Prevalence of Ankle Charcot Neuroarthropathy Presenting in a Tertiary Care Center

Charcot neuroarthropathy's (CN) anatomic classification was originally formulated by the Brodsky article and the Trepman et al modification, including midfoot (type 1), rearfoot (type 2), ankle (type 3a), calcaneus (type 3b), multiarticular (type 4), and forefoot (type 5). In these classic studies, ankle joint and multijoint CN are reported as 9% and 6% to 9%, respectively, but we believe ankle CN to be more common than that in a tertiary setting. We retrospectively reviewed patients presenting initially or as referral between 2004 and 2020. Initial presentation radiographs were reviewed and classified by 3 authors based on Brodsky's model with Trepman and colleagues' modification, and any discrepancies were reviewed by the fourth author. A total of 175 patients (205 feet) were assessed. This revealed 80 cases classified as type 1 (39.0%), 23 cases type 2 (11.2%), 17 cases type 3a (8.3%), 2 cases type 3b (1.0%), and 83 cases type 4 (40.5%). After subdividing type 4, total prevalence included 150 with type 1 anatomic location (73.2%), 103 type 2 (50.2%), 44 type 3a (21.5%), and still 2 type 3b (1.0%). This study revealed a similar prevalence of isolated ankle CN (8.5%) compared to the Trepman et al article (9%), however, in total, ankle CN (21.5%) occurred 2.4-times more than the original 9%. Our study also found there to be a higher prevalence of ankle CN in the setting of multiarticular CN, which has not been evaluated in past studies. The prevalence of multiarticular CN was found to be 4.5-fold greater than the Trepman article (6%-9%).

The Attitudes of Patients Toward Orthopaedic Post-surgical Scars

Background Post-surgical scars (PSS) are an expected consequence of surgery. Several factors have previously been associated with PSS satisfaction including patient age and time elapsed post-operative. Little data are available regarding patient attitudes toward orthopaedic PSS. Knowledge of patient attitudes and the various associated factors may allow physicians to administer peri-operative care to mitigate the potential negative effects of PSS. Our study aims to investigate the attitudes of patients toward their PSS using quantitative scar assessment scales and to identify factors associated with PSS satisfaction. Methods We conducted a retrospective study with a follow-up. We included all patients with orthopaedic PSS on their upper or lower limbs between two and 18 weeks postoperative attending Cork University Hospital, Ireland, between February and August 2022. Patients completed an initial baseline questionnaire and then a follow-up questionnaire six months post-operative. The Patient and Observer Scar Assessment Scale (POSAS) evaluated PSS satisfaction. The European Quality of Life 5 Domain (EQ-5D), alongside several Likert scales, evaluated the patient's quality of life (QoL). Results In total, 91 patients were included. The mean POSAS score was 28.41 (95% CI, 25.85-30.97). Younger patient age (p=0.045) and decreased time passed post-operatively (p=0.002) were associated with poorer PSS satisfaction. Patients reporting their PSS appearing worse than expected were more likely to agree that their QoL had been adversely affected by it (p=0.001). Conclusion Most patients were satisfied with their orthopaedic PSS. This study identified several factors associated with poor PSS satisfaction. Our finding, which associated patient scar expectations and QoL, is novel and has not been previously examined. Accordingly, peri-operative interventions, including scar expectation management, may be implemented to mitigate scar-related QoL impact.

The top 100 most cited articles on artificial intelligence in radiology: a bibliometric analysis

AIM

To identify the most influential publications relating to artificial intelligence (AI) in radiology in order to identify current trends in the literature and to highlight areas requiring further research.

MATERIALS AND METHODS

A retrospective bibliometric analysis was performed of the top 100 most cited articles on this topic. Data pertaining to year of publication, publishing journal, journal impact factor, authorship, article title, institution, country, type of article, article subject, and keywords were collected.

RESULTS

The number of citations per article for the top 100 list ranged from 254 to 3,576 (median 353). The number of citations per year, per article ranged from 10.4 to 894 (median 65.6). The majority of articles (n=62) were published within the last 10 years. The USA was the most common country of origin (n=44). The journal with the greatest number of articles was IEEE Transactions On Medical Imaging (n=38). University Medical Center Utrecht contributed the greatest number of articles (n=6). There were 92 original research articles, 52 of which were clinical studies. The most common clinical subjects were neuroimaging (n=25) and oncology (n=16). The most common keyword used was "deep learning" (n=34).

CONCLUSION

This study provides an in-depth analysis of the top 100 most-cited papers on the use of AI in radiology. It also provides researchers with detailed insight into the current influential papers in this field, the characteristics of those studies, as well as potential future trends in this fast-developing area of radiology.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing

BACKGROUND

Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout.

AIM

To understand factors contributing to hospital transmission of infections, which is necessary for containing spread.

METHODS

An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS).

FINDINGS

Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (C_T = 32) polymerase chain reaction test.

CONCLUSION

This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals

Background

Paediatric early warning systems (PEWS) are a means of tracking physiological state and alerting healthcare professionals about signs of deterioration, triggering a clinical review and/or escalation of care of children. A proactive end-to-end deterioration solution (the DETECT surveillance system) with an embedded e-PEWS that included sepsis screening was introduced across a tertiary children’s hospital. One component of the implementation programme was a sub-study to determine an understanding of the DETECT e-PEWS in terms of its clinical utility and its acceptability.

Aim

This study aimed to examine how parents and health professionals view and engage with the DETECT e-PEWS apps, with a particular focus on its clinical utility and its acceptability.

Method

A prospective, closed (tick box or sliding scale) and open (text based) question, e-survey of parents (n = 137) and health professionals (n = 151) with experience of DETECT e-PEWS. Data were collected between February 2020 and February 2021.

Results

Quantitative data were analysed using descriptive and inferential statistics and qualitative data with generic thematic analysis. Overall, both clinical utility and acceptability (across seven constructs) were high across both stakeholder groups although some challenges to utility (e.g., sensitivity of triggers within specific patient populations) and acceptability (e.g., burden related to having to carry extra technology) were identified.

Conclusion

Despite the multifaceted nature of the intervention and the complexity of implementation across a hospital, the system demonstrated clinical utility and acceptability across two key groups of stakeholders: parents and health professionals.

Health professionals' initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study

Background

Paediatric early warning systems (PEWS) alert health professionals to signs of a child’s deterioration with the intention of triggering an urgent review and escalating care. They can reduce unplanned critical care transfer, cardiac arrest, and death. Electronic systems may be superior to paper-based systems. The objective of the study was to critically explore the initial experiences and perceptions of health professionals about the acceptability of DETECT e-PEWS, and what factors influence its acceptability.

Methods

A descriptive qualitative study (part of The DETECT study) was undertaken February 2020–2021. Single, semi-structured telephone interviews were used. The setting was a tertiary children’s hospital, UK. The participants were health professionals working in study setting and using DETECT e-PEWS. Sampling was undertaken using a mix of convenience and snowballing techniques. Participants represented two user-groups: ‘documenting vital signs’ (D-VS) and ‘responding to vital signs’ (R-VS). Perceptions of clinical utility and acceptability of DETECT e-PEWS were derived from thematic analysis of transcripts.

Results

Fourteen HPs (12 nurses, 2 doctors) participated; seven in D-VS and seven in the R-VS group. Three main themes were identified: complying with DETECT e-PEWS, circumventing DETECT e-PEWS, and disregarding DETECT e-PEWS. Overall clinical utility and acceptability were deemed good for HPs in the D-VS group but there was diversity in perception in the R-VS group (nurses found it more acceptable than doctors). Compliance was better in the D-VS group where use of DETECT e-PEWS was mandated and used more consistently. Some health professionals circumvented DETECT e-PEWS and fell back into old habits. Doctors (R-VS) did not consistently engage with DETECT e-PEWS, which reduced the acceptability of the system, even in those who thought the system brought benefits.

Conclusions

Speed and accuracy of real-time data, automation of triggering alerts and improved situational awareness were key factors that contributed to the acceptability of DETECT e-PEWS. Mandating use of both recording and responding aspects of DETECT e-PEWS is needed to ensure full implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03411-1.

