A multi-site service evaluation of silver diamine fluoride use for children

Introduction The use of silver diamine fluoride (SDF) is relatively new to the UK. It is unknown how it is being used and for what indications in UK paediatric dental services.Aim To: 1) establish how SDF is being used across different paediatric dental settings in the UK; and 2) consider parental and patient views on the treatment experience and side effect of discolouration.Method A multi-site service evaluation was carried out across six paediatric dentistry units covering hospital and community services. Data were collected prospectively from 17/02/2020 to 02/03/2022. Simple descriptive statistics were used to analyse the data.Results Data were collected for 54 patients. The included patients had an age range of 2-13 years, with a mean of 4.9 years. The reason SDF was chosen was reported as: to avoid general anaesthetic (n = 25); to avoid extractions (n = 8); stabilisation (n = 25); acclimatisation (n = 24); and insufficient cooperation for other treatment (n = 17). In total, 42 cases had SDF applied to the primary dentition. This was in the anterior dentition for 18 patients and the posterior dentition for 15, with nine patients having SDF applied both anteriorly and posteriorly. The majority of children and parents were accepting of the technique and immediate aesthetic outcome.Conclusion In the services involved in this multi-site service evaluation, SDF is used for young patients in the primary dentition for the purpose of caries arrest. The technique was viewed positively by the majority of parents and children.

535 Private Trauma Lists: A Pragmatic Panacea During This Pandemic

Introduction

COVID-19 has disrupted the efficiency of hospitals nationwide. Ambulant trauma surgery was minimised to reduce risk of contracting COVID-19. Operating capacity significantly reduced and surgical training dramatically curtailed. Locally, a private hospital has been utilised as a green site with consultant-lead trauma lists. Our aim is to review the safety and efficiency of this service.

Method

Patients underwent pre-assessment, COVID-19 swabs and 7 days isolation pre and post-op. Staff also underwent swabbing. Prospectively data was gathered for all patients operated on at this site from 12/05/2020 to 20/08/2020. Records reviewed for readmission, complications and COVID status. A satisfaction questionnaire was sent to trainees who operated at this site.

Results

79 operations were completed during this period. 50 male and 29 female, average age 49, average ASA 2. No complications or COVID-19 infections were recorded. Mean time to theatre was 18 days. Delays to theatre led to 2 complications. 87% of trainees felt training was maintained.

Conclusions

Establishing a green site enabled efficient and safe management whilst still facilitating surgical training. This requires clear guidelines for staff and patients. We believe this model can help trauma service provision as the pandemic evolves.

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study

PURPOSE

Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.

METHODS

A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019.

RESULTS

Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification.

CONCLUSION

COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Extracts of irradiated mature human tooth crowns contain MMP-20 protein and activity

OBJECTIVES

We recently demonstrated a significant correlation between enamel delamination and tooth-level radiation dose in oral cancer patients. Since radiation can induce the synthesis and activation of matrix metalloproteinases, we hypothesized that irradiated teeth may contain active matrix metalloproteinases.

MATERIALS AND METHODS

Extracted teeth from oral cancer patients treated with radiotherapy and from healthy subjects were compared. Extracted mature third molars from healthy subjects were irradiated in vitro and/or incubated for 0-6 months at 37°C. All teeth were then pulverized, extracted, and extracts subjected to proteomic and enzymatic analyses.

RESULTS

Screening of irradiated crown extracts using mass spectrometry identified MMP-20 (enamelysin) which is expressed developmentally in dentine and enamel but believed to be removed prior to tooth eruption. MMP-20 was composed of catalytically active forms at Mr=43, 41, 24 and 22kDa and was immunolocalized predominantly to the morphological dentine enamel junction. The proportion of different sized MMP-20 forms changed with incubation and irradiation. While the pattern was not altered directly by irradiation of healthy teeth with 70Gy, subsequent incubation at 37°C for 3-6 months with or without prior irradiation caused the proportion of Mr=24-22kDa MMP-20 bands to increase dramatically. Extracts of teeth from oral cancer patients who received >70Gy radiation also contained relatively more 24 and 22kDa MMP-20 than those of healthy age-related teeth.

CONCLUSION

MMP-20 is a radiation-resistant component of mature tooth crowns enriched in the dentine-enamel. We speculate that MMP-20 catalyzed degradation of organic matrix at this site could lead to enamel delamination associated with oral cancer radiotherapy.

Sigmoid sinus thrombosis presenting with posterior alexia in a patient with Behçet's disease and polycythaemia: a case report

Introduction

A 59-year-old Caucasian woman presented with an acute onset of alexia, noticed whilst driving. She described how while she could read car number plates, she had lost the ability to read and understand words on roadside advertisements and car window stickers.

Case presentation

Neurological examination was unremarkable apart from the inability to read full words or sentences. Imaging of the brain, initially computed tomography, followed by magnetic resonance venography, confirmed a diagnosis of sigmoid sinus thrombosis with associated venous infarction. The patient's past medical history revealed that she had suffered an ischemic stroke and following investigation for this, had undergone a nephrectomy for renal cell carcinoma. This was complicated by postoperative deep venous thrombosis. She had a persistent polycythaemia that was managed with venesection, and recently she had been diagnosed with Behçet's disease. Prior to this presentation, she had recently stopped her prophylactic antiplatelet medication as she was due to undergo a total knee replacement for osteoarthritis. She was managed with weight-adjusted, low molecular weight heparin followed by oral anticoagulation, and made a good recovery from her symptoms.

Conclusion

This case illustrates a classical neurological syndrome, highlights the importance of cerebral venous and sinus thrombosis as a cause of stroke, and the importance of remaining vigilant to a person's changing risk of venous thrombosis with evolving comorbidity.

Simultaneous presentation of both true and false aneurysm in the infrarenal aorta

Interventional radiology has resulted in a reduced need for bypass procedures for aorto-occlusive disease. However, there are still indications for surgery of this type, which carries with it a small but significant morbidity and mortality. False aneurysms are well described following such procedures but with the development of inert, strong and non-absorbable materials they are becoming less common. This paper describes the acute presentation of a false aneurysm of the aorta following an aorto-iliac bypass where true aneurysmal change had taken place in the area of the anastomosis.

Percutaneous cholecystolithotomy: risks, benefits, and long-term outcome

BACKGROUND

For symptomatic patients with gallbladder stones and a patent cystic duct who wish to retain their 'functioning' gallbladders, percutaneous cholecystolithotomy (PCCL) offers an alternative to open or laparoscopic cholecystectomy. However, there are few data on the risks and benefits of this approach or on the long-term outcome.

METHODS AND RESULTS

In 21 patients with symptomatic calcified gallstones, PCCL was successful (gallstone clearance) in 17 (81%). Four to 62 (median, 35) months after clearance 9 of the 17 remained symptom-free and stone-free, whereas 4 developed biliary sludge at 7, 30, 32, and 35 months, 2 of whom subsequently developed gallstones. In four other patients gallstones recurred without evidence of preceding biliary sludge at 9, 16, 19, and 27 months, corresponding to an actuarial gallstone recurrence rate at 36 months of 53.4 +/- SEM 15.1%, and a combined stone/sludge recurrence rate of 63.4 +/- 13.5%.

CONCLUSIONS

PCCL is moderately effective but, because of the frequency of complications and sludge/stone recurrence, is likely to have only a limited residual role in the era of laparoscopic cholecystectomy.

MRI of the knee: its cost-effective use in a district general hospital

In the first year of magnetic resonance imaging (MRI) scanning of the knee in the East Berkshire Health District, 175 patients were scanned and 79 of these subsequently had an arthroscopy performed. We found that MRI accurately demonstrated the pathology present in the knee, particularly for meniscal lesions, although it was less accurate for anterior cruciate and cartilage lesions. The relative costs of MRI scanning, arthroscopy and conservative treatment are compared. On the basis of this analysis we have worked out a protocol for the cost-effective use of MRI in imaging the knee. This protocol has reduced the number of arthroscopies performed, allowing us to expend resources on patients who would definitely benefit from arthroscopic surgery.

Management of diffuse esophageal spasm with balloon dilatation

Of 1200 patients referred to the esophageal laboratory at Guy's Hospital for investigation of suspected esophageal motility disorders, 61 (5.1%) were diagnosed as diffuse esophageal spasm. Twenty of these patients whose symptoms were severe did not respond to conservative treatment and were treated by balloon dilatation. Results were good in 14 and poor in six patients, which included one esophageal perforation. Diffuse esophageal spasm was diagnosed where more than 30% nonperistaltic activity was demonstrated by manometry. Lower esophageal sphincter pressure and relaxation were normal in all cases except one. Gastroesophageal reflux was present in four of five poor responders who were examined by 24-h ambulatory pH monitoring, and in only one of 10 good responders. Three of the six patients in whom balloon dilatation was successful proceeded to full-length myotomy, with relief of symptoms in two. The indications for, and results of, balloon dilatation in this condition are discussed, and a new radiological sign is described.

Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy

In a five year study, 55 patients with radiolucent gall stones were treated with the combination of 7.5 mg chenodeoxycholic acid (CDCA) and 5.0 mg ursodeoxycholic acid (UDCA)/kg/day--that is, half the monotherapeutic doses. Side effects were few but four patients could not tolerate the prescribed bile acids because of diarrhoea or nausea. Analysis of fasting duodenal bile confirmed that CDCA+UDCA converted supersaturated into unsaturated bile but the saturation indices did not predict the dissolution response. By actuarial analysis, the confirmed (by ultrasound x2) complete gall stone dissolution rates in all 55 patients were mean (SEM) 29 (7)% at 12 and 44 (8)% at 24 months. The advent of routine computed tomography before treatment enabled comparison of dissolution efficacy in those screened by computed tomography (n = 24), whose maximum gall stone attenuation was less than 100 Hounsfield units, with that in those not screened (n = 29). Although stone size and number were comparable, patients screened by computed tomography had significantly better dissolution rates (p less than 0.025) than those not screened in this way. At 12 months, partial or complete gall stone dissolution rates were 93 (7)% in the screened and 55 (11)% in the non-screened patients. At 18 months, complete dissolution rates were 64 (12%) and 20 (9)% respectively. Computed tomography before treatment is cost effective in selecting those patients likely to achieve gall stone dissolution on treatment with UDCA+CDCA.

Piezo-ceramic lithotripsy of gallbladder stones: initial experience in 38 patients

The efficacy, safety, and side-effects of a piezo-ceramic system for extracorporeal shock-wave lithotripsy of gallbladder stones were assessed in the first 38 patients treated. Gallstone fragmentation was achieved in 34 patients; 25 required more than 1 treatment session (range 1-5). Extracorporeal shock-wave lithotripsy, conducted without sedation, analgesia, or anaesthesia, was well tolerated by all patients; no patient reported pain or discomfort either during or after the procedure. Side-effects were negligible: transient microscopic haematuria in 2 patients, transiently abnormal liver function tests in 1, and short-lived cutaneous petechiae in 4. Initial experience shows that lithotripsy with this system is effective, safe, and well tolerated.

Pneumothorax: radiologic treatment with small catheters

In many institutions, the standard treatment of symptomatic and large pneumothoraxes has been with surgically placed large-bore (22-32-F) chest tubes. During the past 3-4 years, the authors used small catheters (7, 8.2, and 9.4 F) to decompress 30 pneumothoraxes (15 under tension) resulting from percutaneous lung biopsy. The catheters were inserted under computed tomographic or fluoroscopic guidance for the treatment of large (greater than 35%) or symptomatic pneumothoraxes. Twenty-eight of 30 patients were treated successfully with the small catheters alone; two patients underwent surgical placement of 32-F tubes (4 and 12 hours later) because of incomplete resolution of the pneumothoraxes. This series demonstrates that small-caliber catheters effectively decompress pneumothoraxes and that they can be inserted expeditiously by radiologists in the radiology department.

Periappendiceal abscesses: percutaneous drainage

Percutaneous abscess drainage was performed in 21 patients who had periappendiceal abscesses. Fifteen patients had de novo abscesses, while six patients had persistent postsurgical abscesses. Nineteen of the 21 percutaneous drainages were successful. After percutaneous abscess drainage, interval appendectomy was simple and uneventful in all 14 patients in whom it was performed; four patients had appendices removed prior to percutaneous abscess drainage, and three elderly patients have not required appendectomy (follow-up 1 1/2-3 1/2 years). Percutaneous catheter drainage of periappendiceal abscess performed with computed tomographic guidance is effective and safe. Its benefits include imaging demonstration of the abscess; avoidance of an operation for abscess drainage; temporization of extremely ill patients; simplification of appendectomy, which is made elective; obviation of all operations in selected patients (e.g., elderly or with cardiopulmonary disease); and reduction of hospital stay and cost.

Percutaneous diagnostic and therapeutic interventional radiologic procedures in children: experience in 100 patients

Diagnostic and therapeutic interventional radiologic procedures that provide many treatment options in adults are gaining acceptance in pediatric medicine. Diagnostic (69 patients) and therapeutic (31 patients) interventional experiences in 100 children are summarized, and the procedures of choice for various clinical problems are outlined. Procedures include percutaneous biopsy for benign and malignant diseases, transhepatic cholangiography and biliary drainage, genitourinary procedures (nephrostomy, stent placement, balloon dilation), aspiration of fluid for laboratory analysis, therapeutic drainage of abscesses and noninfected fluid collections, and percutaneous gastrostomy and gastroenterostomy. Diagnoses were accurate in 96% of cases, and therapeutic procedures were successful in 84% of patients, usually obviating operation. Complications occurred in six patients (6%); the most severe was hemoptysis causing respiratory distress. There was no procedure-related mortality. Interventional procedures have wide applications in pediatric patients.

Diagnostic and therapeutic percutaneous gallbladder procedures

The authors report their experience with 24 patients who underwent a variety of percutaneous procedures involving the gallbladder. Twenty diagnostic and 13 therapeutic procedures were performed under sonographic, computed tomographic (CT), or fluoroscopic guidance; these procedures included biopsy of the gallbladder, diagnostic cholecystography, diagnostic aspiration of bile, gallstone dissolution and removal, cholecystostomy for drainage, and gallbladder abscess drainage. The indications for percutaneous cholecystostomy (performed in 11 patients) included relief of hydrops and empyema, gallstone dissolution, mechanical gallstone removal, and drainage for malignant obstruction. Each procedure was successful. There was one complicating episode of cholecystitis and four previously described episodes of vagal hypotension. Bile peritonitis did not occur in any of the patients. The authors discuss the various percutaneous gallbladder procedures and specific technical considerations in performing them.

The use of a low-osmolality contrast medium in hysterosalpingography: comparison with a conventional contrast medium

Hexabrix 320 has been compared with Conray 280 in a randomised double-blind study of 97 patients undergoing hysterosalpingography. Although the lower osmolality and higher viscosity of Hexabrix should make it an ideal hysterosalpingographic agent, no differences were detected between the two contrast media, either in the incidence of side-effects or in radiographic image quality.