Healing patient, harming planet? A drive towards sustainable surgery: review of waste production and recyclability of surgical instrument packaging

INTRODUCTION

Healthcare contributes more than 1% of all domestic waste in the United Kingdom (UK), with operating theatre waste alone accounting for approximately 50% of all hospital waste. In November 2022, the UK Surgical Royal Colleges issued an Intercollegiate Climate Emergency Declaration and called for urgent action. We review waste production and the recyclability of surgical instrument packaging used in a common ear, nose and throat procedure (thyroidectomy) and suggest strategies to make this surgery more sustainable,. These strategies can be generalised to other surgeries.

METHODS

We prospectively audited packaging waste from 20 thyroidectomies performed at the Royal Marsden Hospital in the UK between July and December 2022. All packaging was weighed, categorised and analysed after the operation.

RESULTS

On average, each thyroidectomy produced packaging waste comprising 183g (34%) of plain paper/cardboard, 167g (31%) of soft plastic film, 142g (26%) of laminated paper, 37g (7%) of hard plastic and 11g (2%) of metal foil. Of all the packaging collected, only one item had a recycling label. When extrapolated to the 7,851 thyroidectomies performed in the National Health Service during the fiscal year 2021/2022, the estimated total weight of packaging waste would be 4.2 tonnes, of which only 31.4kg would be indicated as recyclable. When converted to an estimated carbon footprint, total carbon emissions would be 1,048kg CO2e, equivalent to three round trips from London to Edinburgh in a petrol car.

CONCLUSION

This audit demonstrates the different categories and vast amount of packaging waste from a common operation. Manufacturers should place clear recyclability labels on packaging, and switch to recyclable materials and a digital information booklet where possible. Local waste audit and analysis can be simple first steps towards making surgery more sustainable.

Extracellular vesicles and exosome-like nanovesicles as pioneering oral drug delivery systems

As extracellular vesicle (EV)-based nanotechnology has developed rapidly, it has made unprecedented opportunities for nanomedicine possible. EVs and exosome-like nanovesicles (ELNVs) are natural nanocarriers with unique structural, compositional, and morphological characteristics that provide excellent physical, chemical, and biochemical properties. In this literature, we examine the characteristics of EVs, including how they are administered orally and their therapeutic activity. According to the current examples of EVs and ELNVs for oral delivery, milk and plant EVs can exert therapeutic effects through their protein, nucleic acid, and lipid components. Furthermore, several methods for loading drugs into exosomes and targeting exosomes have been employed to investigate their therapeutic capability. Moreover, we discuss EVs as potential drug carriers and the potential role of ELNVs for disease prevention and treatment or as potential drug carriers in the future. In conclusion, the issues associated with the development of EVs and ELNVs from sources such as milk and plants, as well as concerns with standardized applications of these EVs, are discussed.

Hypoglycemia and Mortality Risk in Incident Hemodialysis Patients

OBJECTIVE

Hypoglycemia is a frequent occurrence in chronic kidney disease patients due to alterations in glucose and insulin metabolism. However, there are sparse data examining the predictors and clinical implications of hypoglycemia including mortality risk among incident hemodialysis patients.

DESIGN AND METHODS

Among 58,304 incident hemodialysis patients receiving care from a large national dialysis organization over 2007-2011, we examined clinical characteristics associated with risk of hypoglycemia, defined as a blood glucose concentration <70 mg/dL, in the first year of dialysis using expanded case-mix + laboratory logistic regression models. We then examined the association between hypoglycemia during the first year of dialysis with all-cause mortality using expanded case-mix + laboratory Cox models.

RESULTS

In the first year of dialysis, hypoglycemia was observed among 16.8% of diabetic and 6.9% of nondiabetic incident hemodialysis patients. In adjusted logistic regression models, clinical characteristics associated with hypoglycemia included younger age, female sex, African-American race, presence of a central venous catheter, lower residual renal function, and longer dialysis session length. In the overall cohort, patients who experienced hypoglycemia had a higher risk of all-cause mortality risk (reference: absence of hypoglycemia): adjusted hazard ratio (95% confidence interval) 1.08 (1.04, 1.13). In stratified analyses, hypoglycemia was also associated with higher mortality risk in the diabetic and nondiabetic subgroups: adjusted hazard ratios (95% confidence interval's) 1.08 (1.04-1.13), and 1.17 (0.94-1.45), respectively.

CONCLUSIONS

Hypoglycemia was a frequent occurrence among both diabetic and nondiabetic hemodialysis patients and was associated with a higher mortality risk. Further studies are needed to identify approaches that reduce hypoglycemia risk in the hemodialysis population.

The Role of Postoperative Radiotherapy in T4 Rectal Cancer with Synchronous Distant Metastasis

PURPOSE/OBJECTIVE(S)

Studieson the role of surgery and local treatment in M1 rectal cancer have been actively studied recently. However, there is still controversy because no significant results have been reported for local control. The purpose of this study was to analyze the local control rates of postoperative radiotherapy for tumor stage T4 in M1 rectal cancer.

MATERIALS/METHODS

We investigated local recurrence after surgery for M1 rectal cancer that was operated at Seoul St. Mary's Hospital between 1995 and 2021. Locoregional recurrence rates were compared in patients who received postoperative pelvic radiotherapy and those who did not. In addition, an analytical comparison was performed only for patients with T4 rectal cancer. Statistical analysis was performed using the log rank test, and a p-value of less than 0.05 was considered significant.

RESULTS

During the investigation period, a total of 206 patients underwent surgery for M1 rectal cancer. There were 55 patients with T4 tumor stage. Of the 55 patients, 11 patients received radiotherapy after surgery, and 44 patients received systemic treatment such as chemotherapy after surgery without radiotherapy. During a median follow-up of 22 months, locoregional recurrence occurred in 1 (RT group) and 25 (no RT group) patients, respectively. Log-rank analysis of locoregional recurrence showed a significant difference between the two groups (p- value = 0.008). Death occurred in 10 (RT group) and 38 (no RT group) patients, respectively. The 2-year locoregional recurrence free-survival rates were 45.5% and 53.0%, respectively, and there was no significant difference between the two groups in the log-rank analysis.

CONCLUSION

Pelvic radiotherapy could be expected to improve locoregional recurrence in stage T4 of rectal cancer with synchronous distant metastasis. It would be warranted to prove this in a large-scale prospective study.

Evaluation of Usefulness of Yeast-Based Biological Phantom and Preliminary Study for Verification of Hypoxic Effect of Flash Radiotherapy

PURPOSE/OBJECTIVE(S)

As a basic hypothesis for the effectiveness of flash radiation therapy, the effect of preserving normal tissue during flash radiation is due to the instantaneous chemical depletion of oxygen. A yeast-based biological phantom was created to verify the hypoxic effect of flash radiation therapy. A study to upgrade the previously developed X-Band LINAC to a flash irradiation mode is in progress, and a preceding study is conducted to evaluate the usefulness of a yeast-based biological phantom manufactured by analyzing the change in oxygen by irradiating a high dose in a general radiation therapy device.

MATERIALS/METHODS

Freeze-dried yeast sample (Saccharomyces cerevisiae, S288C) is activated and sub-cultured. For mass production of yeast samples, yeast culture medium is prepared by adding yeast colonies to the ypd medium. This study was conducted to verify the hypoxic effect among the biological mechanisms that occur during flash radiation therapy at the basic stage, and the oxygen concentration change during general radiation irradiation was measured in real time using a DO (Dissolved oxygen) meter and fiber optic sensor designed to do that. To prevent scatter, which is a concern during flash irradiation, the fiber form was used, and precise experiments are possible as a non-invasive oxygen concentration measurement method. Based on 10MV of general radiation therapy device, high-dose radiation of 500-10,000 cGy is irradiated to measure real-time oxygen concentration change.

RESULTS

As a result of irradiation with high-dose (500-10,000 cGy) radiation of general LINAC, it was confirmed that the oxygen concentration of the yeast culture medium decreased by 5.7-63.2%, and the usefulness of the biological phantom fabricated based on the yeast culture medium was evaluated.

CONCLUSION

Prior to the analysis of oxygen concentration change in yeast cells during X-Band LINAC flash irradiation, a preliminary study was conducted at a high dose in a general LINAC to obtain a significant result of oxygen concentration change and confirm the usefulness of the yeast-based biological phantom. Prior research was conducted and verified as a general irradiation experiment using a yeast-based biological phantom manufactured based on a DO meter and a fiber optic oxygen sensor. After irradiation with high-dose radiation, the oxygen concentration of the yeast culture medium was measured 5 times, and it was confirmed that there was a change in oxygen concentration of 5.7-63.2%, verifying the usefulness and stability of the biological phantom. The usefulness of the yeast-based biological phantom for high doses was confirmed, and it is expected that the usefulness of the biological phantom for flash radiation can be verified by additionally measuring the change in oxygen concentration of the biological phantom according to the high dose rate in the future.

1245 HEALTH CARE WORKERS’ EXPERIENCES ON WORKING AT RESIDENTIAL CARE HOME FOR THE ELDERLY: AN INTEGRATIVE REVIEW

Introduction

The ageing population poses challenges to the health care industry worldwide. The huge demand for residential care home for the elderly (RCHE) services induces pressure on health care workers (HCWs) recruitment and retention. HCWs are personnel who have prominent roles in direct basic care to the older adults, and all kinds of hands-on care. Due to the “unpleasant” work nature, shift work, and physical demands for HCWs, it is essential to unfold how HCWs comprehend their working experiences.

Methods

An integrative review was conducted to synthesize various streams of literature in order to generate new knowledge. Multiple databases such as CINAHL, ERIC, LWW nursing were adopted to search for relevant literature published between 2012 and 2022.

Results

A total of 24 articles were retrieved at the initial stage, and 7 articles were sorted after in-depth review. In general, results supported that HCWs experienced positively on the works at RCHEs though there were job stresses. The HCWs perceived the roles at RCHEs as routinized and task-oriented by providing direct care to older adults. They perceived their roles at RCHEs as care providers who provided direct care to older adults. Also, their responsibilities to maintain the safety and dignity of older adults was expressed as utmost importance. The meaning of works lay on three levels: interpersonal (e.g. self-achievement), interpersonal (e.g. communication with team members), and job performance (e.g. task compliance).

Conclusions

This study reveals the experiences of working at RCHE from the HCWs’ perspective. The HCWs’ experiences reflected in this study as well as the meaning of works discovered can generate insights for policy-makers on HCWs recruitment and retention.

Acknowledgement

The work described in this abstract was fully supported by a grant from the Research Grants Council of HKSAR, China [RGC: UGC/FDS16/M12/20].

Fabrication, control, and modeling of robots inspired by flagella and cilia

Flagella and cilia are slender structures that serve important functionalities in the microscopic world through their locomotion induced by fluid and structure interaction. With recent developments in microscopy, fabrication, biology, and modeling capability, robots inspired by the locomotion of these organelles in low Reynolds number flow have been manufactured and tested on the micro-and macro-scale, ranging from medicalin vivomicrobots, microfluidics to macro prototypes. We present a collection of modeling theories, control principles, and fabrication methods for flagellated and ciliary robots.

Next-Generation 3D Scaffolds for Nano-Based Chemotherapeutics Delivery and Cancer Treatment

Cancer is the leading cause of death after cardiovascular disease. Despite significant advances in cancer research over the past few decades, it is almost impossible to cure end-stage cancer patients and bring them to remission. Adverse effects of chemotherapy are mainly caused by the accumulation of chemotherapeutic agents in normal tissues, and drug resistance hinders the potential therapeutic effects and curing of this disease. New drug formulations need to be developed to overcome these problems and increase the therapeutic index of chemotherapeutics. As a chemotherapeutic delivery platform, three-dimensional (3D) scaffolds are an up-and-coming option because they can respond to biological factors, modify their properties accordingly, and promote site-specific chemotherapeutic deliveries in a sustainable and controlled release manner. This review paper focuses on the features and applications of the variety of 3D scaffold-based nano-delivery systems that could be used to improve local cancer therapy by selectively delivering chemotherapeutics to the target sites in future.

V-009 ROBOTIC UMBILICAL HERNIA REPAIR WITH RETRORECTUS SUBLAY MESH AND PLICATION OF RECTUS DIASTASIS VIA THE TRANSABDOMINAL PREPERITONEAL (TAPP) APPROACH

Aim

Umbilical hernias and rectus diastasis can greatly reduce patients’ quality of life, especially in this patient who is a professional athlete and coach. We present a robotic umbilical hernia repair with retrorectus sublay mesh and plication of rectus diastasis through the transabdominal preperitoneal (TAPP) approach.

Material & Methods

Video recording from the operating room was included. In the recording, we demonstrate the steps of this robotic approach with clear visualization of anatomic structures.

Results

A 37-year-old male with an enlarging umbilical hernia with intermittent incarceration and associated rectus diastasis presented for repair due to a significant impact on his work and quality of life. The patient underwent a TAPP robotic repair of his umbilical hernia and plication of rectus diastasis with a retrorectus sublay mesh placement. This was a same-day discharge procedure that the patient tolerated without complications.

Conclusions

Umbilical hernias and associated rectus diastasis can effectively be repaired robotically with retrorectus sublay mesh through the TAPP approach.

Engineering Liquid-Vapor Phase Transition for Refreshable Haptic Interfaces

Haptics as a communication medium has been increasingly emphasized across various disciplines. Recent efforts have focused on developing various haptic stimulation technologies; however, most of them suffer from critical drawbacks stemming from their bulk, complexity, large power input, or high cost. Here, we describe a strategy to design portable and affordable refreshable haptic interfaces composed of an array of individually addressable and controllable liquid pouch motor-based haptic units embedded in either rigid or flexible substrates for different application contexts. The pouch motor filled with low boiling fluid, under a controlled manner, expands or contracts by Joule heating or cooling, enabling the haptic pin in contact to be protruded or retracted. Programming the actuation sequence of an array of haptic units enables the haptic interface to apply different stimuli to the skin to convey corresponding information. We finally demonstrate the applications to portable rigid braille displays and flexible epidermal VR devices. This study opens the avenue to the design of ubiquitous refreshable haptic interfaces that is portable, affordable, scalable, and uninjurious.

Effectiveness of Decision Aid in Men with Localized Prostate Cancer: a Multicenter Randomized Controlled Trial at Tertiary Referral Hospitals in an Asia Pacific Country

There are several treatment options for localized prostate cancer with very similar outcome but vary in terms of technique and side effect profiles and risks. Considering the potential difficulty in choosing the best treatment, a patient decision aid (PDA) is used to help patients in their decision-making process. However, the use and applicability of PDA in a country in Asia Pacific region like Malaysia is still unknown. This study aims to evaluate the effectiveness of a PDA modified to the local context in improving patients' knowledge, decisional conflict, and preparation for decision making among men with localized prostate cancer. Sixty patients with localized prostate cancer were randomly assigned to control and intervention groups. A self-administered questionnaire, which evaluate the knowledge on prostate cancer (23 items), decisional conflict (10 items) and preparation for decision-making (10 items), was given to all participants at pre- and post-intervention. Data were analyzed using independent T test and paired T test. The intervention group showed significant improvement in knowledge (p = 0.02) and decisional conflict (p = 0.01) from baseline. However, when compared between the control and intervention groups, there were no significant differences at baseline and post-intervention on knowledge, decisional conflict and preparation for decision-making. A PDA on treatment options of localized prostate cancer modified to the local context in an Asia Pacific country improved patients' knowledge and decisional conflict but did not have significant impact on the preparation for decision-making. The study was also registered under the Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12614000668606 registered on 25/06/2014.

Two-photon excitable membrane targeting polyphenolic carbon dots for long-term imaging and pH-responsive chemotherapeutic drug delivery for synergistic tumor therapy

Long-term dynamic tracking of cells with theranostics properties remains challenging due to difficulty in preparing and delivering drugs by the probes. Herein, we developed a highly fluorescent one- and two-photon...

Hyaluronan-coated Prussian blue nanoparticles relieve LPS-induced peritonitis by suppressing oxidative species generation in tissue-resident macrophages

Excessive inflammatory response during sepsis causes irreversible damage to healthy tissues and results in multi-organ failure. During infection, bacterial endotoxin-triggered inflammatory responses in macrophages facilitate the recruitment of circulating leukocytes,...

Pharmaceutical Aspects of Nanocarriers for Smart Anticancer Therapy

Drug delivery to tumor sites using nanotechnology has been demonstrated to overcome the drawbacks of conventional anticancer drugs. Altering the surface shape and geometry of nanocomposites alters their chemical properties, which can confer multiple attributes to nanocarriers for the treatment of cancer and their use as imaging agents for cancer diagnosis. However, heterogeneity and blood flow in human cancer limit the distribution of nanoparticles at the site of tumor tisues. For targeted delivery and controlled release of drug molecules in harsh tumor microenvironments, smart nanocarriers combined with various stimuli-responsive materials have been developed. In this review, we describe nanomaterials for smart anticancer therapy as well as their pharmaceutical aspects including pharmaceutical process, formulation, controlled drug release, drug targetability, and pharmacokinetic or pharmacodynamic profiles of smart nanocarriers. Inorganic or organic-inorganic hybrid nanoplatforms and the electrospinning process have also been briefly described here.

Anticancer activity of flavonoids accompanied by redox state modulation and the potential for a chemotherapeutic strategy

Since researchers began studying the mechanism of flavonoids' anticancer activity, little attention has been focused on the modulation of redox state in cells as a potential chemotherapeutic strategy. However, recent studies have begun identifying that the anticancer effect of flavonoids occurs both in their antioxidative activity which scavenges ROS and their prooxidative activity which generates ROS. Against this backdrop, this study attempts to achieve a comprehensive analysis of the individual and separate study findings regarding flavonoids' modulation of redox state in cancer cells. It focuses on the mechanism behind the anticancer effect, and mostly on the modulation of redox potential by flavonoids such as quercetin, hesperetin, apigenin, genistein, epigallocatechin-3-gallate (EGCG), luteolin and kaempferol in both in vitro and animal models. In addition, the clinical applications of and bioavailability of flavonoids were reviewed to help build a treatment strategy based on flavonoids' prooxidative potential.

Robotic soft swim bladder using liquid-vapor phase transition

The swim bladder is crucial to underwater robots to enhance their overall performance and to expand their range of motion. However, previous attempts to incorporate this function have failed or have adopted mechanical swim bladders with high-disturbances. This study presents an entirely soft swim bladder capable of controlling buoyancy selectively and noiselessly, making it applicable to sensitive underwater environments. The soft swim bladder, which consists of an elastic cover layer, flexible heating elements, and three expandable pouches filled with low boiling point fluid, can express four modes of motion by varying buoyancy: sinking, suspending, rising, and fast-rising. The varying buoyancy is achieved through liquid-vapor phase transition of the fluid in the selected pouches when Joule heated above its boiling temperature. Moreover, the swim bladder is integrated with a shape memory alloy-based fishtail to form a soft fish robot. The synergy between the bladder and the tail allows the robot to explore a total of ten disparate modes of maneuvers, and their dynamic performance has been evaluated. The results of this study present the potential for the soft swim bladder to be utilized in any underwater robotic applications to enhance their swimming performance.

Tunable protein crystal size distribution via continuous slug-flow crystallization with spatially varying temperature

Under appropriate buffer and pH conditions, the magnitude and dispersion of the product protein crystals were reproducibly manipulated by controlling the spatial temperature along the tube in a continuous tubular crystallizer.

Urethroscrotal fistula complicating large spermatocele in a male ketamine abuser: A case report

Ketamine related urinary tract complications were first reported in Hong Kong since 2007. The current case report describes a 37 years old male with long history of ketamine abuse, renal impairment, hypertension and HCV hepatitis, presented to us with insidious onset of painful scrotal swelling post bilateral nephrectomy, prostate and seminal vesicle preserving cystectomy. Radiological imaging and intraoperative finding revealed that it was a large spermatocele with urethroscrotal fistula, which was likely due to urethra stricture. The review of literature showed no guidelines for treatment, a symptoms based and multidisciplinary team approach is recommended.

Energy transfer from adipocytes to cancer cells in breast cancer

Limitations of the current therapeutic approach have raised the need for a novel therapeutic agent in breast cancer. Recently, interest in drugs targeting the tumor microenvironment (TME) had drawn attention in the treatment of breast cancer. Furthermore, recent studies have suggested the role of adipocytes, which are part of the TME, in tumor initiation, growth, and metastasis. In this study, we investigated the metabolic interaction between adipocytes and breast cancer cells and its potential as a new therapeutic target in breast cancer. Breast cancer cell lines and human breast cancer tissue samples were evaluated. Compared to cancer cells cultured alone, or the control group, those co-cultured with adipocytes showed lipid transfer from adipocytes to cancer cells and it was different according to the molecular subtype of breast cancer. Breast cancer cells affected the lipolysis of adipocytes and adipocytes affected the β-oxidation of breast cancer cells. The key molecule of the process was fatty acid binding protein 4 (FABP4), which is combined with free fatty acid (FFA) and supports its migration to cancer cells. When FABP4 was suppressed, lipid transfer between adipocytes and cancer cells, lipolysis of adipocytes, and β-oxidation of breast cancer cells were reduced. Furthermore, the expression of lipid metabolism-related proteins and lipolysis-related proteins in breast cancer with adipose stroma showed significantly different expression according to the region of breast cancer tissue. Taken together, we demonstrated the metabolic interaction between adipocytes and breast cancer cells. Breast cancer cells increase the lipolysis in adipocytes and produce a fatty acid, and fatty acid enters into cancer cells. Also, adipocytes contribute to the survival and growth of cancer cells through increased mitochondrial β-oxidation by using fatty acid from adipocytes. The key molecule of the process is FABP4 and when FABP4 is suppressed, the metabolic interaction is reduced, suggesting its role as a potential therapeutic target.

COVID-19: Initial experience of an international group of hand surgeons

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

Crosstalk between Stress Granules, Exosomes, Tumour Antigens, and Immune Cells: Significance for Cancer Immunity

RNA granules and exosomes produced by tumour cells under various stresses in the microenvironment act as critical determinants of cell survival by promoting angiogenesis, cancer metastasis, chemoresistance, and immunosuppression. Meanwhile, developmental cancer/testis (CT) antigens that are normally sequestered in male germ cells of the testes, but which are overexpressed in malignant tumour cells, can function as tumour antigens triggering immune responses. As CT antigens are potential vaccine candidates for use in cancer immunotherapy, they could be targeted together with crosstalk between stress granules, exosomes, and immune cells for a synergistic effect. In this review, we describe the effects of exosomes and exosomal components presented to the recipient cells under different types of stresses on immune cells and cancer progression. Furthermore, we discuss their significance for cancer immunity, as well as the outlook for their future application.

Noninvasive Assessment of Exosome Pharmacokinetics In Vivo: A Review

Exosomes, intraluminal vesicles that contain informative DNA, RNA, proteins, and lipid membranes derived from the original donor cells, have recently been introduced to therapy and diagnosis. With their emergence as an alternative to cell therapy and having undergone clinical trials, proper analytical standards for evaluating their pharmacokinetics must now be established. Molecular imaging techniques such as fluorescence imaging, magnetic resonance imaging, and positron emission tomography (PET) are helpful to visualizing the absorption, distribution, metabolism, and excretion of exosomes. After exosomes labelled with a fluorescer or radioisotope are administered in vivo, they are differentially distributed according to the characteristics of each tissue or lesion, and real-time biodistribution of exosomes can be noninvasively monitored. Quantitative analysis of exosome concentration in biological fluid or tissue samples is also needed for the clinical application and industrialization of exosomes. In this review, we will discuss recent pharmacokinetic applications to exosomes, including labelling methods for in vivo imaging and analytical methods for quantifying exosomes, which will be helpful for evaluating pharmacokinetics of exosomes and improving exosome development and therapy.

Consistency test of coincidence-summing calculation methods for extended sources

An internal consistency test of the calculation of coincidence-summing correction factors F_C for volume sources is presented. The test is based on exact equations relating the values of F_C calculated for three ideal measurement configurations. The test is applied to a number of 33 sets of F_C values sent by 21 teams. Most sets passed the test, but not the results obtained using the quasi-point source approximation; in the latter case the test qualitatively indicated the magnitude of the bias of F_C.

Validity of the intra-operative measurement of stem anteversion and factors for the erroneous estimation in cementless total hip arthroplasty using postero-lateral approach

BACKGROUND

Intra-operative estimation of stem anteversion in total hip arthroplasty (THA) using postero-lateral approach is made by the surgeon's visual assessment, using the tibia as a guide, with the assumption that tibial axis is vertical to the trans-epicondylar axis. However, the accuracy of the intra-operative estimation has rarely been verified with postoperative CT-scans, with controversies regarding these measurements particularly in case of knee osteoarthritis. Therefore we performed a prospective study to: (1) determine the accuracy of the intra-operative measurement and (2) investigate factors affecting the discrepancy between the surgeon's estimation and the real stem anteversion.

HYPOTHESIS

Intra-operative estimation of stem anteversion correlated with the real stem anteversion on CT-scan.

PATIENTS AND METHODS

Sixty-seven THAs using cementless straight stems (65 patients) without ipsilateral total knee arthroplasty were prospectively evaluated to compare the intra-operative measurement of stem anteversion with the real stem anteversion on computed tomography (CT) scans. There were 33 men and 34 women with a mean age of 59.7years (range, 27-84years) at the time of surgery. Age, tibia plateau angle, native femoral anteversion, femoro-tibial angle, body mass index, operative site, gender, coronal and sagittal tilt of the stem, stem type, ipsilateral knee osteoarthritis, and preoperative diagnosis were analyzed to evaluate the factors affecting the discrepancy between the intra-operative and CT measurements.

RESULTS

The intra-operative estimation (mean, 21.5°±8.5°; range, 5.0°-39.0°) was greater than the CT measurement (mean, 19.5°±8.7°; range, 4.5°-38.5°) by 2.0°. The mean absolute value of discrepancy was 4.5°. The correlation coefficient between intra-operative and CT measurements was 0.837. The femoro-tibial angle was associated with the discrepancy between the two measurements. In the presence of genu varum deformity, the intra-operative measurement underestimated the stem anteversion.

DISCUSSION

Although intra-operative estimation of stem anteversion was slightly greater than the real stem anteversion, there was an excellent correlation between the two. The femoro-tibial angle should be considered to optimize the stem anteversion during cementless THA using postero-lateral approach.

LEVEL OF EVIDENCE

Level III, prospective case control study.

Risk-based underground pipeline safety management considering corrosion effect

Due to the long term usage and irregular maintenance for corrosion checks, catastrophic accidents have been increasing in underground pipelines. In this study, a new safety management methodology of underground pipeline, risk-based pipeline management, is introduced reflecting corrosion effect. First, principle of the risk-based pipeline management is presented compared with an original method, qualitative measure. It is distinguished from the qualitative measure by reflecting societal risk and corrosion in safety management of underground pipeline. And then, it is applied to an existing underground propylene pipeline in Ulsan Industrial Complex, South Korea. The consequence analysis is based on real information, and the frequency analysis reflects degree of corrosion. For calculation of corrosion rate, direct current voltage gradient (DCVG) and close interval potential survey (CIPS) are conducted. As a result of applying the risk-based pipeline management, risk integral is reduced by 56.8% compared to the qualitative measure. Finally, sensitivity analysis is conducted on variables, which affect the risk of the pipeline. This study would contribute to introduce quantitative measure to pipeline management and increase safety of pipeline.

Ratio of Klebsiella/Bifidobacterium in early life correlates with later development of paediatric allergy

Several studies have reported that intestinal microbial colonisation patterns differ between non-allergic and allergic infants. However, the microbial signature underlying the pathogenesis of allergies remains unclear. We aim to gain insight into the development of the intestinal microbiota of healthy infants and infants who develop allergy in early life, and identify potential microbiota biomarkers of later allergic disease. Using a case-control design in a Chinese sub-cohort of a Singaporean birth cohort (GUSTO), we utilised 16S rRNA gene sequencing to assess intestinal microbial composition and diversity of 21 allergic and 18 healthy infants at 3 weeks, 3 months and 6 months of age, and correlated the microbiota with allergy at ages 18 and 36 months. Pronounced differences in intestinal microbiota composition between allergic and healthy infants were observed at 3 months of age. The intestine of healthy infants was colonised with higher abundance of commensal Bifidobacterium. Conversely, Klebsiella, an opportunistic pathogen, was significantly enriched in the allergic infants. Interestingly, infants with a high Klebsiella/Bifidobacterium (K/B) ratio (above the population median K/B ratio) at age 3 months had an odds ratio of developing allergy by 3 years of age of 9.00 (95% confidence interval 1.46-55.50) compared to those with low K/B ratio. This study demonstrated a relationship between the ratio of genera Klebsiella and Bifidobacterium during early infancy and development of paediatric allergy in childhood. Our study postulates that an elevated K/B ratio in early infancy could be a potential indicator of an increased risk of allergy development. This line of research might enable future intervention strategies in early life to prevent or treat allergy. Our study provides new insights into microbial signatures associated with childhood allergy, in particular, suggests that an elevated K/B ratio could be a potential early-life microbiota biomarker of allergic disease.