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (the DETECT study): A qualitative interview study

BACKGROUND

Failure to recognize and respond to clinical deterioration in a timely and effective manner is an urgent safety concern, driving the need for early identification systems to be embedded in the care of children in hospital. Pediatric early warning systems (PEWS) or PEW scores alert health professionals (HPs) to signs of deterioration, trigger a review and escalate care as needed. PEW scoring allows HPs to record a child's vital signs and other key data including parent concern.

AIM

This study aimed to explore the experiences and perceptions of parents about the acceptability of a newly implemented electronic surveillance system (the DETECT surveillance system), and factors that influenced acceptability and their awareness around signs of clinical deterioration and raising concern.

METHODS

Descriptive, qualitative semi-structured telephone interviews were undertaken with parents of children who had experienced a critical deterioration event (CDE) (n = 19) and parents of those who had not experienced a CDE (non-CDE parents) (n = 17). Data were collected between February 2020 and February 2021.

RESULTS

Qualitative data were analyzed using generic thematic analysis. Analysis revealed an overarching theme of trust as a key factor that underpinned all aspects of children's vital signs being recorded and monitored. The main themes reflect three domains of parents' trust: trust in themselves, trust in the HPs, and trust in the technology.

CONCLUSION

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (The DETECT system) were positive; they found it acceptable and welcomed the use of new technology to support the care of their child.

170 Social and Environmental Benefits of Virtual Fracture Clinics in Trauma and Orthopaedic Surgery: Reduced Patient Travel Time, Patient Cost and Air Pollutant Emissions

Aim

Several papers have analysed the clinical benefits and safety of Virtual Fracture Clinics (VFCs). A significant increase in the use of Trauma and Orthopaedic (T&O) VFCs was seen during the COVID-19 pandemic. This study aims to investigate the social impact of VFCs on the travel burden and travel costs of T&O patients, as well as the potential environmental benefits in relation to fuel consumption and travel-related pollutant emissions.

Method

All patients referred for T&O VFC review from March 2020 to June 2020 were retrospectively analysed. The travel burden and environmental impacts of hypothetical face-to-face consultations were compared with these VFC reviews. The primary outcomes measured were patient travel time saved, patient travel distance saved, patient cost savings and reduction in air-pollutant emissions.

Results

Over a four-month period, 1359 VFC consultations were conducted. The average travel distance saved by VFC review was 88.6 kilometres (range 3.3-615), with an average of 73 minutes (range 9-390) of travel-time saved. Patients consumed, on average, 8.2 litres (range 0.3-57.8) less fuel and saved an average of €11.02 (range 0.41-76.59). The average reduction in air-pollutant vehicle emissions, including carbon dioxide, carbon monoxide, nitric oxides and volatile organic compounds was 20.3 kilograms (range 0.8-140.8), 517.3 grams (g) (range 19.3-3592.3), 38.1g (range 1.4-264.8) and 56.9g (range 2.1-395.2), respectively.

Conclusions

VFCs reduce patient travel distance, travel time and travel costs. In addition, VFCs confer significant environmental benefits through reduced fuel consumption and reduction of harmful environmental emissions.

Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis Comparing Posterior-Only Instrumentation Versus Combined Anterior-Posterior Instrumentation

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To compare the clinical, functional, and radiological outcomes of posterior-only versus combined anterior-posterior instrumentation in order to determine the optimal surgical intervention for thoracolumbar burst fractures.

SUMMARY OF BACKGROUND DATA

Unstable thoracolumbar burst fractures warrant surgical intervention to prevent neurological deterioration and progressive kyphosis, which can lead to significant pain and functional morbidity. The available literature remains largely inconclusive in determining the optimal instrumentation strategy.

METHODS

Electronic searches of MEDLINE (1948-May 2020), EMBASE (1947-May 2020), The Cochrane Library (1991-May 2020), and other databases were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were divided into three categories: radiological (degree of postoperative kyphosis correction; loss of kyphosis correction at final follow-up), functional (visual analogue scale [VAS] pain score; Oswestry Disability Index [ODI] score), and clinical (intraoperative blood loss; length of stay [LOS]; operative time; the number and type of postoperative complications).

RESULTS

Four randomized control trials (RCTs) were retrieved, including 145 randomized participants. Seventy-three patients underwent posterior-only instrumentation and 72 underwent combined instrumentation. No significant difference was found in the degree of postoperative kyphosis correction (P = 0.39), VAS (centimeters) at final follow-up (P = 0.67), ODI at final follow-up (P = 0.89) or the number of postoperative complications between the two approaches (P = 0.49). Posterior-only instrumentation was associated with lower blood loss (P < 0.001), operative time (P < 0.001), and LOS (P = 0.01). Combined instrumentation had a lower degree of kyphosis loss at final follow-up (P = 0.001). There was heterogeneity in the duration of follow-up between the included studies (mean follow-up range 24-121 months).

CONCLUSION

The available literature remains largely inconclusive. In order to reliably inform practice in this area, there is a need for large, high-quality, multicenter RCTs with standardized reporting of outcomes, with a particular focus on outcomes relating to patient function and severe complications causing long-term morbidity.Level of Evidence: 2.

Diagnostic Limitations in Congenital Zika Virus Infection

This is the first documented case of an infant with congenital Zika virus infection (ZVI) born in Ireland. A term infant was delivered with an antenatal diagnosis of severe microcephaly. First trimester bloods confirmed maternal ZVI and although the infant did not have Zika virus RNA or Zika-specific IgM in her blood or urine, she had multiple clinical features of congenital ZVI and Zika virus RNA was present in the placenta.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Comforting Versus Distressing Dreams of the Deceased: Relations to Grief, Trauma, Attachment, Continuing Bonds, and Post-Dream Reactions

Why are some dreams of the deceased experienced as comforting, while others are distressing? We propose that there are different types of dreams serving diverse functions. In particular, we considered three: processing trauma, maintaining a continuing bond, and regulating emotion. We also examined the impact of post-dream reactions on the bereaved's experience of their dreams. Participants were 216 individuals whose romantic partner or spouse had died. They provided reports of dreams of the deceased that were content analyzed and completed measures of grief intensity, posttraumatic symptoms, attachment style, internalized versus externalized continuing bonds, as well as questions about the death, and ratings of how they experienced the dream after awakening. Support was found for the three proposed functions, suggesting dreams of the deceased can actively facilitate adjustment to bereavement. In addition, there was evidence that post-dream reactions can impact both the perception of the dream and grief.

PP31 Strategies to manage emergency ambulance telephone callers with sustained high needs – an evaluation using linked data (STRETCHED)

Background

Ambulance services across the UK have recognised a clinical and operational problem with persistent high users of the 999 service, but there is a lack of evidence about what works in this setting and how. We aim to evaluate the effectiveness, safety and efficiency of multi-agency case management approaches to the care of people who frequently call the emergency ambulance service, and gain understanding of barriers and facilitators to implementation.

Methods

We will carry out a mixed methods evaluation using anonymised linked routine data outcomes in a ‘natural experiment’ cohort design in four UK ambulance services, with one case management intervention site and one control site within each service. We will describe the epidemiology of ‘frequent calling’; assess the effects of case management on process, outcomes, safety and costs up to six months for 300 high users per service (n-1200); and examine the views of stakeholders, including patients, through qualitative methods. We will synthesise quantitative and qualitative findings, informed by a logic model describing predicted mechanisms of change.

Results

We received confirmation of NIHR grant funding for this study in 2018 so do not yet have results to report.

Conclusions

Telephone callers with sustained high needs represent a significant, high profile policy challenge to emergency ambulance services. Such callers may be indicative of gaps elsewhere in the health care system, which could be more effectively addressed by pro-active care. The STRETCHED study provides the opportunity to contribute to the currently sparse evidence base on interventions for this patient group.

A Life-Saving Palsy: Hereditary Neuropathy with Liability to Pressure Palsies (HNPP) Presenting As Hand Weakness during Cardiopulmonary Resuscitation (CPR) Training

Aim To describe a case of acute and transient hand weakness that developed during cardiopulmonary resuscitation (CPR) training. Hereditary neuropathy with liability to pressure palsies (HNPP) should be considered in patients with recurrent, painless motor or sensory neuropathies at sites of peripheral nerve compression. Methods Nerve conduction studies confirmed neuropraxia of the distal ulnar nerve with a mild background demyelinating peripheral neuropathy. Results A positive family history emerged and HNPP was confirmed by genetic testing. HNPP is most reliably diagnosed by molecular testing for peripheral myelin protein 22 (PMP22) gene deletion or point mutation on chromosome 17p11.2. Conclusion CPR, a procedure carried out by medical professionals on a daily basis, is a high-energy manual task and provides multiple opportunities for nerve compression. This case demonstrates the importance of having a high index of clinical suspicion of this disorder in patients. Recognising a diagnosis of HNPP may prevent unnecessary surgical decompression.

The involvement of older inpatients in medical student education

Objectives

To examine older inpatients’ experiences with medical student education, their views on future interactions, and to seek their opinion on the most important curricular topics related to geriatric medicine.

Methods

The study involved 112 non-confused inpatients older than 65 years of age, who completed a uniformed questionnaire on the day of their discharge from a teaching hospital.

Results

The mean age was 81 years, with equal number of male and female participants. 57% interacted with the students during their admission, the majority being interviewed and examined. Almost all (92%) of these patients described their experience as positive, some described it as time-consuming (23%), repetitive (19%) and tiresome (9%). 92% of all participants agreed that the older patients should be part of medical students’ education. Dementia, cardiac conditions, cancer, arthritis, isolation/loneliness were highlighted as the most important topics to teach medical students related to geriatric medicine, while patience and listening were listed as important skills. They suggested practical, easily implemented advice for the improvement of the interaction between students and older patients; including allowing more time for interactions and for students to speak louder.

Conclusions

Older patients felt positively about their interactions with medical students, and believed that older patients should be involved in medical student education. As well as medical conditions such as dementia, cardiac disease and cancer, these patients highlighted isolation and loneliness as important topics for undergraduate geriatric medical education, implying that students should learn about broader aspects of older patients’ health and wellbeing.

The Use of Twitter by the Trauma and Orthopaedic Surgery Journals: Twitter Activity, Impact Factor, and Alternative Metrics

Aim Social media (SoMe) platforms have become leading methods of communication and dissemination of scientific information in the medical community. They allow for immediate discussion and widespread engagement around important topics. It has been hypothesized that the activity on Twitter positively correlates with highly cited articles. The purpose of this study was to analyze the prevalence and activity of Trauma and Orthopaedic Surgery journals on Twitter, with the hypothesis that the impact factor is positively associated with the Twitter usage. Methods The top 50 Trauma and Orthopaedic Surgery journals, ranked by 2016 Impact Factor were analyzed. The Twitter profiles of each journal or affiliated society were identified. Other SoMe platforms used were also recorded. The Twitonomy software (Digonomy Pty Ltd, New South Wales, Australia) was used to analyze the Twitter profiles over a one-year period. The Twitter Klout scores were recorded for each journal to approximate the SoMe influence. The Altmetric scores (the total number of mentions via alternative metrics) were also recorded. The statistical analysis was carried out to identify correlations between journal Impact Factors, SoMe activity, Twitter Klout scores and Altmetric scores.  Results Twenty-two journals (44%) changed to 'had dedicated Twitter profiles [corrected]. Fourteen journals (28%) were associated with societies that had profiles and 14 journals (28%) had no Twitter presence. The mean Impact Factor overall was 2.16 +/- 0.14 (range, 1.07-5.16). The journals with dedicated Twitter profiles had higher Impact Factors than those without (mean 2.41 vs. 1.61; P=0.005). A greater number of Twitter followers were associated with higher Impact Factors (R2 0.317, P=0.03). The journals with higher Twitter Klout scores had higher Impact Factors (R2 0.357, P=0.016). The Altmetric score was positively associated with an Impact Factor (R2 0.310, P=0.015). The journals with higher numbers of retweets (virtual citations in the Twittersphere) had higher Altmetric scores (R2 0.463, P=0.015). Conclusion The Trauma and Orthopaedic Surgery journals with dedicated Twitter profiles have higher Impact Factors than those without. The Altmetrics is likely to play a significant role in the literature evaluation going forward along with the traditional metrics. The engagement with the Twitter by Trauma and Orthopaedic surgeons should be encouraged.

Enhancement strategies for Cu(II), Cr(III) and Cr(VI) remediation by a variety of seaweed species

Various chemical treatments have been applied to six brown, red and green seaweed species with a view to enhancing their metal removal for Cu(II), Cr(III) and Cr(VI). Treatment with acetone resulted in the greatest enhancement for both cationic and anionic species with relatively low mass losses (15-35%), indicating its low risk to biomass operational stability. Cation binding was increased by 69%, while the total Cr removal was augmented by 15%. Cr(VI) binding was shown to be an adsorption-coupled reduction, whereby Cr(VI) was bound to the biomass surface at pH 2 and subsequently reduced to Cr(III). Acetone treatment also resulted in biomasses that were capable of converting up to 83% of Cr(VI) in solution to Cr(III). Blocking of carboxyl and amino functionalities had significant negative effects both on total Cr removal as well as percentage conversion of Cr(VI) to Cr(III). Results therefore indicated the significant role played by these moieties in metal binding to these seaweeds. Potentiometric titrations displayed agreement between the degree of esterification and the decrease in Cu(II) removal for Ulva spp. and Polysiphonia lanosa. FTIR analysis identified changes in biomass functionality and availability after chemical modification, the results of which were in agreement with metal removal studies. In conclusion, these biosorbents represent suitable candidates to replace conventional removal technologies for metal bearing wastewaters, in particular for the detoxification of hazardous Cr(VI) waste streams.

Investigation of dental samples using a 35MHz focussed ultrasound piezocomposite transducer

Dental erosion and decay are increasingly prevalent but as yet there is no quantitative monitoring tool. Such a tool would allow earlier diagnosis and treatment and ultimately the prevention of more serious disease and pain. Despite ultrasound having been demonstrated as a method of probing the internal structures of teeth more than 40 years ago, development of a clinical tool has been slow. The aim of the study reported here was to investigate the use of a novel high frequency ultrasound transducer and validate it using a known dental technique. A tooth extracted for clinical reasons was sectioned to provide a sample that contained an enamel and dentine layer such that the enamel-dentine junction (EDJ) was of a varying depth. The sample was then submerged in water and a B-scan recorded using a custom-designed piezocomposite ultrasound transducer with a centre frequency of 35 MHz and a -6 dB bandwidth of 24 MHz. The transducer has an axial resolution of 180 microm and a spatial resolution of 110 microm, a significant advance on previous work using lower frequencies. The depth of the EDJ was measured from the resulting data set and compared to measurements from the sequential grinding and imaging (SGI) method. The B-scan showed that the EDJ was of varying depth. Subsequently, the EDJ measurements were found to have a correlation of 0.89 (p<0.01) against the SGI measurements. The results indicate that high frequency ultrasound is capable of measuring enamel thickness to an accuracy of within 10% of the total enamel thickness, whereas currently there is no clinical tool available to measure enamel thickness.

Falciparum malaria as a cause of fever in adult travellers returning to the United Kingdom: observational study of risk by geographical area

BACKGROUND

The probability that a returned traveller with a history of fever has malaria is likely to vary by geographical area, but this has not been quantified in travellers.

AIM

To collect data on prevalence of malaria in outpatients returning with a fever or history of fever from malaria-endemic countries, at the point of presentation for a malaria test.

DESIGN

Observational retrospective study. Consecutive patients presenting to an unselected 'walk-in' clinic for returned travellers.

RESULTS

Of 2867 patients meeting inclusion criteria, 337 (11.8%) had malaria, 89.5% originating in sub-Saharan Africa. Of travellers returning from sub-Saharan Africa excluding South Africa with fever/history of fever, 291/1497 had malaria (19.4%, 95% CI 17-21%). A high proportion was visiting friends and relatives. In those from other areas the proportions were: 16/707 (2.3%, 95% CI 1.5-3.8) from Indian subcontinent/Southeast Asia; 2/143 (1.4%) from Southern America; 4/129 (3.1%) from South Africa; 1/44 (2.3%) from North Africa; and 8/41 (19.5%) from Oceania. Compared to other malaria-endemic regions, African travel gave an adjusted odds ratio of 7.8 (95% CI 5.4-11.2, P < 0.0001). Only 45.1% of malaria cases had a fever (> or =37.5 degrees C) at the time of presentation. Only 3% of all diagnoses of malaria had no history of fever. In 28% of cases parasite count increased in the initial 24 h of antimalarial treatment.

CONCLUSION

The likelihood that a patient with fever returning from Africa has malaria is high (around 1 in 5), and is significantly lower from other areas. Absence of fever at presentation does not exclude malaria.

Comparative study of chromium biosorption by red, green and brown seaweed biomass

Dried biomass of the macroalgae Fucus vesiculosus and Fucus spiralis (brown), Ulva spp. (comprising Ulva linza, Ulva compressa and Ulva intestinalis) and Ulva lactuca (green), Palmaria palmata and Polysiphonia lanosa (red) were studied in terms of their chromium biosorption performance. Metal sorption was highly pH dependent with maximum Cr(III) and Cr(VI) sorption occurring at pH 4.5 and pH 2, respectively. Extended equilibrium times were required for Cr(VI) binding over Cr(III) binding (180 and 120min, respectively) thus indicating possible disparities in binding mechanism between chromium oxidation states. The red seaweed P. palmata revealed the highest removal efficiency for both Cr(III) and Cr(VI) at low initial concentrations. However, at high initial metal concentrations F. vesiculosus had the greatest removal efficiency for Cr(III) and performed almost identically to P. lanosa in terms of Cr(VI) removal. The Langmuir Isotherm mathematically described chromium binding to the seaweeds where F. vesiculosus had the largest q(max) for Cr(III) sorption (1.21mmol g(-1)) and P. lanosa had the largest Cr(VI) uptake (0.88mmol g(-1)). P. palmata had the highest affinity for both Cr(III) and Cr(VI) binding with b values of 4.94mM(-1) and 8.64mM(-1), respectively. Fourier transform infrared analysis revealed interactions of amino, carboxyl, sulphonate and hydroxyl groups in chromium binding to Ulva spp. The remaining seaweeds showed involvement of these groups to varying degrees as well as ether group participation in the brown seaweeds and for Cr(VI) binding to the red seaweeds.

The development of novel organically modified sol-gel media for use with ATR/FTIR sensing

The ability to prepare and develop novel pre-concentration media by the sol-gel process, and their integration with mid-infrared transparent waveguides has been demonstrated. This research approach resulted in a mid-infrared sensing methodology in which the properties (porosity, functionality, polarity, etc.) of the recognition layer could be tailored by variation of the sol-gel precursors and processing conditions. Cross-linker type and concentration notably influenced p-xylene absorption and diffusion rate. Unreacted silanol groups appeared to be the dominant factor in the hydrophobicity of sol-gel layers. Variation of sol-gel precursors and thermal treatment altered both film cross-link density and polarity, as demonstrated by variation in the rate of analyte diffusion and equilibrium analyte concentration. The use of a novel 1 : 1 PTMOS : DPDMS material as pre-concentration medium in this analytical sensing approach was validated through the determination of p-nitrochlorobenzene in an aqueous environment. The response demonstrated linearity between 0-30 mg L(-1) with a correlation coefficient of 0.989 and a limit of detection of 0.7 mg L(-1). Sensing times for p-nitrochlorobenzene were also reduced from several hours to 24 minutes, without loss of measurement accuracy or sensitivity, by a 10 degrees C increase in the sensing temperature and the use of a predictive Fickian model previously developed by this research group.

Multiple mechanisms are implicated in the generation of 5q35 microdeletions in Sotos syndrome

BACKGROUND

Sotos syndrome is characterised by learning difficulties, overgrowth, and a typical facial appearance. Microdeletions at 5q35.3, encompassing NSD1, are responsible for approximately 10% of non-Japanese cases of Sotos. In contrast, a recurrent approximately 2 Mb microdeletion has been reported as responsible for approximately 50% of Japanese cases of Sotos.

METHODS

We screened 471 cases for NSD1 mutations and deletions and identified 23 with 5q35 microdeletions. We investigated the deletion size, parent of origin, and mechanism of generation in these and a further 10 cases identified from published reports. We used "in silico" analyses to investigate whether repetitive elements that could generate microdeletions flank NSD1.

RESULTS

Three repetitive elements flanking NSD1, designated REPcen, REPmid, and REPtel, were identified. Up to 18 cases may have the same sized deletion, but at least eight unique deletion sizes were identified, ranging from 0.4 to 5 Mb. In most instances, the microdeletion arose through interchromosomal rearrangements of the paternally inherited chromosome.

CONCLUSIONS

Frequency, size, and mechanism of generation of 5q35 microdeletions differ between Japanese and non-Japanese cases of Sotos. Our microdeletions were identified from a large case series with a broad range of phenotypes, suggesting that sample selection variability is unlikely as a sole explanation for these differences and that variation in genomic architecture might be a contributory factor. Non-allelic homologous recombination between REPcen and REPtel may have generated up to 18 microdeletion cases in our series. However, at least 15 cannot be mediated by these repeats, including at least seven deletions of different sizes, implicating multiple mechanisms in the generation of 5q35 microdeletions.

Adverse events and near miss reporting in the NHS

OBJECTIVES

To conduct a multicentre study on adverse event and near miss reporting in the NHS and to explore the feasibility of creating a national system for collecting these data.

DESIGN

Prospective voluntary reporting by staff with anonymised transfer of data was used by a national system to collect data from 18 NHS trusts.

PARTICIPANTS

Staff from 12 acute trusts, three mental health trusts, two ambulance trusts, and one primary care trust.

MAIN OUTCOMES MEASURED

Number of incidents, date and time of incident, patient age and sex, clinical speciality, location, outcome, risk rating, type and description of incident.

RESULTS

A total of 28 998 incidents were reported including 11 766 (41%) slips, trips and falls, 2514 (9%) medication management incidents, 2429 (8%) resource issues, and 2164 (7%) treatment issues. 138 catastrophic and 260 major adverse outcomes were reported. Slips, trips and falls (n = 11 766) were the most common type of incident.

CONCLUSIONS

Voluntary reporting by staff when linked to a multicentre data collecting system can yield information on a large number of incidents. This provides support for the principle of creating a national IT system to collect and analyse incident data.

Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins

BACKGROUND

The aim was to compare early postoperative subjective outcome measures in a randomized trial of multiple stab incision phlebectomy (MSIP) and transilluminated powered phlebectomy (TIPP) for the treatment of varicose veins.

METHODS

Patients having surgery for varicose veins were randomized to receive either MSIP or TIPP for local avulsion of varicose veins. Operating time, number of incisions and postoperative outcome were analysed in both groups. Quality of life (QoL) was analysed before and 1 and 6 weeks after surgery using domain-specific (Burford pain scale), disease-specific (Aberdeen Varicose Vein Questionnaire) and generic (Short Form 36 and EuroQol 5D) instruments.

RESULTS

Sixty-six patients consented to participate in the trial but four withdrew before surgery, so 33 patients underwent MSIP and 29 patients had TIPP. All patients had symptomatic or complicated varicose veins. There was no significant difference between groups in the total duration of surgery or the time taken for the avulsions. The number of incisions was significantly lower with TIPP. However, skin bruising at 1 and 6 weeks, and Burford pain score at 6 weeks were significantly higher in the TIPP group (P < 0.01 for bruising and P = 0.019 for pain). TIPP also had a greater adverse impact on generic QoL, resulting in a more prolonged recovery.

CONCLUSION

TIPP had the advantage of fewer surgical incisions, but was associated with more extensive bruising, prolonged pain and reduced early postoperative QoL.

Venous thromboembolism associated with hip and knee replacement over a ten-year period

This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease.