Modified transseptal approach in endoscopic transsphenoidal pituitary surgery

OBJECTIVE

Transsphenoidal pituitary surgery is commonly performed via a direct transostial approach with a posterior septectomy. However, a technique via an endoscopic transseptal route has been described that avoids a posterior septectomy, but it comes with its own disadvantages.

METHODS

This paper describes a modification, and discusses its pros and cons.

RESULTS

The initial incision in the mucosa is placed level with the anterior middle turbinate. The mucoperichondrial flap is raised ipsilaterally until the sphenoid sinus ostium. An incision is made at the osseocartilaginous junction, and the contralateral mucoperichondrial flap is raised. The bony septum and posterior aspect of this flap is excised. The size and position of this window can be adapted. At the end of the operation, the lateralised intact mucoperichondrial flap is moved back to the midline.

CONCLUSION

Excision or deflection of the cartilaginous septum is not required. It maintains an intact septal mucosa on one side and avoids a septal perforation.

Efficient aqueous molybdenum removal using commercial Douglas fir biochar and its iron oxide hybrids

Molybdenum (Mo) is a naturally-occurring trace element in drinking water. Most commonly, molybdate anions (MoO₄^2-) are in well water and breast milk. In addition, it is used in medical image testing. Recently, the EPA classified Mo as a potential contaminant, as exposure can lead to health effects such as gout, hyperuricemia, and even lung cancer. We have assessed the sorptive removal of aqueous molybdate using Douglas fir biochar (DFBC) and a hybrid DFBC/Fe₃O₄ composite containing chemically-coprecipitated iron oxide (Fe₃O₄). Adsorption was studied at various: pH values, equilibrium times (5 min-24 h), initial Mo concentrations (2.5-1000 mg/L), and temperatures (5, 25, and 40 °C) using batch sorption and fixed-bed column equilibrium methods. Langmuir capacities for DFBC and DFBC/Fe₃O₄ (at pH 3, 2 hrs equilibrium) were within 459.3-487.9 mg/g and 288-572 mg/g, respectively. These adsorbents and their Mo-laden counterparts were characterized by elemental analysis, BET, PZC, SEM, TEM, EDS, XRD, and XPS. MoO₄^2- adsorption on DFBC is thought to be governed primarily via electrostatic attraction. Adsorption by DFBC/Fe₃O₄ is primarily governed by chemisorption onto magnetite surface hydroxyl groups, while electrostatics prevail in the DFBC-exposed phase. Stoichiometric precipitation of iron molybdates triggered by iron dissolution was also considered. The data suggest that DFBC and DFBC/Fe₃O₄ are promising candidates for molybdate sorption.

Abstract WP27: Beyond The Call: EMS Feedback And Education Improving Stroke Care

Background and Purpose: Emergency Medical Services (EMS) providers are an integral part of the chain of acute stroke care, stroke patient survival and improving patient outcomes. It is imperative that EMS providers have tools to make accurate critical, time-sensitive decisions. This information impacts care patients receive in the Emergency Department (ED). This collaborative quality improvement project was created to provide feedback to paramedics with the goal of continued rapid, high-quality care for stroke patients in the ED. The purpose of this project is to determine if improved assessment, documentation and information gathering in the prehospital setting decreases door-to-thrombolytic times (DTN).

Methods: Collaboration with the Beverly Hills Fire Department (BHFD) educators was initiated in July of 2021. We created a feedback form which included EMS documentation elements for the paramedics to obtain. These forms were completed by BHFD educators and our team. We performed ED chart reviews to extract data correlating items such as last known well time (LKWT), witness contact information and other pertinent data. We then provided a summary of the patient’s hospital course. Forms were returned to BHFD educators who distributed them to the paramedics for feedback purposes. Data was collected and analyzed for 12 data points over three quarters (Q3 and Q4 of 2021 and Q1 of 2022).

Results: Data points analyzed showed sustained improvement. Three data elements demonstrated significant improvement: documentation of LKWT (67% Q3 2021, 89% Q4 2021, 100% Q1 2022), witness contact information collected (11% Q3 2021, 46% Q4, 83% Q1 2022) and over triage reduction (80% Q3 2021, 53% Q4 2021, 50% Q1 2022). Retrospective chart review revealed that patients delivered to our ED by BHFD treated with thrombolytics during Q3 and Q4 202 and Q1 2022 had a median DTN time of 32.6 minutes. This is outstanding and well within the national stroke DTN benchmark.

Conclusion: We found that feedback to the paramedics improves documentation and assessment skills. Having information we need upon the patient’s arrival to the ED expedites and improves the quality of care we provide to our patients. We will continue to track this data with hopes of including other EMS providers in our network.

Batch and fixed bed sorption of low to moderate concentrations of aqueous per- and poly-fluoroalkyl substances (PFAS) on Douglas fir biochar and its Fe3O4 hybrids

Per- and poly-fluoroalkyl substances (PFAS) can cause deleterious effects at low concentrations (70 ng/L). Their remediation is challenging. Aqueous μg/L levels of PFOS, PFOS, PFOSA, PFBS, GenX, PFHxS, PFPeA, PFHxA, and PFHpA (abbreviations defined in Table 1) multi-component adsorption (pH dependence, kinetics, isotherms, fixed-bed adsorption, regeneration, complex matrix) was studied on commercial Douglas fir biochar (BC) and its Fe₃O₄-containing BC. BC is a waste product when syn-gas is produced in a large scale from wet Douglas fir wood fed to gasification at 900-1000 °C and held for 1-20 s. This generates a relatively high surface area (∼700 m²/g) and large pore volume (∼0.25 cm³/g) biochar. Treatment of BC with FeCl₃/FeSO₄ and NaOH to chemically precipitate Fe₃O₄ onto BC. BC and its magnetic Fe₃O₄/BC analogue rapidly adsorbed (20-45 min equilibrium time) significant amounts of PFOS (∼14.6 mg/g) and PFOA (∼652 mg/g) at natural waters' pH range (6-8). Adsorption from μg/L concentrations has produced remediated aqueous PFAS concentrations of ∼50 ng/L or below the detection limits, which is closing in on EPA advisory limits. Column capacities of PFOS were 215.3 mg/g on BC and 51.9 mg/g Fe₃O₄/BC vs 53.0 mg/g and 21.8 mg/g, respectively, for PFOA. Hydrophobic and electrostatic interactions are thought to drive this sorption. Successful stripping regeneration by methanol was achieved. Thus, hydrophobic Douglas fir biochar produced by fast high temperature pyrolysis and its Fe₃O₄/BC analogue are adsorbent candidates for PFAS remediation from the dilute PFAS concentrations often found in polluted environments. Small Fe₃O₄/BC particles can be magnetically removed from batch treatments avoiding filtration.

Evaluation of Electrospun PCL-PLGA for Sustained Delivery of Kartogenin

In this study, kartogenin was incorporated into an electrospun blend of polycaprolactone and poly(lactic-co-glycolic acid) (1:1) to determine the feasibility of this system for sustained drug delivery. Kartogenin is a small-molecule drug that could enhance the outcome of microfracture, a cartilage restoration procedure, by selectively stimulating chondrogenic differentiation of endogenous bone marrow mesenchymal stem cells. Experimental results showed that kartogenin did not affect the electrospinnability of the polymer blend, and it had negligible effects on fiber morphology and scaffold mechanical properties. The loading efficiency of kartogenin into electrospun membranes was nearly 100%, and no evidence of chemical reaction between kartogenin and the polymers was detected by Fourier transform infrared spectroscopy. Analysis of the released drug using high-performance liquid chromatography-photodiode array detection indicated an abundance of kartogenin and only a small amount of its major hydrolysis product. Kartogenin displayed a typical biphasic release profile, with approximately 30% being released within 24 h followed by a much slower, constant rate of release up to 28 days. Although additional development is needed to tune the release kinetics and address issues common to electrospun scaffolds (e.g., high fiber density), the results of this study demonstrated that a scaffold electrospun from biodegradable synthetic polymers is a suitable kartogenin delivery vehicle.

Comparing Clinician Consensus Recommendations to Patient-reported Opioid Use Across Multiple Hospital Systems

OBJECTIVE

We compare consensus recommendations for 5 surgical procedures to prospectively collected patient consumption data. To address local variation, we combined data from multiple hospitals across the country.

SUMMARY OF BACKGROUND DATA

One approach to address the opioid epidemic has been to create prescribing consensus reports for common surgical procedures. However, it is unclear how these guidelines compare to patient-reported data from multiple hospital systems.

METHODS

Prospective observational studies of surgery patients were completed between 3/2017 and 12/2018. Data were collected utilizing post-discharge surveys and chart reviews from 5 hospitals (representing 3 hospital systems) in 5 states across the USA. Prescribing recommendations for 5 common surgical procedures identified in 2 recent consensus reports were compared to the prospectively collected aggregated data. Surgeries included: laparoscopic cholecystectomy, open inguinal hernia repair, laparoscopic inguinal hernia repair, partial mastectomy without sentinel lymph node biopsy, and partial mastectomy with sentinel lymph node biopsy.

RESULTS

Eight hundred forty-seven opioid-naïve patients who underwent 1 of the 5 studied procedures reported counts of unused opioid pills after discharge. Forty-one percent did not take any opioid medications, and across all surgeries, the median consumption was 3 5 mg oxycodone pills or less. Generally, consensus reports recommended opioid quantities that were greater than the 75th percentile of consumption, and for 2 procedures, recommendations exceeded the 90th percentile of consumption.

CONCLUSIONS

Although consensus recommendations were an important first step to address opioid prescribing, our data suggests that following these recommendations would result in 47%-56% of pills prescribed remaining unused. Future multi-institutional efforts should be directed toward refining and personalizing prescribing recommendations.

44 Wirral's Teletriage Service

Introduction

The Wirral Teletriage Service provides non-urgent clinical support to Wirral Care Homes in order to help avoid unnecessary hospital admissions for their residents. It also aims to provide quicker access to clinical assessment than via NHS 111 and to provide this care in the patient’s residence wherever possible.

Methods

Care homes call the Teletriage service when they have concerns about the health of one of their residents. The Teletriage nurse undertakes a clinical assessment of the resident remotely via Skype. Care Homes have been provided with a secure NHS email address to facilitate secure sharing of data. They have also been provided with iPads and training for their staff. After being assessed by Teletriage, residents are signposted to the most appropriate care pathway for their needs.

Results

76 Care Homes have signed up to the service. On average, the Teletriage Service receives 300-400 calls a month. In an 18 month period, the number of calls to NHS 111 have reduced by 76%. Out of all the calls to Teletriage, 22% of patients were managed by the Teletriage team with no onward referral, 57% were managed via community services e.g GPs, Community Geriatricians, and 10% were referred to the ambulance service. Emergency Health Care Plans (EHCPs), Preferred Priorities of Care and EOL (End of Life) wishes are taken into account.

Conclusions

The Teletriage project has reduced the number of phone calls to NHS 111 and the ambulance service, and subsequently has reduced the number of patients conveyed to hospital by 12%. The Teletriage nurses work very closely with various community services as well as GPs, NWAS and Community Geriatricians. The ongoing training and education provided to the Care Home Staff means that overall there has been good engagement with the project from the majority of the Wirral Care Homes.

Abstract WP460: Stroke Awareness is a 911: Stroke Team and EMS Collaboration for Stroke Education

Background: Accurate pre-hospital recognition of acute stroke is essential, but current training of EMS providers varies across agencies. We created targeted classes specifically for prehospital providers to increase their knowledge of stroke symptoms, emphasizing posterior circulating artery stroke (PCA) symptoms, with the goal to increase awareness of neurological emergencies and enhance patient destination decisions.

Purpose: To enhance prehospital providers’ stroke knowledge, improve provider confidence levels of symptom identification and to help guide the prehospital providers with their stroke patient destination decision-making.

Implementation process: Our stroke team collaborated with Beverly Hills Fire Department (BHFD). We created three educational modules using recorded stroke-specific paramedic calls that involved BHFD paramedics and Cedars-Sinai Mobile Intensive Care nurses. 77 EMS providers total attended the three classes. Each educational module outlined pathophysiology of stroke and reviewed treatment provided and final disposition of each case. Pre- and post-class knowledge assessment and evaluation Likert-scale surveys were distributed to each class participant. These surveys were collected and tallied.

Results: Of 63 pre-class survey respondents, 25% felt definitely adequately trained and 54% felt somewhat adequately trained to recognize an acute ischemic neurologic event and felt somewhat likely to designate a patient as a Stroke Center candidate if their chief complaints coincided with PCA symptoms. Of 40 post-class survey respondents, 75% indicated that the class definitely augmented their previous training in recognizing an acute ischemic neurologic event, and 83% would very likely designate a patient as a Stroke Center candidate if their chief complaints coincided with PCA symptoms. Using Chi-square analysis, the improvement is stroke symptom confidence was statistically significant (p<0.01).

Conclusions: The post-class surveys showed a substantial and statistically significant increase in the confidence levels of recognizing PCA symptoms in the field. Further studies will measure persistence of knowledge gained over time and extension of the educational modules to other agencies.

Defining the role of adjuvant therapy for early-stage large cell neuroendocrine carcinoma

INTRODUCTION

Large cell neuroendocrine carcinoma is a rare, high-grade neuroendocrine tumor. The mainstay of treatment for early, node-negative disease is surgical resection, and optimal adjuvant treatment strategies are not well defined.

METHODS

Patients with early, node-negative large cell neuroendocrine carcinoma were identified in the National Cancer Database from 2004 to 2014. Patient, tumor, treatment, and hospital characteristics were examined. Survival differences in patients receiving adjuvant chemotherapy (AC) were evaluated using Kaplan-Meier curves, and adjusted multivariate Cox models were constructed. A conditional landmark analysis was used to address immortal time bias. T-stage-specific propensity score matching was used to address covariate imbalances between groups.

RESULTS

One thousand seven hundred seventy patients were identified, of whom 463 (26.2%) received AC. Patients receiving AC were younger, less comorbid, and more likely to have T2 tumors. AC was associated with significantly longer survival, which persisted after adjustment in Cox models, for patients overall (5-year overall survival, 59.2% vs 45.3%; hazard ratio, 0.69; 95% confidence interval, 0.58-0.82; P < .0001), T2 tumors (overall survival, 59.8% vs 42.1%; hazard ratio, 0.63; 95% confidence interval, 0.50-0.81; P < .0001), and tumors 2 to 3 cm (overall survival, 60.0% vs 42.6%; hazard ratio, 0.64; 95% confidence interval, 0.46-0.8; P = .002), but not tumors smaller than 2 cm. Adjuvant chest radiotherapy was not associated with longer survival. Sublobar resection was associated with worse overall survival compared with lobectomy (hazard ratio, 1.40; 95% confidence interval, 1.20-1.64; P < .0001). Propensity score matching confirmed these findings, but the association with survival for tumors 2 to 3 cm in size was not significant.

CONCLUSIONS

In this national study of early-stage large cell neuroendocrine carcinoma, AC was associated with significantly longer survival for tumors larger than 3 cm, and possibly for tumors 2 to 3 cm. Adjuvant radiation was not associated with prolonged survival.

The Emergence of New Psychoactive Substance (NPS) Benzodiazepines. A Survey of their Prevalence in Opioid Substitution Patients using LC-MS

Benzodiazepines have a wide range of clinical uses being among the most commonly prescribed medicines globally. The EU Early Warning System on new psychoactive substances (NPS) has over recent years detected new illicit benzodiazepines in Europe’s drug market1. Additional reference standards were obtained and a multi-residue LCMS method was developed to test for 31 benzodiazepines or metabolites in urine including some new benzodiazepines which have been classified as New Psychoactive Substances (NPS) which comprise a range of substances, including synthetic cannabinoids, opioids, cathinones and benzodiazepines not covered by international drug controls. 200 urine samples from patients attending the HSE National Drug Treatment Centre (NDTC) who are monitored on a regular basis for drug and alcohol use and which tested positive for benzodiazepine class drugs by immunoassay screening were subjected to confirmatory analysis to determine what Benzodiazepine drugs were present and to see if etizolam or other new benzodiazepines are being used in the addiction population currently. Benzodiazepine prescription and use is common in the addiction population. Of significance we found evidence of consumption of an illicit new psychoactive benzodiazepine, Etizolam.

Abstract P4-03-02: Casting a wide net: Finding actionable results in non-breast cancer (BC) genes on multi-gene panel testing (MGPT) in a BC cohort

Background: MGPT for hereditary cancer syndromes allows for concurrent analysis of genes associated with many different cancer types. This may lead to the identification of unexpected mutations in genes with no BC link. The objective of this study was to examine the landscape of pathogenic mutations in a BC cohort who underwent MGPT, to assess if there was clinical suspicion for identified mutations and if the results would affect subjects' medical management.

Methods: Retrospective review of subjects with BC seen at a single institution who underwent MGPT from 1/1/15- 5/31/18 was conducted. MGPT was defined as testing of more than the 9 genes associated with BC (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, TP53). Deidentified pedigrees were analyzed by genetic counselors to determine whether there was clinical suspicion of the presence of the mutations using national testing guidelines or clinical diagnostic criteria.

Results: Among 3044 subjects, 365 (12%) were found to have one pathogenic mutation in at least one cancer susceptibility gene. Subjects with mutations in APC I307K, moderate-penetrance BC genes (NBN, RAD50, BARD1), and MUTYH were excluded from further analysis. We identified 52 pathogenic mutations in genes not typically associated with risk for BC in 51 (2%) subjects (table 1). There was clinical suspicion for the identified mutation in 17 (33%).

Table 1:Non-BC gene mutation landscape Number of MutationsClinical Suspicion (%)Lynch syndrome117 (64%)MLH110MSH221MSH632PMS254Ovarian181 (6%)BRIP1*111RAD51C40RAD51D30SHDx62 (33%)SDHA*30SDHC*32Other156 (40%)FH10HOXB13*32MITF32NF142VHL40CDKN2A21 (50%)Total5217 (33%)*Contains individuals that also have a mutation in a BC susceptibility gene

Conclusion: Of 3044 BC patients who underwent MGPT, 2% were found to have a pathogenic gene mutation that would have been missed by a smaller BC gene panel. Medical or surgical management would be affected by the MGPT result in 86% of subjects. Only 6% of subjects with genetic risk for ovarian cancer had a family history of this disease. The single FH and 3 of 4 VHL mutations are only associated with disease in the biallelic state; these findings do not affect the subjects' care, but have implications for reproductive risk. The HOXB13 mutations were found in female subjects only, but would have implications for their male relatives. NF1 mutations are associated with BC risk, but were included in this analysis due to a historically distinct clinical phenotype. Only 50% of NF1+ subjects had a clinical diagnosis or family history of NF1. In all cases, cascade testing was offered to at-risk family members, allowing for cancer and reproductive risk stratification and management. This study demonstrates how comprehensive MGPT can provide a more complete and personalized cancer risk assessment for BC patients and their families.

Citation Format: Culver S, Kipnis L, Stokes S, Bychkovsky B, Scheib R, Rana H, Garber J. Casting a wide net: Finding actionable results in non-breast cancer (BC) genes on multi-gene panel testing (MGPT) in a BC cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-03-02.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Pregabalin Abuse amongst Opioid Substitution Treatment Patients

Pregabalin (Lyrica®) is used in treating epilepsy, nerve pain and anxiety. Pregabalin was initially thought to have a low misuse potential however there are emerging reports of Pregabalin being abused. A study was commenced at the National Drug Treatment Centre's (NDTC) Drug Analysis Laboratory to determine the level of usage of Pregabalin within the addiction services population in Ireland. A total of 498 urine samples representing samples from 440 individual opioid substitution patients, initially screened by immunoassay for drugs of abuse, were subjected to further analysis for Pregabalin by Liquid Chromatography/Mass Spectrometry (LC/MS). Of 440 patients tested, 39 tested positive for Pregabalin (9.2%). Only 10 patients from this group were prescribed this drug to our knowledge thus giving an estimated rate of misuse of 7.0%. Other drugs detected in the Pregabalin positive patients were Opiates (31.8%), Cocaine (11.4%), Benzodiazepines (79.5%) and Cannabis (77.8%). Our study confirms that Pregabalin abuse is taking place amongst the addiction services population. We believe that misuse of this prescription drug is a serious emerging issue which should be monitored carefully.

Impact of obesity on the risk of venous thromboembolism in an inpatient pediatric population

INTRODUCTION

The incidence of venous thromboembolism in children has increased significantly over the past 20 years. Over the same period of time, there was an increase in the prevalence of obesity in the pediatric population. Obesity is a known risk factor for VTE in adults, but little information is available in children.

METHODS

This study evaluates the relation between obesity and VTE using a retrospective, case-control design, comparing the body mass index (BMI) of patients admitted with a diagnosis of VTE versus patients admitted with other diagnoses, at a single institution, between 2007 and 2011.

RESULTS

We studied 48 inpatients diagnosed with deep venous thrombosis or pulmonary embolism and a control group of 274 age and gender matched patients admitted with other diagnoses. We found obese patients (BMI > 95th percentile) to have significantly higher risk of VTE (odds ratio 2.1, with 95% CI 1.1-4.2) than patients of normal weight (BMI < 85th percentile). Overweight patients (BMI 85th-95th percentile) did not demonstrate a significant change in risk. Most of the VTE patients were adolescents and the majority of them had other identifiable risk factors for thrombosis.

CONCLUSION

This study establishes a correlation between obesity and VTE in a group of hospitalized children, showing a risk for VTE in obese children similar to the one described in much larger adult cohorts.

A day in the life of a doctor working at the Himalayan Rescue Association

The Himalayan Rescue Association's (HRA) clinic in Pheriche, Nepal (4243m) is one of a number of high altitude medical posts where demands for services are increasing. Every year international doctors see over 1000 patients, assisting local people with basic health needs and providing emergency care for trekkers with both altitude-related and general illnesses and injuries. This article describes the work of the voluntary clinic and some of the challenges it faces.

Ultrasound in the selective screening of developmental dysplasia of the hip

INTRODUCTION

Developmental dysplasia of the hip (DDH) can result in chronic pain, gait abnormalities and degenerative arthritis. Infants with a family history, Breech delivery or unstable/"clicking" of the hip on examination are at higher risk. The goal is to detect cases early enough for normal hip development and function by the end of adolescence, but clinical examination alone is ineffective.

MATERIALS AND METHODS

All infants born at the West Middlesex University Hospital, Isle-worth, U.K., between 3/3/2005 and 21/10/2006 underwent prospective clinical screening to reveal risk factors of unstable hip on examination, family history of DDH and Breech delivery. Infants with risk factors underwent static and dynamic ultrasound of the hips (Harke's method with Terjesen measurements), performed by a consultant radiologist or sonographer. The infant was then examined by an Orthopaedic Surgeon who was blinded to the ultrasound findings until after creating a management plan.

RESULTS

5772 infants were born during the study period. 200 (3.5%) at-risk infants were identified, resulting in 400 hip ultrasounds. Following review of ultrasound findings, the majority of cases (163/200, 81.5%) lead to no change in management. Change in timing or type of clinical follow up occurred in 31 cases with normal ultrasounds and 20 cases with abnormal (immature hip) ultrasounds. Dysplasia was demonstrated in 6 infants (3%) on ultrasound, who were treated with Parvlik Harness. Of these, only 5 were detected on examination. Therefore, the ultrasound findings lead to 1 intervention with Parvlik Harness which would have otherwise gone undiagnosed from clinical examination.

CONCLUSION

Whereas type and timing of follow up was adjusted in 18.5% of the at-risk infants, targeted screening of at-risk with ultrasound lead to only one intervention. This encourages discussion on the resource implication and viability of ultrasound screening, as only one from two hundred lead to an intervention.

Head shop compound abuse amongst attendees of the Drug Treatment Centre Board

The use of "Head Shop" compounds has received much media attention lately. There is very little research in the current literature with regard to the extent of the usage of these substances amongst the drug using population in Ireland. We conducted a study to examine the extent of the usage of Mephedrone, Methylone and BZP amongst attendees of Methadone maintenance programs at the DTCB. Two hundred and nine samples in total were tested. The results showed significant usage of these compounds amongst this cohort of drug users, with 29 (13.9%) of samples tested being positive for Mephedrone, 7 (3.3%) positive for Methylone and 1 (0.5%) positive for BZP.

Evidence for pi-stacking as a source of stereocontrol in the synthesis of the core pyranochromene ring system common to calyxin I, calyxin J, and epicalyxin J

A diastereoselective synthesis of the tetrahydropyranochromene ring system common to several natural product isolates of Alpinia blepharocalyx is reported. We have shown that a stereochemical preference exists for a syn configuration between the anomeric aryl substituents, representative of the C-7 and C-7' substituents in the natural products. Further, our results show that stereocontrol is under kinetic control, and calculations suggest that a favorable pi-stacking interaction may be the source of this stereocontrol.

Postmodernism in marriage and family therapy training: doctoral students' understanding and experiences

The purpose of this study is to advance our understanding of how doctoral students perceive postmodernism's influence in the field of Marriage and Family Therapy (MFT). According to the literature, postmodernism has had a profound impact on many fields, including MFT. However, tracking of how postmodernism is actually being rendered in theory, research, practice, and training warrants investigation. This study utilized focus group interviews to investigate the perceptions of MFT doctoral students. Findings suggest that while participants are attracted to postmodern tenets, they also report feeling a mixture of liberation and excitement with confusion and fear regarding how postmodernism is influencing MFT models of therapy.

Urodynamic verification of noninvasive back-pressure recordings from the urinary bladder

Obstructive voiding is best evaluated with urodynamics, especially simultaneous measurement of bladder-pressure and urine flow rates. As an alternative to catheterization for urodynamics, noninvasive back-pressure methods using an external condom system have been introduced. This device uses one side tube in the condom for pressure recording and an outlet tube that is clamped for short periods of time during voiding. However, there have been problems with accurate back-pressure recording, including leaking, clamping techniques, hydrostatic pressures associated with pressure recording below the level of the symphysis pubis, and assessment of back pressures in relation to bladder and detrusor pressures. To address these issues, we have modified the condom for passing a catheter into the urethra for simultaneous direct bladder and back-pressure recording. The clamping device on the outlet tube also has been modified to produce back flushing of urine in addition to clamping. Hydrostatic issues have been addressed by making pressure recordings at the level of the symphysis pubis. Seven patients with obstructive symptoms were evaluated using these new devices. Back pressures were not statistically different than detrusor pressures recorded with a urethral catheter. Thus, the modifications have improved back-pressure recording techniques. The use of noninvasive back-pressure recording may be an important adjunct in the evaluation of obstructive uropathy.

The influence of surgical approach and intraoperative venography on successful varicocelectomy in adolescents

PURPOSE

We evaluated the importance of intraoperative venography and surgical approach on varicocele recurrence after surgical varicocelectomy in male adolescents.

MATERIALS AND METHODS

The analysis was done using local data and composite data from the literature. We reviewed the records of patients undergoing varicocele ligation between 1986 and 1995 at our institution. Data were stratified by surgical approach and performance of venography, and compared by cross table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and cross table analysis.

RESULTS

At our institution 33 boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative post-ligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate in these patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of 3 published studies, totaling 252 varicoceles with comparable groupings. Mean success rate after a suprainguinal and inguinal approach was 95.6 (93.2 to 97.4) and 88.3% (82.7 to 100%), respectively. Recurrence tended to be less common after a suprainguinal than an inguinal approach (p = 0.06). Post-ligation venography did not statistically affect the success rate after stratification according to surgical approach but it was associated with a higher success rate when performed with the inguinal approach.

CONCLUSIONS

Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Post-ligation intraoperative venography fails to affect significantly the success of varicocele ligation but it may be useful during an inguinal approach.

Simultaneous microsurgical vasal reconstruction and varicocele ligation: safety profile and outcomes

OBJECTIVES

Simultaneous varicocele ligation and vasal reconstruction has previously been avoided because of concern regarding testicular devascularization. This study sought to investigate the safety of a simultaneous combined approach in the hands of an experienced microsurgeon.

METHODS

A retrospective review was conducted of the records of 47 men who underwent vasal reconstruction, 10 (21%) of whom had simultaneous ligation of a clinically palpable varicocele. Specific attention was focused on the development of postoperative testicular atrophy and hydrocele and the analysis of postoperative semen parameters.

RESULTS

No patient developed postoperative testicular atrophy or hydrocele. No statistically significant difference existed in postoperative seminal parameters between those patients who had vasal reconstruction alone and those who had a combined procedure.

CONCLUSIONS

In the hands of an experienced microsurgeon, simultaneous vasal reconstruction and varicocele ligation is a management strategy that has an excellent safety profile. This approach is not recommended for the occasional microsurgeon.

Reduction of risk of watery diarrhea with point-of-use water filters during a massive outbreak of waterborne Cryptosporidium infection in Milwaukee, Wisconsin, 1993

The occurrence of a massive waterborne outbreak of Cryptosporidium infection in Milwaukee, Wisconsin provided an opportunity to evaluate the effectiveness of point-of-use home water filters in preventing diarrheal illness associated with Cryptosporidium infection. Of 155 filter owners who responded to a televised request to contact the City of Milwaukee Health Department, 99 (64%) completed a self-administered questionnaire regarding their sources of drinking water, the characteristics of their home water filters, and diarrheal illness during the outbreak. Diarrhea among respondents was independently associated with residence in southern or central Milwaukee (the area served by the implicated South water treatment plant), having a home water filter with a pore diameter of greater than 1 micron, and drinking unfiltered tap water in a public building in southern Milwaukee. Among residents of southern and central Milwaukee, two (18%) of 11 persons who drank only submicron-filtered water at home and who did not drink unfiltered South plant water at work had watery diarrhea, compared with 50% (n = 2), 63% (n = 35), and 80% (n = 15) who reported drinking South plant water that was unfiltered or passed through a filter with a pore diameter > 1 micron at work only, home only, or both home and work, respectively (P = 0.02). The data indicate that use of submicron point-of-use water filters may reduce risk of waterborne cryptosporidiosis.

Electropalatographic and perceptual analysis of the speech of Cantonese children with cleft palate

This study used electropalatographic and perceptual analysis to investigate the speech of two Cantonese children with repaired cleft palate. Some features of their speech, as identified from the perceptual analysis, have been previously reported as being typical of children with cleft palate. For example, fricatives and affricates were vulnerable to disruption, and obstruent sounds were judged by listeners to have posterior placement. However, some apparently language-specific characteristics were identified in the Cantonese-speaking children. First there was a relatively high incidence of initial consonant deletion, and for one subject /s/ and /f/ targets were produced as bilabial fricatives. EPG error patterns for target lingual obstruents were largely similar to those reported to occur in English- and Japanese-speaking children. In particular, broader and more posterior tongue-palate contact was observed, and intrasubject variability was noted. There was also evidence of simultaneous labial/velar and alveolar/velar constriction for labial and velar targets respectively. The clinical implications of the findings are discussed.

Prognostic factors and results of radiotherapy alone in the management of pituitary adenomas

Prognostic factors and results of therapy were analyzed in a retrospective review of 70 patients with pituitary adenomas treated with radiotherapy alone from January 1954 through December 1982 at the Radiation Oncology Center, Mallinckrodt Institute of Radiology. The 10-year overall and disease-free survival was 77.8 and 76.0%. The expected survival for an age-, sex-, and race-matched population was not significantly greater at 87.2%. The 10-year disease-free survival for the distinct tumor types was 100% for Cushing's disease, 82.3% for patients with amenorrhea/galactorrhea, 79.6% for non-functioning adenomas, 69.0% for acromegaly, and 66.7% for Nelson's syndrome. Prognostic variables analyzed were age, race, sex, tumor type, tumor extent, visual field defects at diagnosis, and volume irradiated. Only the presence of visual field defects at diagnosis conferred a poor prognosis (p less than 0.001). There was a tendency toward superior tumor control with radiation doses greater than 4500 cGy (p = 0.15). The median time to progression of disease was 4.2 years, with the last failure occurring at 12 years following the completion of radiotherapy. Severe complications were apparent in 5 patients (7.1%), including one death from central nervous system radionecrosis.