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Surgeons treating advanced carcinoma of the tongue with total glossectomy face many conflicts in view of the morbidity and poor functional and survival outcomes following surgery. It is pertinent to study the patients undergoing total tongue compartment resection as a separate cohort to analyse their outcomes. This study investigated the oncological outcomes of 150 patients with advanced tongue squamous cell carcinoma who underwent total glossectomy. The results suggest that compartment resection significantly improved local control, irrespective of margin status. The presence of multiple positive nodes was found to be an independent poor prognostic factor, and adjuvant radiation significantly improved survival. Total glossectomy is feasible and safe in both the primary and salvage setting and should be considered as the surgical option for advanced tongue cancer.

BACKGROUND: Negative pressure wound therapy (NPWT) has been established over years for treatment of chronic and complex wounds. OBJECTIVE: Aim of this study was to investigate the effect NPWT on the microperfusion. METHODS: Prospective single centre analysis of patients treated with NPWT due to acute (ACUTE) wounds after fasciotomy or patients with chronic wounds (CHRONIC) due to a chronic limb threatening ischemia was performed. NPWT was conducted through a three days sequence with a negative pressure of –120 mmHg. Before after and during the entire period of therapy the microperfusion was assessed (O2C™, LEA Medizintechnik). RESULTS: Comparison of the perfusion values of 28 patients (CHRONIC/ACUTE 5/23, women/men 8/20) before and after the NPWT sequence showed a non-significant improvement in the CHRONIC group (supine position: p = 0.144, elevated position p = 0.068) and a significant decrease in the ACUTE group (supine position p = 0.012, elevated position p = 0.034). This effect could also been demonstrated during the NPWT over time (CHRONIC: supine position: p = 0.320, elevated position: p = 0.053, ACUTE: supine position: p = 0.021, elevated position: p = 0.012). CONCLUSION: Microperfusion measurements showed alterations and differences in wound bed perfusion of acute and chronic wounds; acute wounds tended to a decrease of blood flow, whereas this effect was not seen in chronic wounds in peripheral artery disease.

Purpose: Patients with chronic ureteric obstruction (CUO) are traditionally managed with polymer stents/nephrostomy. However, these are prone to failure and require regular exchange. This study eva...

We investigated the reliability of the 4Fusion® quadripodal memory staple in a consecutive series of 59 four-corner arthrodeses in a single centre. Forty-one patients (46 wrists) had a radiological and clinical assessment at a mean follow-up of 7.4 years. Thirteen patients (13 wrists) were lost to follow-up. Bone union was achieved in all but one patient. Seven patients were reoperated, six for device removal and one for nonunion. Most patients were satisfied, had a functional range of wrist mobility, good strength and were free of pain, comparable with the best previously reported series. Level of evidence: IV

To evaluate and compare the outcomes of two different surgical protocols for palatoplasty for midfacial growth in patients with cleft lip and palate. A retrospective observational cohort study was conducted in 80 patients with cleft lip and palate, who were divided into two groups. Group 1 comprised patients who underwent operation between 9 and 11 months of age using the Bardach two-flap technique without a palatal pushback. Group 2 comprised patients who had undergone operation between 18 and 20 months of age using either a Bardach two-flap technique with a palatal pushback or a von Langenbeck technique. Patient follow-up was done between 8 and 9 years of age when they reported to the centre for secondary alveolar bone grafting. Post-surgical cephalometric measurements were taken for midfacial growth analysis. Group 1 underwent palatoplasty at significantly younger ages than Group 2 (p 0.01). A statistically significant difference(p 0.01) was found between the two groups of patients on comparison of cephalometric parameters such as SNA, ANB, CoA, NperpA ANS-PNS, N-ANS, N-Me, Witt's (AO-BO). Group 2 had more positive cephalometric values as compared to Group 1, thereby implying that there was less incidence of midfacial hypoplasia in patients treated at the age of 18-20 months. Between the types of palatoplasty techniques within Group 2, i.e., Bardach two-flap and von Langenbeck, there was no statistical difference found in the post-opertative cephalometric values, i.e., SNA, ANB, CoA, ANS-PNS, N-ANS, N-Me, Witt's (AO-BO) except for Nperp-A, which showed a statistical difference (p = 0.03). Within the limitations of the study which is only a single center experience it seems that palatal closure should be carried out at 18-20 months of age for better midfacial growth, leading to decreased incidence of maxillary hypoplasia at a later stage in life. Repair at less than 18 months of age is also associated with mid-facial hypoplasia.

The costs of open and endovascular revascularisation to treat peripheral artery disease (PAD) have not been fully established. This study examined the costs of both the index admission and any readmissions to hospital within 30 days of discharge for people having revascularisation at a single centre in Australia.This was a retrospective analysis of prospectively collected data. Eligible participants were those presenting with chronic limb ischaemia requiring revascularisation between 2002 and 2017. Generalised linear modelling was used to estimate mean (95% confidence interval [95% CI]) hospital costs for the index and readmission hospital treatments.A total of 302 participants presenting with intermittent claudication (n=219; 72.5%) or chronic limb threatening ischaemia (n=83; 27.5%) treated by open (n=116; 38.4%) or endovascular (n=186; 61.6%) revascularisation were included. Forty-eight (48) (15.9%) participants were readmitted within 30 days of discharge from their index admission. The mean estimated index admission hospital cost was AUD$13,827 (95% CI, $11,935-$15,818) per person. This cost was significantly greater for open as compared to endovascular revascularisation (p0.001). The mean estimated hospital cost was AUD$15,324 ($10,944-$19,966) per person readmitted. When comparing participants treated before and after 2010, the total hospital costs decreased, mainly due to decreased lengths of hospital stay for open procedures.In this study the hospital costs were less for endovascular than open revascularisation of chronic limb ischaemia. Costs decreased over time. Readmission is an important contributor to the overall costs of peripheral revascularisation.

To describe the respiratory and nutritional supportive care and hospitalisations required in the real-world scenario in children with SMA type 1 treated with nusinersen.Single-centre observational cohort study of children with SMA1 commencing nusinersen from November 2016 to September 2018. Motor, respiratory and nutritional clinical characteristics and management are described from initiation of nusinersen for a minimum of two years.Nine children (5 females, 4 males), median age 10.7 months (range 2.7-181.2) commenced treatment with nusinersen and outcomes were assessed over a total of 270.5 patient months and 209 hospital admissions. Supportive care in newly-diagnosed patients (n = 7) included gastrostomy insertion (n = 4) and commencement of noninvasive ventilation (n = 4) at an average of 8.3 and 4.5 months after diagnosis, respectively. The annualised hospitalisation rate was 9.3/patient/year, average length of stay (LOS) of 3.3 days (SD = 5.6). Children with two SMN2 copies required more gastrostomies (p 0.05) and had more frequent admissions (p 0.05). Number of total admissions halved from the first to the second year of treatment in all patients (p 0.005).Children with treated SMA1 experienced considerable respiratory and bulbar comorbidities, necessitating substantial respiratory and nutritional supportive care. Proactive respiratory and nutritional surveillance and management is essential in SMA1 patients treated with nusinersen.

Patients and methods : A prospective registration of patients with colorectal cancer and a colonoscopy within the last 10 years. We tried to classify these post-colonoscopy colorectal cancers (PCCRCs) by most reasonable explanation and into subcategories suggested by the World Endoscopy Organization (WEO) and calculated the unadjusted PCCRC rate. Results : 47 PCCRCs were identified. The average age at diagnosis of PCCRC was 73 years. PCCRCs were more located in the right colon with a higher percentage of MSI-positive and B-RAF mutated tumours. The average period between index colonoscopy and diagnosis of PCCRC was 4.2 years. Sixty-eight % of all PCCRCs could be explained by procedural factors. The mean PCCRC-3y of our department was 2.46%. Conclusions : The data of our centre are in line with the data of the literature from which can be concluded that most post-colonoscopy colorectal cancers are preventable. The PCCRC-3y is an important quality measure for screening colonoscopy. Ideally all centres involved in the population screening should measure the PCCRC-3 y annually, with cooperation of the cancer registry and reimbursement data provided by the Intermutualistic Agency (IMA).

Background Evidence regarding the outcomes of percutaneous coronary intervention (PCI) in low-and-middle incomes countries remains limited. Objectives To report the outcomes post PCI at discharge, 30 days and 12 months in Vietnam and identify the key factors associated with adverse outcomes at 12 months. Methods We used data from a single centre prospective cohort in Vietnam. Data regarding demographics, clinical presentation, procedural information, and outcomes of patients were collected and analysed. Primary outcomes were mortality and major adverse cardiac and cerebrovascular events. Results In total, 926 patients were included. Poor outcomes were relatively low in those undergoing PCI. Predictors of mortality and major adverse cardiac and cerebrovascular events at 12 months post-PCI included being older than 75, being male, having acute myocardial infarction, left ventricular ejection fraction ≤ 40%, prior cerebral vascular disease and having an unsuccessful PCI. Conclusions Adverse outcomes of patients undergoing PCI in Vietnam are relatively low in comparison with those reported in other countries across the Asia Pacific region. Identification of factors associated with poor outcomes is beneficial for improving the quality of cardiac care and developing the prediction model of outcomes post-PCI in Vietnam.

Purpose Children affected by premature fusion of the cranial sutures due to craniosynostosis can present with raised intracranial pressure and (turri)brachycephalic head shapes that require surgical treatment. Spring-assisted posterior vault expansion (SA-PVE) is the surgical technique of choice at Great Ormond Street Hospital for Children (GOSH), London, UK. This study aims to report the SA-PVE clinical experience of GOSH to date. Methods A retrospective review was carried out including all SA-PVE cases performed at GOSH between 2008 and 2020. Demographic and clinical data were recorded including genetic diagnosis, craniofacial surgical history, surgical indication and assessment, age at time of surgery (spring insertion and removal), operative time, in-patient stay, blood transfusion requirements, additional/secondary (cranio)facial procedures, and complications. Results Between 2008 and 2020, 200 SA-PVEs were undertaken in 184 patients (61% male). The study population consisted of patients affected by syndromic (65%) and non-syndromic disorders. Concerns regarding raised intracranial pressure were the surgical driver in 75% of the cases, with the remainder operated for shape correction. Median age for SA-PVE was 19 months (range, 2–131). Average operative time for first SA-PVE was 150 min and 87 for spring removal. Median in-patient stay was 3 nights, and 88 patients received a mean of 204.4 ml of blood transfusion at time of spring insertion. A single SA-PVE sufficed in 156 patients (85%) to date (26 springs still in situ at time of this analysis); 16 patients underwent repeat SA-PVE, whilst 12 underwent rigid redo. A second SA-PVE was needed in significantly more cases when the first SA-PVE was performed before age 1 year. Complications occurred in 26 patients with a total of 32 events, including one death. Forty-one patients underwent fronto-orbital remodelling at spring removal and 22 required additional cranio(maxillo)facial procedures. Conclusions Spring-assisted posterior vault expansion is a safe, efficient, and effective procedure based on our 12-year experience. Those that are treated early in life might require a repeat SA-PVE. Long-term follow-up is recommended as some would require additional craniomaxillofacial correction later in life.

Summary Background Electrosurgery makes dissection with simultaneous haemostasis possible. The produced heat can cause injury to the surrounding tissue. The PEAK PlasmaBlade™(PPB) is a new electrosurgery device which may overcome this by having the ability to operate on a lower temperature, therefore reducing collateral thermal damage. Method A single-centre, double-blinded, randomised controlled trial (RCT) was conducted which included 108 abdominal-based free-flap breast reconstruction patients who had their flap raise performed using either the PPB (n = 56) or the conventional diathermy (n = 52). Data were collected during their in-patient stay and out-patient appointments. The primary outcome value was the number of days the abdominal drains were required. Results Baseline characteristics were similar between the groups, except a significantly lower flap weight in the PPB group. The median number of days the drains were required did not differ significantly (p = 0.48; 6.0 days for the diathermy and 5.0 days for the PPB). The total drain output (p = 0.68), the inflammatory cytokine in the drain fluid (p>0.054) and complications (p>0.24) did not differ significantly between the two groups. At the 2-week follow-up appointment, there was a trend towards less abdominal seromas on abdominal ultrasound (p = 0.09) in the PPB group which were significantly smaller (p = 0.04). Conclusion The use of the PPB did not result in a significant reduction of drain requirement, total drain output or inflammatory cytokines but did reduce the size of seroma collections at the 2-week follow-up appointment. Therefore, the use of the PPB device could reduce early seroma formation after drain removal.

Objective: To describe the short and long-term complications of over 1000 cases of Holmium laser enucleation of the prostate (HoLEP) in a single centre. Methods: A prospective database of all HoLEP procedures performed between December 2003 and March 2017 was analysed. Results: A total of 1016 HoLEP procedures were performed. Median patient age was 72 years (range 41–95). There was a significant improvement in urinary flow, post-void residual volume, IPSS and QoL score ( p < 0.0001). Pre-operative acute urinary retention was present in 403 patients (39.7%). Post-operatively five patients (1.2%) continued with a long-term catheter. Early and late complications consisted of failed initial voiding trial (10.6%), stress incontinence (transient 6.5%; persistent 0.3%), frequency/dysuria (5.6%), urinary tract infection (5.3%), urethral stricture (4.8%), submeatal stenosis (1.9%), return to theatre (1.5%), bladder neck stenosis (1.3%), bleeding (1.2%), epididymitis (0.7%), confusion (0.3%), transurethral resection of the prostate conversion (0.2%), ureteric obstruction (0.2%), vomiting (0.2%), anuric renal failure (0.1%), chest infection (0.1%), chest pain (0.1%), myocardial infarction (0.1%), rectoprostatic fistula (0.1%), supraventricular tachycardia (0.1%) and urinary sepsis (0.1%). Five-year reoperation rate was 3.7%. Conclusion: HoLEP is a safe treatment for bladder outflow obstruction secondary to an enlarged prostate. It is associated with few early and late complications and has a low reoperation rate. Level of evidence: 4

AimsTo describe the incidence of postoperative cystoid macular oedema (CMO) after endothelial keratoplasty (EK) and to identify its contributory risk factors.Methods2233 patients undergoing EK at Ospedali Privati Forlì ‘Villa Igea’, between January 2005 to October 2018 for Descemet stripping automated endothelial keratoplasty (DSAEK) and June 2014 to August 2018 for Descemet membrane endothelial keratoplasty (DMEK) with a minimum follow-up of 18 months were evaluated. Univariate and multivariate analyses were conducted to identify and quantify contributory risk factors. Receiver operating characteristic (ROC) curve analysis were performed to determine ideal cut-off points of continuous variables.ResultsCMO was identified in 2.82% (n=63) of the cases. CMO occurred in 2.36% of DSAEK eyes and in 5.56% of DMEK eyes (p=0.001). Average onset of CMO was 4.27±6.63 months (range: 1–34 months) postoperatively. Compared with those who did not develop CMO, a higher proportion of patients in the CMO group had diabetes (24.2% vs 9.8%, p67 years (OR=2.35, 95% CI: 1.30 to 4.26, p=0.005) were more likely to develop CMO. There were no other significant differences between the groups.ConclusionsOlder age (>67 years), diabetes mellitus and DMEK have been identified as independent risk factors for postoperative CMO following EK. Close observation is necessary during the first postoperative year after EK, particularly in patients with risk factors.

Introduction. The impact of a mother’s MS on the intrauterine and postnatal development of the infant remains controversial. Aim: to study the influence of mother’s MS, and pathogenetic therapy, on the formation of psychomotor skills in first-year infants under comparison with a group of infants from healthy mothers (“case-control”). Materials and methods. Prospective observational study (“case-control”) at months 3, 6, 9 and 12. The WHO-recommended scale of motor development (WHO six milestones), 46 infants from MS mothers and 46 infants from the control group. Results. The duration of the mother’s MS disease, the severity of the neurological deficit, and the disease course’s activity was found not significantly to affect the motor and neuropsychiatric development of the child in the first year of life. Significant differences were established between the groups of children and patients with MS from the control group in terms of mastering the skills of standing and walking; the presence of better motor parameters in children from patients receiving pathogenetic therapy was established too. The negative influence of interferons in the first trimester on speech skills in infants was revealed. Conclusion. The main influencing factor was mother multiple sclerosis and the pathogenetic therapy received by the mother before and during pregnancy. This fact can play a significant role in managing this infant cohort. Special exercises such as stimulation of motor and speech skills need to be included.

Background Acute surgical assessment units (ASAUs) aim to optimise management of surgical patients compared to the traditional ‘on-call’ emergency department (ED) system. Acute appendicitis (AA) is the most common acute surgical condition requiring emergency surgery. Aim We set out to assess if the ASAU improved care provided to patients with AA compared to those managed through the ED. Methods Patients admitted via the ED with AA in the 6 months prior to opening the ASAU were compared to those admitted via the ASAU in the first six months following its implementation. Relevant data was collected on key performance indicators from their charts. Results In the ASAU cohort, the mean time to be seen was one hour less than the ED cohort (21 min vs 74 min). The mean time to surgery was also 8.8 h shorter. Most patients in the ASAU group (78.6%) underwent surgery during the day, compared to 40.3% of ED patients. The ASAU patients also had a lower postoperative complication rate (0.9% vs 3.9%), as well as a lower negative appendicectomy rate (14.2% vs 18.6%) and lower conversion-to-open surgery rate. Greater consultant supervision and presence was observed. Conclusions The ASAU has resulted in better outcomes for patients with AA than those admitted via ED. More operations were performed in safer daytime hours with greater consultant presence, allowing for improved senior support for trainee surgeons. Our study supports the role of the ASAU in improving the quality and efficiency of emergency general surgery.

Accurate epidemiological hip fracture data is essential for healthcare planning and targeted prevention strategies. Limited reports of hip fracture incidence rates in the Republic of Ireland (ROI) exist. The aim is to calculate the current age- and gender-specific incidence of hip fractures in a level 1 Trauma Centre in the ROI, and the difference in these rates over a 10 year period.This was a retrospective, population-based, observational study. The local Hospital In-Patient Enquiry (HIPE) database was used to generate data for analysis; capturing all patients admitted for hip fracture in three time periods over 10 years. Patients55 years old, pathological fractures, and periprosthetic fractures were excluded. Age- and gender-specific incidence rate was calculated using HIPE and national census data.Absolute number of hip fractures rose by 8.5% between 2008/09 (n = 800) and 2018/19 (n = 868) time periods. Cervical hip fractures dominated in all 3 time periods. The average age of patients remained at 80 years but length of stay for patients was reduced by 16% 5 years later and by 21% 10 years later from the initial study point. Both the entire and susceptible (55 years) population numbers increased by 13% and 30%, respectively, yet overall hip fracture incidence rate declined 10 years on. Hip fracture incidence rate in the entire population fell by 3.23 per 100,000 population, and by 65.11 per 100,000 population in the susceptible population. The majority of both male and female age groups exhibited declining annual incidence rates over the 10 year study period.Results are consistent with the global experience of declining overall incidence rate of hip fractures, despite rising susceptible population numbers. This report adds to the sparse hip fracture incidence data available in the ROI which can be applied in future healthcare planning strategies.

Purpose The study aims to evaluate the number of examined newborns and the results of screening for twelve years (2008–2019) and to assess the effectiveness of the established system of neonatal hearing screening. Design and methods The study was designed as a retrospective longitudinal data analysis. The data included all the children (19,043) born in the hospital and also children (74) transferred from other healthcare facilities. A total of 19,117 children were included in the research group. Results In the first three years, a higher number of children did not pass the hearing screening, which was followed by a declining trend in the following years. After the first year of screening (2008), there was an improvement in diagnosis linked with a decrease in false-positive screening results (from 9.4% to 6.4%; p = 0.002). From 2008 to 2015, the ratio of children with positive screening to those with negative screening had a steady or declining trend. Conclusions The results showed a reduction in false-positive results after the first year of the screening program, probably due to improved care management and a gradual increase in the skills of the nurses performing the screening. Practice implications The cornerstones of neonatal hearing screening are a sufficient number of trained neonatology nurses, their mutual substitutability and the availability of a hearing screening device in the newborn ward every day. The results imply the importance of periodic evaluation of the obtained data, enabling early detection of possible deficiencies in the hearing screening system. