administration versus post-administration of a potent non-selective cannabinoid agonist HU210 and a selective CB2 receptor agonist JWH-133 on hindpaw weight bearing and paw oedema in the carrageenan model of inflammatory hyperalgesia. For comparative purposes we also determined the effects of the mu-opioid receptor agonist morphine and the COX2 inhibitor rofecoxib in this model. At 3 h following intraplantar injection of carrageenan (2%, 100 microl) there was a significant (P < 0.001) reduction in weight bearing on the ipsilateral hindpaw, compared to vehicle treated rats and a concomitant increase in ipsilateral hindpaw volume (P < 0.001), compared to vehicle treated rats. Systemic administration of HU210 (10 microg/kg) and JWH-133 (10 mg/kg) at 3 h following injection of carrageenan, significantly attenuated decreases in ipsilateral hindpaw weight bearing (P < 0.05 for both) and paw volume (P < 0.001 for both). Pre-administration of HU210 and JWH-133 had similar effects on weight bearing in this model. Pre-administered HU210 also significantly decreased carrageenan-induced changes in paw volume (P < 0.001), this was not the case for JWH-133. Effects of post-administered HU210 and JWH-133 on ipsilateral hindpaw weight bearing and paw volume were comparable to the effect of systemic post-administration of morphine and rofecoxib (3 mg/kg for both). In summary, both HU210 and JWH-133 attenuated established inflammatory hypersensitivity and swelling, suggesting that cannabinoid-based drugs have clinical potential for the treatment of established inflammatory pain responses.

Another use of the Foley catheter: retraction for operations on the floor of mouth and ventral aspect of the tongue

A Foley catheter that is passed through the nose and sutured to the tip of the tongue can be used to facilitate retraction for operations on lesions on the ventral aspect of the tongue and the floor of the mouth. It provides excellent access and is simple, inexpensive, atraumatic, minimises frustration, reduces the operating time, and eliminates some of the difficulties associated with the use of metal retractors.

Transmasseteric antero-parotid approach for open reduction and internal fixation of condylar fractures

The morbidity that results from surgical approaches to the condylar neck, and the time-consuming nature of the operation inhibits many surgeons from using open reduction and internal fixation for the treatment of condylar fractures. The many approaches that have been described stand testimony to the disadvantages of the individual techniques. The most common problems are limited access and injury to the facial nerve. We describe the transmasseteric antero-parotid (TMAP) technique, which offers swift access to the condylar neck while substantially reducing the risk to the facial nerve and eliminating the complications associated with transparotid approaches.

Surgical management of incompletely excised basal cell carcinomas of the head and neck

We made a retrospective audit of all basal cell carcinomas excised in the Maxillofacial Units at St. Richard's Hospital, Chichester and the Worthing and Southlands NHS Trust between 1990 and 1999. A total of 3795 BCCs were excised. Of these, 3560 were completely excised (93.8%) and 235 were incompletely excised (6.2%), which compares favourably with other series. Of these, 84 patients had further excision, 11 had radiotherapy, and 140 were kept under review. Residual tumour was present in 45% of the re-excised specimens. Of the 140 cases managed by observation, 21% recurred. Notably, 31% of patients in the observation cohort died of other causes without recurrence. Incomplete excision was significantly more likely (P < 0.001) if multiple lesions were excised at the time of operation. Involvement of multiple margins was not a significant risk factor for recurrence in the 'observed' cohort. This study shows that a flexible strategy, which balances observation, further excision and radiotherapy, is superior to any single approach.

Thoracotomie transverse de réanimation

The technique of resuscitative transverse thoracotomy is for use in case of circulatory arrest in the trauma patient. This technique, performed after orotracheal intubation, is initiated by a 5th intercostal space thoracostomy in each mid-axillary line. If the circulatory arrest is not caused by a tension pneumothorax, bilateral thoracotomies in the 5th intercostal spaces with transverse transsection of the sternum is performed. Middle vertical incision of the pericardium allows the evacuation of a cardiac tamponade. This wide surgical access has proved simple to perform, even by non experienced operators. It allows digital control of a heart wound, cross-clamping of the thoracic descending aorta or of pulmonary hilum, rapid perfusion of warm fluids through the right auricle and the performance of bimanual internal cardiac massage.

Manipulation of operant responding for an ethanol-paired conditioned stimulus in the rat by pharmacological alteration of the serotonergic system

It is becoming increasingly clear that environmental stimuli play a critical role in the maintenance of drug taking behaviour. This has led to investigations into the neural mechanisms by which environmental stimuli can come to control behaviour using paradigms such as conditioned reinforcement. The majority of this work has involved the use of food-paired conditioned stimulus rodent paradigms. Relatively few studies have attempted to investigate the neuropharmacology of behaviour maintained by presentation of a stimulus paired with ethanol drinking. Several lines of research support an important role for brain serotonin (5-HT) neurotransmitter systems in the control of alcohol drinking behaviour. The aim of the present study was, initially, to establish a procedure in which rats respond for an ethanol-paired conditioned stimulus, and second, to study the effects of a range of serotonergic compounds previously shown to be effective in reducing oral ethanol self-administration, on responding for this conditioned stimulus. Results showed that the 5-HT releaser d-fenfluramine, the selective serotonin reuptake inhibitor fluoxetine, the 5-HT1A receptor agonist 8-hydroxy-2[di-n-propylamino]tetralin, the partial 5-HT1A receptor agonist buspirone, and the 5-HT1B/5-HT2C receptor agonist 1-(3-trifluoromethylphenyl)piperazine, but not the 5-HT2A/5-HT2C receptor agonist 1-(2,5-dimethoxy-4-iodophenylaminopropane)-2, selectively reduced responding on a lever leading to presentation of an ethanol paired conditioned stimulus. In addition the non-specific D1/D2 dopamine receptor antagonist haloperidol was active in this paradigm. Results are consistent with involvement of the dopaminergic and 5-HT systems, in particular activation of 5-HT1A and 5-HT1B receptor subtypes, in mediation of the conditioned or secondary reinforcing properties of ethanol.

Allergy to local anaesthetic: the importance of thorough investigation

A case report is presented which highlights the importance of a good history in arriving at the correct diagnosis in cases where allergy to local anaesthetic is suspected. Management of the patient is discussed and the topic of 'adverse reaction' briefly reviewed.

Can some physical therapy and manual techniques generate potentially osteogenic levels of strain within mammalian bone?

BACKGROUND AND PURPOSE

Although physical therapy techniques are used to alleviate pain and stiffness in joint injuries, whether these methods are capable of affecting bone is unknown. For example, can these techniques potentially influence bone formation or resorption? To begin exploring this possibility, this study investigated the ability of 4 manual techniques to generate levels of compressive strains that presumably can stimulate bone metabolism.

SUBJECTS

Six 3,4 metacarpals from three 3-year-old Merino ewes were used.

METHODS

A rosette strain gauge was implanted onto the dorsomedial cortex of each ovine 3,4 metacarpal. Four different manual procedures were applied on 2 occasions on each metacarpal in vivo and ex vivo. Mean peak principal compressive strains were calculated for each technique.

RESULTS

Levered bending produced greater mean peak compressive strains than almost all other manual procedures tested in vivo or ex vivo.

CONCLUSION AND DISCUSSION

Manual levered bending created levels of compressive strain similar in magnitude to those created by mechanical devices used in previous animal experiments to induce new bone formation (osteogenesis). This animal model appears to be suitable for investigating the effects of manually applied procedures on bone and may establish whether manual techniques can stimulate bone formation.

Effects of pergolide treatment on in vivo hydroxyl free radical formation during infusion of 6-hydroxydopamine in rat striatum

This study focused on the early neurochemical events involved in 6-hydroxydopamine (6-OHDA) neurotoxicity and the putative neuroprotective effects of pergolide. 6-OHDA in 0.1% ascorbic acid/saline was delivered into rat striatum by means of microdialysis and 2,3-dihydroxybenzoic acid (2,3-DHBA) was measured as an index of hydroxyl free radical formation using salicylate trapping. Infusion of 6-OHDA (2-20 mM) via the dialysis probe for 15 min was associated with an immediate and striking increase in the extracellular levels of 2,3-DHBA and dopamine, and this effect was dose-dependent. An infusion of 10 mM 6-OHDA, equivalent to a direct injection of approximately 4 microgram free base, resulted in dopamine overflow with a maximum approx. 200-fold above the baseline. This massive overflow of toxic amounts of dopamine, much greater than expected of reuptake inhibition, seems to be the earliest response of nigrostriatal neurones to 6-OHDA. In rats treated with pergolide mesylate (7 days 0.5 mg/kg/day, i.p.), the average amount of 2, 3-DHBA associated with 6-OHDA striatal infusion was significantly smaller than that in controls. This suggests that pergolide treatment leads to an increased ability of striatal tissue to quench hydroxyl radical formation in vivo.

An investigation into the effects of 5-HT agonists and receptor antagonists on ethanol self-administration in the rat

Pharmacological manipulation leading to altered 5-HT function has been widely demonstrated to reduce ethanol intake in free choice tests. The aim of the present study was to examine the effects of a range of compounds known to influence 5-HT neurotransmission, including selective 5-HT receptor agonists and antagonists, on ethanol ingestion and maintained behaviour in an operant self-administration paradigm. Female Sprague-Dawley rats were trained to respond for 8% ethanol (v/v) in a 60-min test by a previously described technique. The number of responses and ethanol reinforcers (dipper deliveries), ethanol consumption (g/kg of body weight), and locomotor activity (LMA) were measured following administration of 5-HT agonists (5-HT, d-fenfluramine, fluoxetine, buspirone, TFMPP, and DOI) and antagonists (metergoline, ritanserin, and ondansetron) 30 min prior to testing. d-Fenfluramine, fluoxetine, buspirone, TFMPP, and DOI all produced a reduction in ethanol ingestion and maintained behaviour at doses that failed to reduce LMA. Conversely, metergoline and ritanserin only reduced ethanol self-administration at doses that concomitantly reduced LMA. 5-HT and ondansetron were without effect on any measure. These results demonstrate that, under the present experimental conditions, activation of central 5-HT1A, 5-HT1B, and 5-HT2 receptors reduced ethanol intake and reinforced behaviour in an operant paradigm.

Strain differences in ethanol preference and reinforced behaviour: a comparison of two-bottle choice and operant self-administration paradigms

An animal's volitional consumption of ethanol may be influenced by both genetic and environmental factors. In addition, genetic control of ethanol intake may depend on the test paradigm used. In the present study, performance for, and intake of ethanol in a limited access oral operant paradigm, and preference for ethanol in a two-bottle free choice test in the home-cage were compared in female rats of the heterogeneous Sprague Dawley (SD) and inbred Lewis strains. A smaller proportion of SD rats reached criterion on the self-administration task (four of 10 SD vs eight of 10 Lewis), but those SD rats that did achieve criterion maintained higher levels of responding and greater ethanol intake, relative to the Lewis strain, in the operant self-administration paradigm. Additionally, SD but not Lewis rats exhibited increased locomotor activity and an increase in performance for ethanol compared with water. In marked contrast, Lewis rats exhibited a greater preference for 10% ethanol over water in the two-bottle choice test compared with the SD strain, which preferred water to ethanol. These results suggest that both genotype and test paradigm are involved in the extent to which ethanol serves as a positive reinforcer and that unlike two-bottle choice preference tests, self-administration studies are more highly predictive of the reinforcing properties of ethanol.

Survival following pre-hospital arrest with on-scene thoracotomy for a stabbed heart

A 34-year-old man was stabbed in the heart with the loss of all signs of life at the site of the incident. A resuscitative thoracotomy was performed at the roadside rather than transport a lifeless patient to hospital. Thoracotomy revealed asystole, pericardial tamponade and a right ventricular stab wound. Following further roadside resuscitation and subsequent air transport, and 30 min after loss of signs of life the patient was defibrillated in hospital and regained sinus rhythm. He recovered and was discharged at 25 days with normal neurology and mentation. Pre-hospital thoracotomy on a patient who had lost signs of life following a penetrating chest wound is an alternative to a "scoop and run' policy.

Children falling from a height in London

OBJECTIVES

To determine the frequency and geographical distribution of children falling from a height in London and to suggest possible causes and preventative measures.

METHODS

All relevant cases attended by the Helicopter Emergency Medical Service (HEMS) in a three and a half year period were reviewed and the locations related to the boroughs. The rates, per 1,000 resident children, were compared with socioeconomic indices for the boroughs concerned. In addition, a survey was undertaken of window fittings and maintenance in high rise flats close to one particular incident.

RESULTS

A total of 90 incidents were attended involving 91 patients (64 male, 27 female) of whom five died. HEMS attends approximately one third of incidents involving serious trauma. In the study period the maximum frequency was 0.2 fallers per 1,000 resident children, occurring in three boroughs. In three boroughs there were no fallers. There was no overlap in socioeconomic indices between the five boroughs with the highest fall rates and the five with the lowest. The building survey found a high incidence of faulty window catches, a slow response rate for repair, and a lack of safety advice for residents.

CONCLUSIONS

The frequency of falling is related to urban deprivation, poor maintenance, and lack of safety information. A combination of regulation and targeted education could substantially decrease deaths and injuries in children from this cause.

The 5-HT1A receptor agonist 8-OH-DPAT reduces ethanol intake and maintained behavior in female Sprague-Dawley rats

Agents affecting serotonergic (5-hydroxytryptamine, 5-HT) function influence ethanol consumption in rats and primates. In the present study female Sprague-Dawley rats were trained to orally self-administer 8% ethanol (v/v) in a large operant chamber in a 60-min test period by a prandial drinking technique. The number of response, ethanol reinforcers (dipper deliveries), and ethanol consumption (g/kg) were measured following administration of the 5-HT1 A agonist 8-OH-DPAT (0.001 1.0 mg/kg, ip) 30 min prior to testing. Locomotor activity (LMA) was also measured to assess activity changes induced by 8-OH-DPAT. 8-OH-DPAT selectively reduced ethanol ingestion from 17.1 +/- 3.2 dipper deliveries under vehicle conditions to 6.6 +/- 3 at a dose of 0.1 mg/kg. Higher doses of 8-OH-DPAT (0.5 and 1.0 mg/kg) significantly reduced both ethanol ingestion and LMA. Lower doses of 0.001-0.01 mg/kg of 8-OH-DPAT were without effect on ethanol intake and maintained behavior. These results demonstrate that, under the present experimental conditions, the 5-HT1A receptor agonist 8-OH-DPAT reduced ethanol self-administration in the rat, and support a role for 5-HT1A receptors in the mediation of ethanol reinforcement.

Vehicle entrapment rescue and pre-hospital trauma care

From 1 April 1991 to 31 March 1993 the Royal London Hospital Helicopter Emergency Medical Service (HEMS) attended 737 road traffic accidents, 90 (12 per cent) of which involved entrapments. Nine casualties (10 per cent) died, of which five died at the scene. Thirty-two patients with a median ISS 17 (range 1-59) were transported by helicopter to the Royal London Hospital. Of these, four subsequently died in hospital. The median ISS of the non-survivors was 44 (range 24-59). The remaining 53 patients were transported to the nearest hospital. In 45 cases (50 per cent) patient extrication took longer than 30 min. The methods and standards for the release of trapped road traffic accident victims were reviewed to allow physicians a working understanding of Fire Service techniques. Entrapment rescue should create rapid access to the accident victim, allowing stabilization and release with minimum delay. Immediate and uncontrolled release of trapped victims is only indicated if there is immediate danger to life from the surroundings. We recommend a rigorous target of less than 30 min for the release of the casualty. To achieve this will require systematic extrication training for Fire Service crews and medical teams who are involved in immediate care.

Pre-hospital management of patients with severe thoracic injury

The physiological variables of oxygen saturation, blood pressure and pulse rate were compared in the pre-hospital phase and on arrival at hospital in a group of 63 patients with severe chest injury. Eighty-nine pre-hospital thoracic drainage procedures were carried out. Pre-hospital Advanced Trauma Life Support (ATLS) was associated with a significant improvement in all three variables. Median oxygen saturation increased by 17 per cent (P < 0.001), median blood pressure increased from 90 to 120 mmHg (P < 0.001) and median pulse rate decreased from 125 to 105 (P < 0.001). Pre-hospital intervention is indicated for tension pneumothorax, and contraindicated for haemothorax without respiratory compromise. In other situations further evidence is required, and standard ATLS protocols should be used until this is available.

The Effect of a Helicopter Trauma Service on the Workload of Accident and Emergency Departments

A helicopter trauma service caused little change in the number of patients seen in accident and emergency departments within its operating area. It is concluded that the formation of trauma networks will have little impact on the workload of non-specialist units.

The effect of a helicopter trauma service on the workload of accident and emergency departments

A helicopter trauma service caused little change in the number of patients seen in accident and emergency departments within its operating area. It is concluded that the formation of trauma networks will have little impact on the workload of non-specialist units.

Blood pressure changes in head-injury patients during pre-hospital anaesthesia with propofol

Intubation at the site of accident is often necessary for patients who have sustained significant head injuries. Propofol can attenuate the hypertensive response to intubation, and cause hypotension in anaesthetic doses which can be greatly exaggerated in hypovolaemic patients. We studied nine patients with isolated head injuries and 11 multiply injured patients with associated head injuries. Patients were resuscitated and then intubated with a small dose of propofol, titrated to ensure unconciousness, and then suxamethonium. In neither group was there a statistically significant fall in blood pressure afterwards although the multiply injured patients tended have greater falls. We conclude that propofol used thus does not cause clinically important hypotension in these potentially unstable patients, but only doctors with suitable anaesthetic and pre-hospital experience should attempt it.

Role of the beta subunit in determining the pharmacology of human gamma-aminobutyric acid type A receptors

A cDNA encoding the human gamma-aminobutyric acid (GABA)A receptor beta 2 subunit has been cloned and sequenced. The deduced amino acid sequence of this cDNA shows only a single amino acid change from the rat sequence (Asn-347 in rat, serine in human). Using polymerase chain reaction amplification of human-specific products from human x rodent somatic cell hybrid DNAs, the gene has been assigned to human chromosome 6. By expressing recombinant human GABAA receptors containing different beta subunits (beta 1, beta 2 or beta 3) in both transfected cells and Xenopus oocytes, we have been able to determine the influence of the beta subunit on the pharmacology of the receptor. For a number of benzodiazepine binding site compounds, a barbiturate, and several neurosteroids, neither the affinity nor the efficacy of the compounds is influenced by the type of beta subunit present in the receptor molecule. These data suggest that the beta subunit does not significantly influence the benzodiazepine, barbiturate, or steriod site pharmacologies of human GABAA receptor subtypes.

On-scene medical decision making and overtriage

This study examined whether a hospital-based helicopter trauma service led to 'overtriage' of patients back to the multispecialty base hospital. All accident-site triage decisions made during 1991 were studied. Seven of the 574 decisions (1.2 per cent) led to inappropriate movement of the patient to a specialist centre. Twenty-six decisions (4.5 per cent) were based on mechanism of injury alone and the possibility of overtriage by this method is discussed. A trained doctor can select the correct destination for a patient with trauma without inappropriately using the base hospital in preference to local centres.

Prehospital surgical airway management: 1 year's experience from the Helicopter Emergency Medical Service

Advanced Trauma Life Support requires surgical airway techniques to be used in patients when oral or nasal intubation is impossible or contraindicated. Few reports have examined the results of surgical cricothyroidotomy in prehospital trauma management. During a 12-month period, 600 patients were seen and treated by the Helicopter Emergency Medical Service medical team. Advanced airway techniques were performed at the scene in 143 cases (24 per cent). Of these cases, orotracheal intubation was performed in 132 (92.3 per cent) and surgical cricothyroidotomy in 11 (7.7 per cent). The indications for cricothyroidotomy were: (1) failed intubation in patients with facial injuries, (2) intubation impossible due to patient position during entrapment, and (3) severe burns. Four patients, who were already in cardiopulmonary arrest, succumbed in the field despite cricothyroidotomy. Three patient later died in hospital and four (37 per cent) survived. Three of the survivors made a good recovery, including one who was in cardiorespiratory arrest at the scene, and one remains severely disabled. Surgical cricothyroidotomy is a life-saving procedure in prehospital trauma management that must be performed without delay or hesitation if conventional airway manoeuvres are impossible or fail.

Helicopter Emergency Medical Service operating from the Royal London Hospital: the first year

The additional workload on the support hospital created by using a helicopter for emergency trauma has been assessed in the first year of operation. A total of 135 patients were brought to the Royal London Hospital, of whom 30 died, 34 were transferred for convalescence or rehabilitation to another hospital, and 71 discharged home. The median Injury Severity Score was 17 (range 0-75) and 82 patients (60.7 per cent) had a reduced Revised Trauma Score at the scene. Blunt injury greatly outnumbered penetrating trauma (117 versus 15 patients). Accidental injuries accounted for 77.0 per cent of the total, self-inflicted wounds 14.1 per cent and assaults 8.9 per cent. Parameters employed to assess workload were hospital bed-days used (total 2361), operations (118, occupying 287 h of theatre time) and blood transfusion (total 702 units used). The second 6-month study period showed a considerable increase in the number of patients admitted (102 versus 33) because of increased efficiency in call-out procedures.

The Royal London Hospital Helicopter Emergency Medical Service: first phase 1990

A Helicopter Emergency Medical Service (HEMS) has been introduced to improve trauma care in the Southeast of England. The majority of the workload comes from the area bounded by the M25 ring road. In 1989 a Dauphin 365N helicopter equipped for pre-hospital primary rescue and emergency inter-hospital secondary transfer was certified by the Civil Aviation Authority. The helicopter commenced carrying patients with a paramedic and a doctor on board early in 1990. In September 1990 this service was further improved by the opening of a helipad at the Royal London Hospital and a designated HEMS desk at London Ambulance Service central control. Eighty-four patients were transported in primary rescue missions and 107 as emergency transfers in 1990.

Psoriatic arthropathy of the temporomandibular joint

A case of psoriatic arthritis of both temporomandibular joints is described with a brief review of the literature and discussion on the management of this condition. To date, psoriatic arthritis has been successfully treated by conservative means. In the case reported, surgical replacement of the condyles became necessary to eliminate pain and restore function.

Combined use of Doppler and conventional ultrasound for the diagnosis of vascular and other lesions in the head and neck

Twenty-three patients with swellings of the head and neck were prospectively investigated by Doppler ultrasound and ultrasound imaging to determine the type and vascularity of the lesions and thereby aid pre-operative diagnosis. Four vascular lesions were correctly identified while vascularity was not found in patients with lipoma, cysts, abscess, or muscular hypertrophy. Increased vascularity was found in or near some tumours and lymphangiomas, but by careful comparison of findings these lesions were not confused with true vascular lesions. The value of the investigations was demonstrated by a change in the treatment in 6 of the cases in this series.