An exploration of testicular cancer survivors' experience of ejaculatory dysfunction following retroperitoneal lymph node dissection-a sub-study of the PREPARE clinical trial

PURPOSE

Ejaculatory dysfunction secondary to retrograde ejaculation or anejaculation is a complication of retroperitoneal lymph node dissection (RPLND) for survivors of testicular cancer. We explored survivors' experiences of ejaculatory dysfunction following RPLND.

METHODS

In a sub-study of a single-arm phase 2 clinical trial (ACTRN12622000537752/12622000542796), participants reporting ejaculatory dysfunction ≥ 6 months following RPLND were invited to complete semi-structured interviews. Purposive sampling was used. Interviews continued until thematic saturation occurred, and codebook thematic analysis of interviews was performed.

RESULTS

Of 58 individuals recruited to the trial, 33 (57%) reported ejaculatory dysfunction. Of these, 32 (97%) agreed to interview and 15 participated. Participants interviewed had median age 34 years (range 24-66), 12 (80%) in a long-term relationship with median time from surgery 36 months (range 11-112). Three overarching themes were identified. The first reflected the value of RPLND despite ejaculatory dysfunction. The second illuminated the impact(s) of ejaculatory dysfunction closely mapped to life stage, with flow-on impacts to fertility, sex, psychological wellbeing and communication. The third reflected information needs. Fertility was a substantial source of concern for some participants. Ejaculatory dysfunction had no effect on sex for some, whilst for others, sex was less pleasurable. Some reported benefits. Few reported ejaculatory dysfunction challenged masculinity, confidence, or self-esteem.

CONCLUSIONS

Future research should examine interventions to reduce distress related to fertility, challenged masculinity and body image.

IMPLICATIONS FOR CANCER SURVIVORS

Whilst most participants considered ejaculatory dysfunction to have little impact on their sexual function and relationships, some reported significant difficulties varying by life stage and relationship status.

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients

INTRODUCTION

The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients.

METHODS

A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05.

RESULTS

449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05).

CONCLUSION

In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

Pelvic and acetabular trauma in amateur equestrian enthusiasts - A retrospective review

INTRODUCTION

Horse riding related accidents can present with devastating pelvic and acetabular fractures. This study examines the nature, management and treatment outcomes of severe pelvic and acetabular trauma in amateur horse riders presenting to a national tertiary referral centre. We also aim to define certain at-risk groups.

METHODS

This was a retrospective descriptive cohort of all patients who were referred to the National Centre for Pelvic and Acetabular trauma resulting from horse riding accidents. All patients who were referred to the National Centre for Pelvic and Acetabular Trauma between January 2018 and July 2020 were included. Professional horse riders were excluded. Clinical and treatment outcome measures were stratified to four different mechanisms of injury: fall from horse (FFH), horse crush (HC), Horse Kick (HK) and Saddle Injury (SI).

RESULTS

There were 31 equestrian related injuries referred to our centre between January 2018 and July 2020. One patient was a professional jockey and was thus excluded from the study. Eighteen were female and the mean age at referral was 37 years old. The majority of these were pelvic ring injuries (73%). Fifty per cent of patients required surgical intervention and the majority of these were male.

CONCLUSION

Horse riding is a potentially dangerous recreational pursuit with significant risk of devastating injury. Pelvic and acetabular fractures secondary to horse riding are frequently associated with other injuries and the need operative intervention is common in this group. Young women and older men are higher risk groups.

A Big HIIT: A Fracture Dislocation of the Hip in a Young Man Participating in Extreme Conditioning Exercise: A Case Report

CASE

Hip dislocations with associated acetabular fracture are rare events usually associated with high-energy trauma. We describe an unusual case of low-energy acetabular fracture dislocation sustained by a 30-year-old athletic male athlete during a high-intensity training program.

CONCLUSION

Correct execution of training programs is important. Healthcare professionals as well as participants and instructors of extreme conditioning programs should be aware of this serious complication. Avoidance of this injury may be possible with increased interval recovery and improved technique.

Nutritional status of neurologically impaired children: Impact on comorbidity

BACKGROUND AND AIMS

Malnutrition is common in neurologically impaired (NI) children. It is, however, ill-defined and under-diagnosed. If not recognized and treated, it increases the burden of comorbidities and affects the quality of life of these children. The aim of this study was to characterize the nutritional status of a cohort of children followed up at a reference center for cerebral palsy (CP) in Brussels, Belgium, and to investigate possible links with the occurrence of comorbidities.

MATERIAL AND METHODS

We conducted a single-center retrospective study including all the children followed up at the Inter-university Reference Center for Cerebral Palsy ULB-VUB-ULg. The data were obtained by reviewing medical files. Anthropometric measurements as well as the etiology of neurological impairment, comorbidities, feeding patterns, and laboratory test results were collected. The children were assigned a nutritional diagnosis according to the World Health Organization and Waterlow definitions.

RESULTS

A total of 260 children with cerebral palsy were included, 148 males and 112 females. Their mean age was 10.9±4.3 years. The gross motor function classification system (GMFCS) level was I for 79 children, II for 63 children, III for 35 children, IV for 33 children, and V for 50 children. Of the children, 54% had a normal nutritional status, 34% showed malnutrition, and 8% were obese; 38% had oropharyngeal dysphagia. The sensitivity of mean upper arm circumference of<p10 to detect severe malnutrition was 95%. Specific growth charts for CP were neither sensitive nor specific for predicting the risk of comorbidities. Malnutrition was associated with an increased risk of comorbidities (relative risk of 2.4 [1.7; 3.4]). It was also associated with the occurrence of pneumonia, pressure ulcers, and pathological bone fracture.

DISCUSSION AND CONCLUSION

Children who are NI should be systematically and thoroughly screened for malnutrition, in the hope of offering early nutritional support and reduce comorbidities.

Where does Pelvic and Acetabular Fracture Treatment fit into the Newly Proposed Major Trauma Model in Ireland?

Aim To provide the most up to date reference of referral patterns for pelvis and acetabular (PA) fractures in Ireland and discuss where services should ideally be located. Methods A retrospective review was conducted of all referrals to the national referral centre for PA fractures in Ireland for 2016 and 2017. Results Over the two-year study period 456 referrals were made. Mean age of patients was 53 years, 62.9% were male. Management was conservative in 60.7%, operative in 38.2% while 1.1% died prior to transfer. Nearly half of fractures (47.8%) were due to falls with 38.6% due to road trauma. Referrals from the proposed central trauma network accounted for 76.1% of referrals. Median length of stay was 7 days. Average cost of operative treatment was €11,774. Conclusions PA trauma is associated with significant morbidity and costs to both patients and society. Consideration needs to be given to where best to place PA services to ensure the highest quality care in this cohort of patients

Major histocompatibility complex class I in the horse (Equus caballus) placenta during pregnancy and parturition

BACKGROUND

Major histocompatibility protein class I (MHC-I) is believed to be expressed in the horse allantochorion only in limited areas at limited times. However, its expression has only been investigated in early pregnancy with non-quantitative techniques that cannot reliably detect small amounts of protein.

OBJECTIVE

To quantify the relative expression of MHC-I in the allantochorion and endometrium during days 90-240 of pregnancy (PREG), parturition with physiological delivery of fetal membranes (PHYS), and parturition with retention of these membranes (FMR). Also, to visualize protein expression and determine whether classical or non-classical MHC-I mRNA is expressed.

ANIMALS

Heavy draft horses.

SETTING

PREG horses (n = 12) were sampled postmortem at a slaughterhouse. PHYS (n = 6) and FMR (n = 5) horses were sampled at farms in the vicinity of Olsztyn, Poland.

METHODS

For relative quantification of MHC-I, western blotting with densitometry was used. To visualize MHC-I, immunohistochemistry was used. For mRNA identification, RT-PCR was performed.

RESULTS

Although the quantity of MHC-I was lower during PREG than parturition, it was present in the allantochorion and endometrium during PREG. During parturition, MHC-I expression was upregulated in the allantochorion (PHYS vs. PREG: 2.7-times higher, 95% confidence interval, 1.3- to 5.7-times higher; FMR vs. PREG: 3.2-times higher, 95% confidence interval, 1.5- to 6.7-times higher). At parturition, staining for MHC-I was detected in the microcotyledons. Classical and non-classical MHC-I were expressed in both tissues during PREG, PHYS, and FMR.

CONCLUSION

MHC-I protein is present in the horse allantochorion and endometrium for at least the first two-thirds of pregnancy and at parturition.

When Environmental Forces Collide

Multiple factors often interact to amplify the effects of severe storms, droughts, and other extreme water-related events.

Hemoglobin Solutions Coupled with Polyethylene Glycol 1900: Preparation, Purification, Quality Control and Pharmacological Trials by Hemorrhagic Shock

The usefulness of hemoglobin solutions as oxygen transporters is limited by their high affinity for oxygen and rapid elimination from the circulation. Various chemical modifications of hemoglobin aimed at overcoming these two handicaps have been suggested. We have developed a conjugate of pyridoxylated human hemoglobin with monomethoxypolyoxyethylene 1900, whose preparation and properties are described. We present comparative results on short-term or definitive survival of Wistar rats which, during hemorrhagic shock due to the loss of 60 or 80% of their blood mass, were given a solution of native or modified hemoglobin, in some cases purified by ion-exchange chromatography to remove non-heme proteins, lipids, and some endotoxins. The more complex the treatment used to improve the properties and the purity of the hemoglobin solutions, the longer the animals survived. The loss of hemoglobin in the urine was greatly reduced after conjugation: after 20 h, less than 6% of the total infused.

The effect of social media (#SoMe) on journal impact factor and parental awareness in paediatric urology

BACKGROUND

Social media (SoMe) comprises a number of internet-based applications that have the capability to disseminate multimodal media and allow for unprecedented inter-user connectivity. The role of Twitter has been studied in conferences and education; moreover, there is increasing evidence that patients are more likely to use social media for their own health education.

OBJECTIVE

The aim of this study was to assess the impact of social media platforms on the impact factor of both urological and paediatric journals that publish on paediatric urology, and to assess parental awareness of social media in paediatric urology.

STUDY DESIGN

A filtered Journal of Citation Reports (JCR) search was performed for the period 2012-16 for journals that published articles on paediatric urology. Journals were ranked according to impact factor, and each individual journal website was accessed to assess for the presence of social media. Parents in paediatric urology clinics and non-paediatric urology patients also filled out a questionnaire to assess for awareness and attitudes to social media. All statistical analysis was performed using Prism 6 software (Prism 6, GraphPad Software, California, USA).

RESULTS

Overall, there were 50 urological journals and 39 paediatric journals with a mean impact factor of 2.303 and 1.766, respectively. There was an overall average increase in impact factor across all urological journals between 2012 and 16. The presence of a Twitter feed was statistically significant for a rise in impact factor over the 4 years (P = 0.017). The cohort of parents was statistically more likely to have completed post-secondary education, to have and access to a social media profile, use it for health education, and use it to access journal/physician/hospital social media accounts.

DISCUSSION

This study examined, for the first time, the role of social media in paediatric urology, and demonstrated that SoMe use is associated with a positive influence in impact factor, but also a parental appetite for it. Limitations included a non-externally validated questionnaire. There may also have been bias in larger journals that generate and maintain social media platforms such as Twitter, which may then in turn have an influence on impact factor.

CONCLUSIONS

Social media use within paediatric urology was associated with a higher impact factor, which remained significant after 4 years of analysis. Parents were more likely to use a wide variety of social media to search for conditions and physicians/healthcare providers; therefore, journals and institutions need to embrace and endorse SoMe as a potential source of important clinical information.

Assessing quality of life of patients with hypospadias: A systematic review of validated patient-reported outcome instruments

BACKGROUND

Patient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential.

OBJECTIVE

To identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population.

METHODS

A systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains.

RESULTS

A total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae.

CONCLUSIONS

While many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.

Bowel preparation prior to percutaneous ilio-sacral screw insertion: is it necessary?

PURPOSE

The aim of this study was to compare the outcomes of ilio-sacral (IS) screw fixation with and without the use of bowel preparation, in terms of obtaining adequate visualisation, malpositioning of screw requiring revision surgery and neurovascular injury.

METHODS

A retrospective case control study was performed. We reviewed 74 consecutive cases of IS screw fixation performed at our institution within the last 5 years. We included all patients who had undergone percutaneous IS screw fixation. Two groups, one consisting of patients who underwent bowel preparation prior to surgery (Group 1) and one consisting of patients who had no bowel preparation (Group 2), were compared in terms of the above outcomes. There were 37 patients in each group. The mean age in Group 1 was 41 years (17-63) and in Group 2 was 47 years (12-89).

RESULTS

In Group 1 there were two procedures abandoned due to poor visualisation. In Group 2 there were no cases abandoned for poor visualisation. There were two nerve injuries in Group 1 and no nerve injuries in Group 2. Revision surgery was performed in four patients in Group 1-for malposition, persistent buttock pain, sciatic nerve palsy and inadequate fixation while one revision performed in Group 2 for persistent buttock pain.

CONCLUSION

Based on these results, we conclude that bowel preparation is not necessary to obtain adequate visualisation for safe and accurate percutaneous IS screw insertion. In fact, in Group 1 two procedures were abandoned and there was higher incidence of complications. Therefore, it would appear that this treatment arm should be abandoned all together. Further studies to prove it conclusively and explain the reasons are required.

The validity of questionnaire measures for assessing depression after stroke

Objective: Depression has been reported to occur frequently after stroke. The aim of the study was to assess the validity of questionnaire measures for screening for depression after stroke.

Design: Cross-sectional correlational study between questionnaire measures of mood and psychiatric interview.

Setting: Hospital and community.

Participants: Stroke patients were recruited from hospital wards and from a randomized controlled trial of cognitive behavioural therapy.

Main measures: Beck Depression Inventory, Wakefield Depression Inventory, General Health Questionnaire 28 and Schedules for Clinical Assessment in Neuropsychiatry.

Results: Poor agreement was found between psychiatric diagnosis and questionnaire measures of mood. The sensitivity of the questionnaire measures was high, but specificity was low. No cut-off points with satisfactory sensitivity and specificity could be identified from ROC curves.

Conclusions: Although questionnaire assessments of depression provide a satisfactory screening method, specificity values are too low to provide a basis for the diagnosis of depression. Measures need to be developed with higher specificity to facilitate screening for depression after stroke.

Prenatal Oxycodone Exposure Alters CNS Endothelin Receptor Expression in Neonatal Rats

Prenatal opioid exposure such as oxycodone is linked to significant adverse effects on the developing brain. Endothelin (ET) and its receptors are involved in normal development of the central nervous system. Opioid tolerance and withdrawal are mediated through ET receptors. It is possible that adverse effect of oxycodone on the developing brain is mediated through ET receptors. We evaluated brain ETA and ETB receptor expression during postnatal development in rats with prenatal oxycodone exposure. Timed pregnant Sprague-Dawley rats received either oxycodone or placebo throughout gestation. After birth, male rat pups were sacrificed on postnatal day (PND) 1, 7, 14 or 28. Brain ETA and ETB receptor expression was determined by Western blot analysis. Oxycodone pups compared to placebo demonstrated congenital malformations of the face, mouth, and vertebrae at the time of birth [4/69 (5.7%) vs. 0/60 (0%); respectively] and intrauterine growth retardation [10/69 (15%) vs. 2/60 (3.3%); respectively]. On PND 28, oxycodone pups compared to placebo had lower body and kidney weight. ETA receptor expression in the oxycodone group was significantly higher compared to placebo on PND 1 (p=0.035), but was similar on PND 7, 14, or 28. ETB receptor expression decreased in oxycodone compared to placebo on PND 1 and 7 (p=0.001); and increased on PND 28 (p=0.002), but was similar on PND 14. Oxycodone-exposed rat pups had lower birth weight and postnatal weight gain and greater congenital malformations. ETB receptor expression is altered in the brain of oxycodone-treated rat pups indicating a possible delay in CNS development.

Is there a role for antifibrinolytics in pelvic and acetabular fracture surgery?

BACKGROUND

Pelvic and acetabular fractures are rare, complex injuries associated with significant morbidity. Fixation of these injuries requires major orthopaedic surgery which in itself is associated with substantial blood loss owing to the extensile operative approach and prolonged operating time required to address the complex fracture anatomy. In order to reduce morbidity, a multifactor approach to blood conservation must be adopted.

CURRENT ROLE OF ANTIFIBRINOLYTICS IN ORTHOPAEDIC SURGERY

The use of antifibrinolytics to reduce operative blood loss is well documented in many surgical specialties, including orthopaedic surgery. Elective spinal surgery and joint arthroplasty have benefited from the introduction of antifibrinolytics; however, their role in trauma and fracture surgery is not fully defined. Pelvic and acetabular fracture surgery would benefit from further investigation on the benefit and safety of these agents.

CONCLUSION

Routine use cannot be recommended at this time but agents may be considered on a case-specific basis.

Differences in extracellular matrix remodeling in the placenta of mares that retain fetal membranes and mares that deliver fetal membranes physiologically

INTRODUCTION

In mammals, placenta separation at term may involve degradation of the extracellular matrix by matrix metalloproteinases (MMPs). The activity of MMPs is modulated by TIMPs. We hypothesized that the placentas of mares that deliver fetal membranes physiologically and those that retain fetal membranes (FMR) differ in terms of histology; mRNA expression of MMP-2 and MMP-9; protein expression of MMP-2, MMP-9, and TIMP-2; and the potential activity of both MMPs.

METHODS

Placenta biopsies were taken from mares (n = 9; 4 FMR, 5 controls) immediately after foal expulsion. Retention was defined as failure to expel all fetal membranes within 3 h of expulsion. All mares were monitored for time of expulsion. The degree of allantochorial/endometrial adhesion was determined in FMR mares, and biopsies from all mares were histologically examined. mRNA expression, protein immunolocalization, protein amount and potential enzyme activity were determined with RT-PCR, immunohistochemistry, Western Blotting and zymography, respectively.

RESULTS

FMR mares had strong to extremely strong allantochorial/endometrial adhesion, and significantly more connective tissue in the allantochorial villi than controls. The range of MMP-2 mRNA expression levels was more than 13 times greater in FMR mares than in controls. Protein content of both MMPs and TIMP-2 differed significantly between groups. The range of potential MMP-2 and MMP-9 activity was larger in FMR mares, and MMP-2 potential activity was 1.4 times higher in controls (P = 0.02).

DISCUSSION

These results indicate differences in extracellular matrix remodeling in FMR mares and controls, and suggest dysregulation of MMP expression and activation in FMR mares.

Stimulation of endothelin B receptors by IRL-1620 decreases the progression of Alzheimer's disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by severe cognitive impairment that ultimately leads to death. Endothelin (ET) and its receptors have been considered as therapeutic targets for AD. Recent studies in our lab have shown that stimulation of ETB receptors provide significant neuroprotection following Aβ1-40 administration. It is possible that IRL-1620 may be neuroprotective due to angiogenesis. However, the effect of IRL-1620 on neurovascular remodeling following Aβ1-40 administration has not been established. The purpose of this study was to determine the effect of stimulation of ETB receptors by IRL-1620 on vascular and neuronal growth factors after Aβ1-40 administration. Rats were treated with Aβ1-40 (day 1, 7 and 14) in the lateral cerebral ventricles using stereotaxically implanted cannula and received three intravenous injections of IRL-1620 (an ETB agonist), and/or BQ788 (an ETB antagonist) at 2-h interval on day 8; experiments were performed on day 15. Rats were sacrificed for estimation of brain ETB receptors, vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) expression using immunofluorescence and Western blot. In the Morris swim task, amyloid-β (Aβ)-treated rats showed a significant (p<0.0001) impairment in spatial memory. Rats treated with IRL-1620 significantly (p<0.001) reduced the cognitive impairment induced by Aβ. BQ788 treatment completely blocked IRL-1620-induced improvement in cognitive impairment. IRL-1620 treatment enhanced the number of blood vessels labeled with VEGF compared to vehicle treatment. Additionally, cells showed increased (p<0.001) positive staining for NGF in IRL-1620-treated animals. ETB, VEGF and NGF protein expression significantly (p<0.001) increased in the brain of IRL-1620-treated rats as compared to vehicle. Pretreatment with BQ788 blocked the effects of IRL-1620, thus confirming the role of ETB receptors in the neurovascular remodeling actions of IRL-1620. Results of the present study demonstrate that IRL-1620 improves both acquisition (learning) and retention (memory) on the water maze task and enhances angiogenic and neurogenic remodeling. These findings indicate that the ETB receptor may be a novel therapeutic target for AD and other neurovascular degenerative disorders.

Frequency of delirium and subsyndromal delirium in an adult acute hospital population

Background The frequency of full syndromal and subsyndromal delirium is understudied. Aims We conducted a point prevalence study in a general hospital. Method Possible delirium identified by testing for inattention was evaluated regarding delirium status (full/subsyndromal delirium) using categorical (Confusion Assessment Method (CAM), DSM-IV) and dimensional (Delirium Rating Scale-Revised-98 (DRS-R98) scores) methods. Results In total 162 of 311 patients (52%) screened positive for inattention. Delirium was diagnosed in 55 patients (17.7%) using DSM-IV, 52 (16.7%) using CAM and 58 (18.6%) using DRS-R98⩾12 with concordance for 38 (12.2%) individuals. Subsyndromal delirium was identified in 24 patients (7.7%) using a DRS-R98 score of 7-11 and 41 (13.2%) using 2/4 CAM criteria. Subsyndromal delirium with inattention (v. without) had greater disturbance of multiple delirium symptoms. Conclusions The point prevalence of delirium and subsyndromal delirium was 25%. There was modest concordance between DRS-R98, DSM-IV and CAM delirium diagnoses. Inattention should be central to subsyndromal delirium definitions.

Should money follow the patient: Financial implication for being the National Centre for the Treatment and Management of Pelvic and Acetabular Fractures in Ireland

BACKGROUND

Pelvic and acetabular fractures are complex injuries requiring specialist treatment. Our institution is the National Centre for Treatment and Management of these injuries.

AIM

To audit all referrals to our institution over a 6-month period and calculate the cost incurred by being the national referral centre.

METHODS

Retrospective review of database, and subsequent allocation of Casemix points to assess total cost of treatment for each patient referred to our institution.

RESULTS

103 patients referred with pelvic or acetabular fracture for operative management. The furthest referral distance was 181miles. Over-all, the length of stay was 15.4 days. The average inclusive cost for a referral to our unit for operative management was €16,302.

CONCLUSION

Pelvic and acetabular fractures are complex injuries that require specialist referral unit management. However for these units to remain sustainable money needs to "follow the patient".

Pelvic and acetabular fractures

Patients that sustain pelvic and/or acetabular trauma in Ireland and require surgical intervention are treated at the Adelaide and Meath National Children's Hospital (AMNCH). For this study an audit was conducted of all pelvic and acetabular fractures referred to the AMNCH over a 12 month period from July 2010 to June 2011. This study was conducted with the purpose of recording the different fracture patterns, methods of injury and surgical procedures performed over this time frame. The results demonstrate that 109 patients were referred to the AMNCH with the majority of these fractures being sustained as the result of an RTA (43) or a fall from a height (45). Seventy one patients suffered an acetabular fracture while 43 patients suffered a fracture of their pelvic ring with some patients suffering both. There were 129 surgical procedures performed with 25 patients having more than one surgical procedure.

A bilateral crescent and anterior ring pelvic fracture sustained by inadvertently performing the 'splits'

A case is presented of a healthy 57 year old female who slipped and fell awkwardly into what is known in athletic terms as the front splits. As a result of her fall she sustained bilateral crescent and superior and inferior rami pelvic fractures. Successful operative fixation was undertaken by a combination of open and percutaneous techniques. To our knowledge this is the first reported case of bilateral crescent fractures, and of a pelvic fracture as a result of this mechanism of injury.

Disruption of gallbladder smooth muscle function is an early feature in the development of cholesterol gallstone disease

BACKGROUND; Decreased gallbladder smooth muscle (GBSM) contractility is a hallmark of cholesterol gallstone disease, but the interrelationship between lithogenicity, biliary stasis, and inflammation are poorly understood. We studied a mouse model of gallstone disease to evaluate the development of GBSM dysfunction relative to changes in bile composition and the onset of sterile cholecystitis.

METHODS

BALB/cJ mice were fed a lithogenic diet for up to 8 weeks, and tension generated by gallbladder muscle strips was measured. Smooth muscle Ca(2+) transients were imaged in intact gallbladder.

KEY RESULTS

Lipid composition of bile was altered lithogenically as early as 1 week, with increased hydrophobicity and cholesterol saturation indexes; however, inflammation was not detectable until the fourth week. Agonist-induced contractility was reduced from weeks 2 through 8. GBSM normally exhibits rhythmic synchronized Ca(2+) flashes, and their frequency is increased by carbachol (3 μm). After 1 week, lithogenic diet-fed mice exhibited disrupted Ca(2+) flash activity, manifesting as clustered flashes, asynchronous flashes, or prolonged quiescent periods. These changes could lead to a depletion of intracellular Ca(2+) stores, which are required for agonist-induced contraction, and diminished basal tone of the organ. Responsiveness of Ca(2+) transients to carbachol was reduced in mice on the lithogenic diet, particularly after 4-8 weeks, concomitant with appearance of mucosal inflammatory changes.

CONCLUSIONS & INFERENCES

These observations demonstrate that GBSM dysfunction is an early event in the progression of cholesterol gallstone disease and that it precedes mucosal inflammation.

Injectable PLA-based in situ forming implants for controlled release of Ivermectin a BCS Class II drug: solvent selection based on physico-chemical characterization

In situ forming implants (ISI) prepared from biodegradable polymers such as poly(D,L-lactide) (PLA) and biocompatible solvents can be used to obtain sustained drug release after parenteral administration. The aim of this work was to study the effect of several biocompatible solvents with different physico-chemical properties on the release of ivermectin (IVM), an antiparasitic BCS II drug, from in situ forming PLA-based implants. The solvents evaluated were N-methyl-2-pyrrolidone (NMP), 2-pyrrolidone (2P), triacetine (TA) and benzyl benzoate (BB). Hansen's solubility parameters of solvents were used to explain polymer/solvent interactions leading to different rheological behaviours. The stability of the polymer and drug in the solvents were also evaluated by size exclusion and high performance liquid chromatography, respectively. The two major factors determining the rate of IVM release from ISI were miscibility of the solvent with water and the viscosity of the polymer solutions. In general, the release rate increased with increasing water miscibility of the solvent and decreasing viscosity in the following order NMP>2P>TA>BB. Scanning electron microscopy revealed a relationship between the rate of IVM release and the surface porosity of the implants, release being higher as implant porosity increased. Finally, drug and polymer stability in the solvents followed the same trends, increasing when polymer-solvent affinities and water content in solvents decreased. IVM degradation was accelerated by the acid environment generated by the degradation of the polymer but the drug did not affect PLA stability.

Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review

PURPOSE

Fowler and Stephens showed that by dividing the spermatic vessels a high intra-abdominal testis could be placed in the scrotum. Testicular atrophy is a potential complication of this technique. We conducted a systematic review to determine whether single or 2-stage Fowler-Stephens orchiopexy results in better testicular viability.

MATERIALS AND METHODS

We searched electronic databases, clinical trial registries and gray literature. We included reports describing boys younger than 18 years with a primary outcome of "testicular viability and position." We performed a meta-analysis using random effects models. Heterogeneity was assessed using forest plot and I(2) statistic.

RESULTS

We identified 1,807 citations and included 61 articles. Single stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage procedure in 36 and both approaches in 16. There were no randomized controlled trials, and most studies were cohort or case series. The pooled estimate of success rates was 80% for single stage Fowler-Stephens orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy (95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the 2-stage procedure. There was no difference in the success rate between laparoscopic and open techniques in either single or 2-stage Fowler-Stephens orchiopexy. There was no evidence of asymmetry on the funnel plot. There were no complications reported with single stage, while ileus, hematoma and infection were the most common complications with 2-stage Fowler-Stephens orchiopexy.

CONCLUSIONS

Both techniques have a fairly high success rate but 2-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage). Laparoscopic and open techniques had the same success rate. However, the level of evidence of the studies was low, and a study of a more robust design, such as a randomized controlled trial, should be performed.

Eye tracking technology: a fresh approach in delirium assessment?

The objective of this paper is to highlight the potential role of eye tracking technology (ETT) in the assessment of delirious patients. Delirium occurs in one in five general hospital admissions (Siddiqi, 2006) and its frequency will increase as society gets older. Despite its frequency and significant independent impact upon morbidity and mortality, delirium remains under studied and is frequently missed, detected late, or misdiagnosed (Farrell & Ganzani, 1995; Inouye, 2001; Kakuma, 2003). Detection is a key target for both clinical and research efforts. Assessment of attention is key to diagnosing delirium, yet nurses and non-research medical staff often fail to correctly identify inattention (Inouye et al., 2001; Lemiengre et al., 2006; Ryan et al., 2008). Eye tracking measures have been used in a plethora of key areas of psychiatric research (Crawford et al., 2005; Corden, Chilvers, & Skuse, 2008; Hardin, Schroth, Pine, & Ernst, 2007; Holzman, Leonard, Proctor, & Hughes, 1973), and provide an accurate and non-invasive method in the assessment of cognitive function. The potential of ETT for direct clinical applications in the assessment of attention and comprehension, key cognitive symptoms of delirium, are promising. This paper considers potential new approaches which recent advancements in non-invasive ETT may bring to the examination and understanding of delirium.

Validation of the confusion assessment method in the palliative care setting

The Confusion Assessment Method (CAM) is widely used in the palliative care setting despite the fact that its performance in this population has not been validated. The aim of the study was to determine the sensitivity and specificity of the CAM when used by Non-Consultant Hospital Doctors (NCHDs) working in a specialist palliative care unit. A pilot phase was performed in which NCHDs received a 1-hour training session based on the original CAM training manual. 32 patients underwent 33 assessments in the pilot phase but the sensitivity of the CAM was only 0.5 (0.22-0.78) and specificity was 1.0 (0.81-1.0). An 'enhanced' training programme was devised that took place over two 1-hour sessions and involved case-based learning focused on the areas where the NCHDs were experiencing difficulty. 52 patients underwent 54 assessments in the main phase of the study and the performance of the CAM improved significantly. Sensitivity was 0.88 (0.62-0.98) and specificity was 1.0 (0.88-1.0). The results suggest that the CAM is a valid screening tool for delirium in the palliative care setting but its performance is dependent on the skill of the operator. NCHDs require a certain standard of training before becoming proficient in its use.

Reversibility of delirium in terminally ill patients and predictors of mortality

In this study, factors related to reversibility and mortality in consecutive cases of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) delirium [n = 121] occurring in palliative care patients were evaluated. Delirium was assessed with the revised Delirium Rating Scale (DRS-R98) and Cognitive Test for Delirium (CTD). Patients were followed until recovery from delirium or death. In all, 33 patients (27%) recovered from delirium before death. Mean time until death was 39.7 +/- 69.8 days in patients with reversible delirium [n = 33] versus 16.8 +/- 10.0 days in those with irreversible delirium [n = 88; P < 0.01]. DRS-R98 and CTD scores were higher in irreversible delirium (P < 0.001) with greater disturbances of sleep, language, long-term memory, attention, vigilance and visuospatial ability. Irreversible delirium was associated with greater disturbance of CTD attention and higher DRS-R98 visuospatial function. Survival time was predicted by CTD score (P < 0.001), age (P = 0.01) and organ failure (P = 0.01). Delirium was not necessarily a harbinger of imminent death. Less reversible delirium involved greater impairment of attention, vigilance and visuospatial function. Survival time is related to age, severity of cognitive impairment and evidence of organ failure.

An overview and comparative analysis of singing on the nest in North American birds

Bird song is used to defend territories and attract mates and tends to make the singer conspicuous. Singing on the nest (SOTN) has been mentioned since 1904 but has remained largely unexplored. This behavior occurs in 10.1% of breeding birds of North America. Factors that predict the likelihood of SOTN for any species include colonial nesting, incubation sharing and feeding, and taxonomic family. If SOTN is as conspicuous as other forms of singing, this behavior may incur significant costs, such as increased nest predation and parasitism. Data collected from the literature regarding nest vocalizations of adult birds (calls and songs) showed those costs were not significantly different between vocalizing and silent birds. There was greater variance in the rates of nest predation and parasitism for vocalizing birds, which may suggest greater risk. The function(s) of SOTN are not well understood and are mostly untested. Several hypotheses are presented to explain this behavior. This is the first attempt to examine this behavior in any depth and demonstrates the need for further research to explore its function(s) and consequences.

