277 Smoking and Alcohol Use Assessments in Head and Neck Surgical Inpatients: An Audit to Improve Health Promotion

Aim

Head and neck cancer incidence is expected to rise, with smoking and alcohol consumption the greatest risk factors. The related CQUIN target encourages identification of patients who smoke and drink harmful amounts of alcohol. Locally these questions are integrated into discharge summaries. We aimed to review questionnaire completion and encourage staff to give advice to minimise patients’ future head and neck cancer risk.

Method

We conducted a retrospective audit of adult patients admitted locally under head and neck surgeons in a three-month period. Local audit standard was completion of the questionnaires in 95% of patients. Intervention was education of ENT juniors (foundation and core trainees) alongside ward-based prompts. Re-audit was conducted for two-months following intervention.

Results

Initial audit reviewed 99 discharge summaries, and re-audit reviewed 115. Following intervention there was improved documentation of smoking status from 27.3% to 48.7% (n = 27/99 vs n = 56/115) and alcohol use from 36.3% to 51.3% (n = 36/99 vs n = 59/115) respectively. However, even in re-audit a significant proportion were documented as ‘unable' to answer (smoking 41.7%, alcohol 42.6%); of these the majority were day case procedures (smoking n = 35/48, alcohol n = 42/49).

Conclusions

Staff education can encourage doctors to discuss smoking and alcohol and represents health promotion and a reduction in risk of malignancy. Many day case patients were documented as ‘unable’ to answer; this may reflect that discharge paperwork is frequently completed in the immediate post-operative period. Further improvement could be achieved with educational interventions for registrars and consultants, and consideration of the practical challenges negatively impacting questionnaire completion for day case patients.

Neuronal antibody prevalence in children with seizures under 3 years: A prospective national cohort

OBJECTIVE

To report the prevalence of anti-neuronal antibodies in a prospective whole-nation cohort of children presenting with seizures before their third birthday.

METHODS

This was a prospective population-based national cohort study involving all children presenting with new-onset epilepsy or complex febrile seizures before their third birthday over a 3-year period. Patients with previously identified structural, metabolic, or infectious cause for seizures were excluded. Serum samples were obtained at first presentation and tested for 7 neuronal antibodies using live cell-based assays. Clinical data were collected with structured proformas at recruitment and 24 months after presentation. In addition, patients with seizures and clinically suspected autoimmune encephalitis were independently identified by a review of the case records of all children <3 years of age in Scotland who had undergone EEG.

RESULTS

Two hundred ninety-eight patients were identified and recruited and underwent autoantibody testing. Antibody positivity was identified in 18 of 298 (6.0%). The antibodies identified were GABA receptor B (n = 8, 2.7%), contactin-associated protein 2 (n = 4, 1.3%), glycine receptor (n = 3, 1.0%), leucine-rich glioma inactivated 1 (n = 2, 0.7%), NMDA receptor (n = 1, 0.3%), and GABA receptor A (n = 1, 0.3%). None of these patients had a clinical picture of autoimmune encephalitis. Seizure classification and clinical phenotype did not correlate with antibody positivity.

CONCLUSIONS

Autoimmune encephalitis is very rare in early childhood. However serum neuronal antibodies are identified in 6.4% of children presenting with seizures at <3 years of age. Antibody testing should not be a routine clinical test in early childhood-onset epilepsy because, in the absence of other features of autoimmune encephalitis, antibody positivity is of doubtful clinical significance. Antibody testing should be reserved for patients with additional features of encephalitis.

Incidence and phenotypes of childhood-onset genetic epilepsies: a prospective population-based national cohort

Epilepsy is common in early childhood. In this age group it is associated with high rates of therapy-resistance, and with cognitive, motor, and behavioural comorbidity. A large number of genes, with wide ranging functions, are implicated in its aetiology, especially in those with therapy-resistant seizures. Identifying the more common single-gene epilepsies will aid in targeting resources, the prioritization of diagnostic testing and development of precision therapy. Previous studies of genetic testing in epilepsy have not been prospective and population-based. Therefore, the population-incidence of common genetic epilepsies remains unknown. The objective of this study was to describe the incidence and phenotypic spectrum of the most common single-gene epilepsies in young children, and to calculate what proportion are amenable to precision therapy. This was a prospective national epidemiological cohort study. All children presenting with epilepsy before 36 months of age were eligible. Children presenting with recurrent prolonged (>10 min) febrile seizures; febrile or afebrile status epilepticus (>30 min); or with clusters of two or more febrile or afebrile seizures within a 24-h period were also eligible. Participants were recruited from all 20 regional paediatric departments and four tertiary children’s hospitals in Scotland over a 3-year period. DNA samples were tested on a custom-designed 104-gene epilepsy panel. Detailed clinical information was systematically gathered at initial presentation and during follow-up. Clinical and genetic data were reviewed by a multidisciplinary team of clinicians and genetic scientists. The pathogenic significance of the genetic variants was assessed in accordance with the guidelines of UK Association of Clinical Genetic Science (ACGS). Of the 343 patients who met inclusion criteria, 333 completed genetic testing, and 80/333 (24%) had a diagnostic genetic finding. The overall estimated annual incidence of single-gene epilepsies in this well-defined population was 1 per 2120 live births (47.2/100 000; 95% confidence interval 36.9–57.5). PRRT2 was the most common single-gene epilepsy with an incidence of 1 per 9970 live births (10.0/100 000; 95% confidence interval 5.26–14.8) followed by SCN1A: 1 per 12 200 (8.26/100 000; 95% confidence interval 3.93–12.6); KCNQ2: 1 per 17 000 (5.89/100 000; 95% confidence interval 2.24–9.56) and SLC2A1: 1 per 24 300 (4.13/100 000; 95% confidence interval 1.07–7.19). Presentation before the age of 6 months, and presentation with afebrile focal seizures were significantly associated with genetic diagnosis. Single-gene disorders accounted for a quarter of the seizure disorders in this cohort. Genetic testing is recommended to identify children who may benefit from precision treatment and should be mainstream practice in early childhood onset epilepsy.

Total disc replacement versus anterior cervical discectomy and fusion: a systematic review with meta-analysis of data from a total of 3160 patients across 14 randomized controlled trials with both short- and medium- to long-term outcomes

Aims

The aim of this study was to determine how the short- and medium- to long-term outcome measures after total disc replacement (TDR) compare with those of anterior cervical discectomy and fusion (ACDF), using a systematic review and meta-analysis.

Patients and Methods

Databases including Medline, Embase, and Scopus were searched. Inclusion criteria involved prospective randomized control trials (RCTs) reporting the surgical treatment of patients with symptomatic degenerative cervical disc disease. Two independent investigators extracted the data. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. The primary outcome measures were overall and neurological success, and these were included in the meta-analysis. Standardized patient-reported outcomes, including the incidence of further surgery and adjacent segment disease, were summarized and discussed.

Results

A total of 22 papers published from 14 RCTs were included, representing 3160 patients with follow-up of up to ten years. Meta-analysis indicated that TDR is superior to ACDF at two years and between four and seven years. In the short-term, patients who underwent TDR had better patient-reported outcomes than those who underwent ACDF, but at two years this was typically not significant. Results between four and seven years showed significant differences in Neck Disability Index (NDI), 36-Item Short-Form Health Survey (SF-36) physical component scores, dysphagia, and satisfaction, all favouring TDR. Most trials found significantly less adjacent segment disease after TDR at both two years (short-term) and between four and seven years (medium- to long-term).

Conclusion

TDR is as effective as ACDF and superior for some outcomes. Disc replacement reduces the risk of adjacent segment disease. Continued uncertainty remains about degeneration of the prosthesis. Long-term surveillance of patients who undergo TDR may allow its routine use. Cite this article: Bone Joint J 2018;100-B:991-1001.

Carbon dating cancer: defining the chronology of metastatic progression in colorectal cancer

Background

Patients often ask oncologists how long a cancer has been present before causing symptoms or spreading to other organs. The evolutionary trajectory of cancers can be defined using phylogenetic approaches but lack of chronological references makes dating the exact onset of tumours very challenging.

Patients and methods

Here, we describe the case of a colorectal cancer (CRC) patient presenting with synchronous lung metastasis and metachronous thyroid, chest wall and urinary tract metastases over the course of 5 years. The chest wall metastasis was caused by needle tract seeding, implying a known time of onset. Using whole genome sequencing data from primary and metastatic sites we inferred the complete chronology of the cancer by exploiting the time of needle tract seeding as an in vivo 'stopwatch'. This approach allowed us to follow the progression of the disease back in time, dating each ancestral node of the phylogenetic tree in the past history of the tumour. We used a Bayesian phylogenomic approach, which accounts for possible dynamic changes in mutational rate, to reconstruct the phylogenetic tree and effectively 'carbon date' the malignant progression.

Results

The primary colon cancer emerged between 5 and 8 years before the clinical diagnosis. The primary tumour metastasized to the lung and the thyroid within a year from its onset. The thyroid lesion presented as a tumour-to-tumour deposit within a benign Hurthle adenoma. Despite rapid metastatic progression from the primary tumour, the patient showed an indolent disease course. Primary cancer and metastases were microsatellite stable and displayed low chromosomal instability. Neo-antigen analysis suggested minimal immunogenicity.

Conclusion

Our data provide the first in vivo experimental evidence documenting the timing of metastatic progression in CRC and suggest that genomic instability might be more important than the metastatic potential of the primary cancer in dictating CRC fate.

Effects of dynamic upper-body exercise on lower-limb isometric endurance

Following preliminary indications that in some individuals arm exercise enhanced rather than reduced simultaneous leg endurance, ten young men and women performed three forms of intermittent work to volitional exhaustion, under duty cycles of 45 s work, 15 s rest. The protocols were as follows: (A) knee extensions at 30% maximum voluntary contraction (MVC); (B) 30% MVC knee extensions combined with arm cranking at 130% of their own lactate threshold; (C) combined 30% MVC knee extensions and arm cranking at 20% of their own lactate threshold. Heart rate, oxygen uptake (VO(2)), and blood lactate concentration were among the variables recorded throughout. All physiological indicators of demand were substantially higher in protocol B than in protocols A or C [heart rate: (A) 154 beats . min(-1), (B) 171 beats . min(-1), (C) 150 beats . min(-1); VO(2): (A) 11.9 ml . kg(-1) . min(-1), (B) 21.7 ml . kg(-1) . min(-1), (C) 14.2 ml . kg(-1) . min(-1); blood lactate concentration: (A) 3.3 mmol . l(-1), (B) 5.1 mmol . l(-1), (C) 2.8 mmol . l(-1)], yet there were no significant differences (P > 0.05) in the endurance times between the three conditions [(A) 11.43 min, (B) 11.1 min, (C) 10.57 min] and seven participants endured longest in protocol B. Results from protocol (C) cast doubt on explanations in terms of psychological distraction. We suggest that lactic acid produced by the arms is shuttled to the legs and acts there either as a supplementary fuel source or as an antagonist to the depressing effects of increased potassium concentration.

To close or not to close, that is one of the questions? Perceptions of Trauma Association of Canada surgical members on the management of the open abdomen

BACKGROUND

The optimal abdominal closure in critically ill surgical/trauma patients remains controversial with a wide variety of commonly employed techniques. We sought to evaluate clinical equipoise by surveying Canadian surgeons regarding the use of temporary abdominal closure strategies in damage control and emergency situations.

METHODS

A structured mixed-mode (Website and paper), scenario-based questionnaire was developed by members of the Canadian Trauma Trials Collaborative and directed to surgical members of the Trauma Association of Canada (TAC).

RESULTS

The overall response rate was 84% (86 out of 102). In resuscitated hemodynamically stable trauma patients, 42% (29 out of 69) of respondents elected to primarily close an "extremely tight" abdominal cavity while only 23% (16 out of 70) would primarily close the same patient when physiologic exhaustion (Damage control (DC) conditions-hypothermia, acidosis, and coagulopathy) supervened. Although the majority reported preference for temporizing abdominal closures [73% (51 out of 70) non-DC, 75% (52 out of 69) DC] when the fascia was physically impossible to close; the reported primary use of mesh in these situations was quite high [24.6% (17 out of 69) non-DC, 24% (16 out of 69) DC], including a reported 7% (5 out of 69) nonabsorbable mesh usage in a contaminated octogenarian abdomen.

CONCLUSION

Reported opinions suggest an overall appreciation for markers of "Damage Control," although clinical equipoise exists regarding the preferred technique and a frequent early use of mesh. These results highlight the necessity for further research but suggest challenges in defining a common standard for multicenter trials.

Pediatric trauma registries: the foundation of quality care

BACKGROUND/PURPOSE

Traumatic injuries cause substantial morbidity and mortality in children. Trauma registries are essential to assess and improve standards of trauma care. An interprovincial study of pediatric trauma between 6 centers across Canada who use identical software components was completed.

METHODS

Data were collected from April 1, 1995 to December 31, 1998 for children aged 1 day to 17 years with an injury severity score of > or = 12. Cause of injury, injury time and day, gender, age, injury scores, length of hospital stay, and outcomes were compared.

RESULTS

A total of 1,276 patients were included. Mean age was 10.3 +/- 5.6 years. Motor vehicle collisions were the most common mechanism of injury (56%). Boys were more often injured (66%; P < .05). Injuries occurred mainly between 1600 and 2400 hours (P < .0001). Mean hospital stay was 11.5 +/- 16.6 days. The longest stays in the hospital were among those who had an abdominal abbreviated injury score (AIS) of 1 (P < or = .03). Patients with similar injury severities remained twice as long in Winnipeg Children's Hospital (hospital 5), hospital 2, and hospital 6 as compared with patients in hospital 3 (P < .05). Differences existed in discharge placement between hospitals (P < .0001).

CONCLUSIONS

This study was the first to compare pediatric patients in multiple Canadian centers using identical trauma registries. Variations in length of stay and discharge placements between hospitals were identified. Further analysis of data in the registries may clarify these differences and serve as a foundation for hospitals to improve the quality of patient care.

Is cataract surgery justified in patients with age related macular degeneration? A visual function and quality of life assessment

AIMS

To determine whether patients with age related macular degeneration (ARMD) benefit from cataract surgery in terms of visual function and quality of life measures, and to assess the impact of surgery on the progression of ARMD.

METHODS

A prospective study was carried out of patients with and without ARMD undergoing cataract surgery. Data were collected from 187 patients at the Princess Alexandra Eye Pavilion, Edinburgh and the Oxford Eye Hospital, Oxford. The patients were divided into three groups: (1) a control group with ARMD and no surgery (n=41), (2) a study group of patients with ARMD who underwent cataract surgery (n=90), and (3) a second control group of patients without ocular comorbidities who underwent cataract surgery (n=56). Visual function and quality of life assessments were carried out at baseline and 3-5 months after baseline or surgery.

RESULTS

There were significant improvements both in terms of quality of life and visual function measures in the study group. Benefits were greater in patients with moderate cataract irrespective of the degree of ARMD. No increased incidence in progression to the "wet" form of ARMD was found. Improvements in quality of life measures and visual function were more pronounced in patients with no ocular comorbidities.

CONCLUSIONS

Patients with mild and moderate degrees of ARMD do benefit from cataract surgery and the benefits are greater in patients with moderate degrees of lens opacity. Longer follow up is required to assess the risk of increased ARMD progression.

Directed mutation of the basic domain of v-Jun alters DNA binding specificity and abolishes its oncogenic activity in chicken embryo fibroblasts

Overexpression of v-Jun in chicken embryo fibroblasts (CEF) leads to oncogenic transformation phenotypically characterized by anchorage independent growth and release from contact inhibition (focus formation). The mechanisms involved in this oncogenic conversion however, are not yet clear. Because Jun is a transcription factor, it has been assumed that oncogenic transformation results directly from deregulated AP-1 target gene expression. However, a number of experimental observations in avian cell culture models fail to correlate oncogenesis with AP-1 activity suggesting that transformation induced by v-Jun may occur through an indirect mechanism. To test this possibility, we introduced point mutations into the basic DNA binding domain of v-Jun and created mutants that exhibit altered binding specificity. When expressed in CEF, these mutants fail to deregulate three known v-Jun target genes (JTAP-1, apolipoprotein A1, c-Jun) thus demonstrating in vivo specificity changes. Each of the binding specificity mutants was also tested for its ability to induce oncogenic transformation. Interestingly, expression of these mutants in CEF results in a phenotype indistinguishable from the vector control with respect to growth rate, focus formation and the ability to form colonies in soft agar. These results are consistent with a model requiring direct AP-1 target deregulation as a prerequisite of v-Jun induced cell transformation. With this in mind, we generated a series of additional mutants that retain the ability to bind AP-1 sequence elements, but vary in their oncogenic potential. We demonstrate the use of these mutants to screen v-Jun induced gene targets for a functional role in cell transformation.

The sodium iodide symporter gene and its regulation by cytokines found in autoimmunity

Iodide concentration by the thyroid gland, an essential step for thyroid hormone synthesis, is mediated by the Na+/I- symporter (NIS). To identify factors that may regulate this process, we have studied NIS gene expression in the Fisher rat thyroid cell line (FRTL-5) by a semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) technique. Increasing concentrations of bovine TSH (0.1, 1, 10, 50 and 100 mU/l), with or without tumour necrosis factor-alpha (TNF alpha), interferon-gamma (IFN gamma) or interleukin-1 alpha (IL-1 alpha) were added to FRTL-5 cells previously deprived of TSH for a minimum of 5 days. RNA was extracted and samples were studied for NIS expression. TSH enhanced NIS mRNA expression in a dose-dependent manner, with induction evident at 0.1 mU/l, reaching a peak at 50 mU/l, an effect detected after 6 h of stimulation, but not in the first 2 h. Both TNF alpha and, to a lesser extent, IL-1 alpha inhibited basal and TSH-induced NIS expression. High concentrations of IFN gamma also downregulated TSH-stimulated NIS mRNA expression. Using the same technique, we also investigated NIS mRNA tissue distribution in two male and one female Wistar rats. High levels of NIS expression were detected in the thyroid, stomach, and mammary gland, lower levels were found in the intestine, adipose tissue and liver, borderline levels were expressed in the salivary gland, and no expression was detected in the kidneys. In summary, we have shown that TSH upregulates rat NIS gene expression in vitro, and this induction can be modulated by cytokines. Analysis of the distribution of rat NIS mRNA ex vivo demonstrated variable levels of NIS transcription in different tissue samples.

Differential effect of thyroid-stimulating hormone (TSH) on intracellular free calcium and cAMP in cells transfected with the human TSH receptor

The thyroid-stimulating hormone (TSH) binds to a receptor which activates adenylate cyclase and elevates cAMP concentration. In addition, effects of TSH on intracellular calcium and inositol phosphate accumulation have been reported. However, the mechanism of TSH-stimulated accumulation of inositol phosphates and elevation of calcium levels is unresolved. Previous work from this laboratory has shown TSH to cause acute transient increases in intracellular calcium in pig, human and FR TL-5 rat thyroid cells as well as in cell transfected with the human TSH receptor (JPO9 cells) in some (but not all) experiments. The aim of this study was to investigate the variability of the calcium response to TSH in JPO9 cells to learn more about the nature of this calcium signal induction. Calcium responses to TSH were determined using the fluorochrome fura-2 in both monolayers of adherent cells and adherent single cells. The responses to a single addition and to repetitive additions of TSH were compared. We also determined the cAMP response to TSH using these two protocols of TSH addition. Our data show that, whereas the cAMP response to TSH is highly predictable and consistent and does not require multiple exposures to TSH, cells were unlikely to respond to TSH with an increase in calcium unless they received multiple challenges with the hormone. A single addition of 10 mU/ml TSH failed to increase calcium in any of 40 single cells examined and in only 4 of 15 monolayers of cells (27%) examined; in contrast, 10 of 12 monolayers eventually responded with an increase in calcium after multiple exposure to TSH and 18 of 67 single cells. Similar data were obtained whether calcium was measured in single cells or in populations of cells. We also demonstrated cooperativity between an adenosine derivative, N6-(L-2-phenylisopropyl)adenosine, and TSH such that their co-administration resulted in a consistent and marked elevation in calcium levels not achieved with either agonist alone. In summary, we suggest that the coupling between the TSH receptor and the intracellular signalling system that leads to activation of intracellular calcium in JPO9 cells requires repetitive stimulation or the influence of other agonists, in contrast with the coupling between the TSH receptor and activation of the adenylate cyclase enzyme.

The modulation of the human sodium iodide symporter activity by Graves' disease sera

The transport of iodide into the thyroid, catalyzed by the Na+/I- symporter (NIS), is the initial and rate-limiting step in the formation of thyroid hormones. To study the basic characteristics of the human (h) NIS, we have established a Chinese hamster ovary cell line stably expressing the hNIS (CHO-NIS9). In agreement with previous work on the rat NIS, iodide uptake in these cells was initiated within 2 min of the addition of 131I, reaching a plateau after 30 min. Both perchlorate and thiocyanate inhibited iodide uptake in a dose-dependent manner, with inhibition evident at concentrations of 0.01 and 0.1 micromol/L, respectively, and reaching complete inhibition at 20 micromol/L and 500 micromol/L, respectively. Ouabain, which blocks the activity of the Na+/K+ adenosine triphosphatase, also inhibited iodide uptake in a dose-dependent manner, starting at concentrations of 100 micromol/L and reaching maximum inhibition at 1600 micromol/L, indicating that iodide uptake in these cells is sodium dependent. CHO-NIS9 cells were further used to study 88 sera from patients with Graves' disease, for iodide uptake inhibitory activity, which were compared with sera from 31 controls. Significant iodide uptake inhibition was taken as any inhibition in excess of the mean + 3 SD of the results with the control sera. On this basis, 27 (30.7%) of the Graves' sera, but none of the controls, inhibited iodide uptake in CHO-NIS9. IgGs from these patients also inhibited iodide uptake, indicating that this inhibitory activity was antibody mediated. In summary, we have established a CHO cell line stably expressing the hNIS and shown that antibodies in GD sera can inhibit iodide uptake in these cells. This further emphasizes the role of NIS as a novel autoantigen in thyroid immunity.

Creutzfeldt-Jakob disease in the elderly

Creutzfeldt-Jakob disease (CJD) is typically described as a pre-senile dementia. However, cases do occur in the elderly and a case of sporadic CJD in an 86-year-old patient is described. The database of the UK national surveillance unit has been studied, and the age-specific incidences for various age groups over the period 1980-93 calculated. Cases of CJD in those over 80 years old have been identified and their clinical characteristics examined. There is no evidence that CJD presents atypically in the elderly, or that large numbers of cases are being missed in the elderly due to poor ascertainment.