The synthetic molecules YK51 and YK73 attenuate replication of dengue virus serotype 2

Dengue virus infection has been posing alarming economic and social burden on affected nations. It is estimated that 50-100 million dengue infections occur annually with over 2.5 billion people at risk for endemic transmission. In the effort to develop effective antiviral agents, we previously reported potential antiviral activities from selected array of natural products and compounds against dengue virus serotype 2 (DV2). In this study, we report the synthesis of two efficacious novel compounds, YK51 and YK73, and their activities against DV2 replication. Both compounds were chemically synthesised from nicotinic acid using a modified method for the synthesis of dihydropyridine. The products were tested with cell-based assays against DV2 followed by a serine protease assay. As a result, both YK51 and YK73 exhibited intriguing antiviral properties with EC₅₀ of 3.2 and 2.4 µM, respectively. In addition, YK51 and YK73 were found to attenuate the synthesis of intracellular viral RNA and protect the switching of non-classic mechanism of protein translation. These compounds demonstrated inhibitory properties toward the activity of DV2 serine protease in a dose dependent manner. These findings demonstrate that both YK51 and YK73 serve as DV2 serine protease inhibitors that abrogate viral RNA synthesis and translation. Further investigation on these compounds to corroborate its therapeutic properties towards dengue is warranted.

ICSH recommendations for modified and alternate methods measuring the erythrocyte sedimentation rate

INTRODUCTION

The gold standard for the determination of the erythrocyte sedimentation rate (ESR) is the Westergren method. Other methods to measure the ESR have become available. They range from modest modifications of the Westergren method to very different methodologies. The ICSH therefore established a Working Group to investigate these new approaches and compile recommendations for their validation and verification.

METHODS

A panel of six experts in laboratory hematology examined the peer-reviewed literature and EQA surveys from over 6000 laboratories on four continents performing ESR testing. This information was used to create lists of ESR instrument manufacturers and their methods.

RESULTS

Only 28% of laboratories surveyed used the unmodified Westergren method, while 72% of sites used modified or alternate methods. Results obtained with the new instruments could differ from results obtained with the Westergren method by up to 142%. Different non-Westergren methods showed differences from each other of up to 42%. The new methods were often significantly faster, safer, and less labor-intensive. They reduced costs and often used standard EDTA tubes, eliminating the need for a dedicated ESR tube.

CONCLUSION

Based on the consensus of the Working Group, recommendations for manufacturers for the validation of new ESR methods were developed. In addition, a list of recommendations for laboratories that are moving to modified or alternate methods was compiled, addressing instrument performance verification and communications of results to clinical users.

Prevalence of Maternal Affective Disorders in Chinese Mothers of Preschool Children with Autism Spectrum Disorders

OBJECTIVES

To evaluate the prevalence of affective disorders and identify their associated factors among Chinese mothers of preschool children diagnosed with autism spectrum disorders.

METHODS

This cross-sectional study was conducted at the Autism Spectrum Disorders Multidisciplinary Clinic of the United Christian Hospital from August 2012 to June 2013. All mothers of a consecutive series of preschool children diagnosed with autism spectrum disorders at their first visit to the clinic were recruited. Information regarding the child-related, maternal, and environmental factors was collected. Psychiatric diagnoses were made according to the Chinese-Bilingual Structured Clinical Interview for DSM-IV Axis I Disorders. Independent factors associated with maternal affective disorders were determined by univariate and multivariate analyses.

RESULTS

Of the 121 subjects, the point prevalence of affective disorders as a group was 29.8%. The point prevalence of major depressive disorders, adjustment disorders, anxiety disorders, and bipolar affective disorders was 14.9%, 10.7%, 3.3% and 0.8%, respectively. A higher level of disruptive and self-absorbed behaviours in the children (as assessed by the Developmental Behaviour Checklist), a higher level of affiliate stigma (as assessed by 22-item Affiliate Stigma Scale), and a history of psychiatric disorders were independently associated with current affective disorders.

CONCLUSION

Psychiatric disorders, predominantly affective disorders, are common among Chinese mothers of preschool children with autism spectrum disorders. Identification of independent factors associated with maternal affective disorders can aid in the early detection of cases and planning of early intervention programmes to address both child and maternal psychological needs.

Cytotoxicity Evaluation of Essential Oil and its Component from Zingiber officinale Roscoe

Zingiber officinale Roscoe has been widely used as a folk medicine to treat various diseases, including cancer. This study aims to re-examine the therapeutic potential of co-administration of natural products and cancer chemotherapeutics. Candidate material for this project, α-zingiberene, was extracted from Zingiber officinale Roscoe, and α-zingiberene makes up 35.02 ± 0.30% of its total essential oil. α-Zingiberene showed low IC50 values, 60.6 ± 3.6, 46.2 ± 0.6, 172.0 ± 6.6, 80.3 ± 6.6 (μg/mL) in HeLa, SiHa, MCF-7 and HL-60 cells each. These values are a little bit higher than IC50 values of general essential oil in those cells. The treatment of α-zingiberene produced nucleosomal DNA fragmentation in SiHa cells, and the percentage of sub-diploid cells increased in a concentration-dependent manner in SiHa cells, hallmark features of apoptosis. Mitochondrial cytochrome c activation and an in vitro caspase-3 activity assay demonstrated that the activation of caspases accompanies the apoptotic effect of α-zingiberene, which mediates cell death. These results suggest that the apoptotic effect of α-zingiberene on SiHa cells may converge caspase-3 activation through the release of mitochondrial cytochrome c into cytoplasm. It is considered that anti-proliferative effect of α-zingiberene is a result of apoptotic effects, and α-zingiberene is worth furthermore study to develop it as cancer chemotherapeutics.

Effect of Pre-operative Angiotensinconverting Enzyme Inhibitors on Haemodynamic Parameters and Vasoconstrictor Requirements in Patients Undergoing Off-pump Coronary Artery Bypass Surgery

The effects of pre-operative angiotensin-converting enzyme inhibitor (ACEI) treatment on haemodynamic status and vasoconstrictor requirements during off-pump coronary artery bypass surgery (OPCAB) were studied. Eighty patients selected for OPCAB were divided into those who had been treated with ACEIs for 4 weeks or more pre-operatively (ACEI group) (n = 43) and those who had not been treated with ACEIs (control group) (n = 37). Noradrenaline was infused during the operation when the mean systemic arterial pressure (SAP) fell below 60 mmHg. No significant differences in the haemodynamic parameters measured were detected between the two groups, except for cardiac output, which was found to be significantly greater in the control group. During anastomosis of the obtuse marginal branch of the left circumflex artery (OM), a significantly larger amount of noradrenaline was required by the ACEI group compared with the control group. In conclusion, pre-operative treatment with ACEIs significantly increased the amount of vasoconstrictor necessary to maintain the target SAP during OM anastomosis during OPCAB.

Empirical evaluation of the Q-Genie tool: a protocol for assessment of effectiveness

INTRODUCTION

Meta-analyses of genetic association studies are affected by biases and quality shortcomings of the individual studies. We previously developed and validated a risk of bias tool for use in systematic reviews of genetic association studies. The present study describes a larger empirical evaluation of the Q-Genie tool.

METHODS AND ANALYSIS

MEDLINE, Embase, Global Health and the Human Genome Epidemiology Network will be searched for published meta-analyses of genetic association studies. Twelve reviewers in pairs will apply the Q-Genie tool to all studies in included meta-analyses. The Q-Genie will then be evaluated on its ability to (i) increase precision after exclusion of low quality studies, (ii) decrease heterogeneity after exclusion of low quality studies and (iii) good agreement with experts on quality rating by Q-Genie. A qualitative assessment of the tool will also be conducted using structured questionnaires.

DISCUSSION

This systematic review will quantitatively and qualitatively assess the Q-Genie's ability to identify poor quality genetic association studies. This information will inform the selection of studies for inclusion in meta-analyses, conduct sensitivity analyses and perform metaregression. Results of this study will strengthen our confidence in estimates of the effect of a gene on an outcome from meta-analyses, ultimately bringing us closer to deliver on the promise of personalised medicine.

ETHICS AND DISSEMINATION

An updated Q-Genie tool will be made available from the Population Genomics Program website and the results will be submitted for a peer-reviewed publication.

A systematic review of diagnostic accuracy of vertebral fracture assessment (VFA) in postmenopausal women and elderly men

This systematic review was performed to compare the diagnostic accuracy of vertebral fracture assessment (VFA) with that of spinal radiography for identification of vertebral fractures (VFs). VFA appeared to have moderate sensitivity and high specificity for detecting VFs when compared with spinal radiography.

INTRODUCTION

VFs are recognized as the hallmark of osteoporosis, and a previous VF increases the risk of a future fracture. Therefore, the timely detection of VFs is important for prevention of further fractures. This systematic review examined the diagnostic accuracy of VFA using dual X-ray absorptiometry (DXA) to identify VFs.

METHODS

We searched for potentially relevant studies using electronic databases, including Ovid-Medline, Ovid-EMBASE, Cochrane library, and four Korean databases, from their inception to May 2013. We compared the diagnostic accuracy of VFA with that of spinal radiography for detection of VFs by analyzing the sensitivity and specificity using a 2 × 2 contingency table. Subgroup analyses were also performed on studies with a low risk of bias and applicability.

RESULTS

Twelve studies were analyzed for the diagnostic accuracy of VFA. The sensitivity and specificity were 0.70-0.93 and 0.95-1.00, respectively, analyzed on a per-vertebra basis, and 0.65-1.00 and 0.74-1.00 on a per-patient basis. The sensitivity and specificity of five studies in subgroups with a low risk of bias in the intervention test were 0.70-0.84 and 0.96-0.99, respectively. In studies with a low risk of bias in the patient selection, those based on a per-vertebra basis in three studies were 0.70-0.93 and 0.96-1.00, respectively.

CONCLUSIONS

VFA had moderate sensitivity and high specificity for detecting VF when compared with spinal radiography. However, the present findings are insufficient to assess whether spinal radiography should be replaced by VFA.