Minimally-invasive treatment of high velocity intra-articular fractures of the distal tibia

The pilon fracture is a complex injury. The purpose of this study was to evaluate the outcome of minimally invasive techniques in management of these injuries. This was a prospective study of closed AO type C2 and C3 fractures managed by early (<36 hours) minimally invasive surgical intervention and physiotherapist led rehabilitation. Thirty patients with 32 intra-articular distal tibial fractures were treated by the senior surgeon (GK). Our aim was to record the outcome and all complications with a minimum two year follow-up. There were two superficial wound infections. One patient developed a non-union which required a formal open procedure. Another patient was symptomatic from a palpable plate inferiorly. An excellent AOFAS result was obtained in 83% (20/24) of the patients. Early minimally invasive reduction and fixation of complex high velocity pilon fractures gave very satisfactory results at a minimum of two years follow-up.

Nanoparticles of hydrophobically modified dextrans as potential drug carrier systems

Nanoparticles combining a hydrophobically modified dextran core and a polysaccharide surface coverage were elaborated. Their suitability for applications like drug delivery was evaluated. The selected polysaccharide, dextran, was chemically modified by the covalent attachment of hydrocarbon groups (aliphatic or aromatic) via the formation of ether links. According to the extent of modification, either water-soluble or water-insoluble dextran derivatives were obtained. The latter exhibited solubility in organic solvents like tetrahydrofuran or dichloromethane saturated with water. Water-soluble dextran derivatives were used as polymeric surfactants for the control of nanoparticles surface characteristics. Nanoparticles were prepared either by o/w emulsion or solvent-diffusion methods. The size and surface properties of dextran nanoparticles were correlated to processing conditions. The stability of colloidal suspensions was examined as a function of ionic strength and related to the particle surface characteristics. The redispersability of freeze-dried suspensions without the addition of cryoprotectant was demonstrated. Finally, the degradability of modified dextrans was compared to that of starting dextran, after enzymatic hydrolysis in the presence of dextranase.

Paediatric spinal trauma and associated injuries

Paediatric spinal injuries, although rare (1-2% of all paediatric fractures) are associated with the highest mortality rate of all orthopaedic injuries in children. The low incidence is due, not only to the plasticity of the paediatric spine, but also the difficulty of diagnosis and the usually severe if not fatal associated injuries. A 10-year (1995-2004) retrospective study was undertaken of all patients treated for a spinal injury at our institute, which functions as both an acute care centre and a tertiary referral centre for seriously injured children. The study was performed in order to highlight the unique features of spinal injuries in children, and to assess the incidence and pattern of associated injuries. A total of 40 patients had a documented diagnosis of spinal injury. The charts and radiographs of all patients were retrieved and reviewed. The median age was 10 years (range 2-15) and 25 were male. The causative factors were motor vehicle accidents in 16, falls in 14, sport injuries in 7 and assaults in 3. Over 65% of the children sustained one or more associated injuries, the mean injury severity score was 18.95. There were two deaths, both in patients with severe multiple trauma and associated spinal fracture. Treatment included closed reduction in two patients and posterior open reduction and stabilisation in two patients, with one of these also requiring decompression. Spinal injuries in children differ from adults due primarily to the biomechanical and anatomical features of the developing musculoskeletal system. When a spinal injury is identified on initial radiographic or clinical evaluation of an injured child, one should have a high index of suspicion that concurrent, potentially life-threatening injuries may be present.

Determining the absolute efficiency of a delay line microchannel-plate detector using molecular dissociation

We present a method to measure the absolute detection efficiency of a delay-line microchannel-plate detector using the breakup of diatomic molecular ions. This method provides the absolute total detection efficiency, as well as the individual efficiency for each signal of the detector. The method is based on the fact that molecular breakup always yields two hits on the detector, but due to finite detection efficiency some of these events are recorded as single particles while others are detected in pairs. We demonstrate the method by evaluating the detection efficiency for both timing and position signals of a delay-line detector using laser-induced dissociation of molecular ions. In addition, the detection efficiency as a function of position has been determined by dividing the detector into sectors.

Implementing a space-time rainfall model for the Sydney region

This paper investigates a Spatial Neyman-Scott Rectangular Pulse (SNSRP) model, which is one of only a few models capable of continuous simulation of rainfall in both space and time. The SNSRP is a spatial extension of the Neyman-Scott Rectangular Pulse model at a single point. The model is highly idealized having six parameters: storm arrival, cell arrival, cell radius, cell lifetime and two cell intensity parameters. A spatial interpolation of the scale parameter is used so that the model can be simulated continuously in space, rather than as a multi-site model. The parameters are calibrated using least-squares fits to statistical moments based on data aggregated to hourly and daily totals. The SNSRP model is calibrated to a very large network of 85 gauges over metropolitan Sydney and shows a good agreement to calibrated statistics. A simulation of 50 replicates over the region compares favourably to several observed temporal statistics, with an example given for one site. A qualitative discussion of the simulated spatial images demonstrates the underlying structure of non-advecting cylindrical cells.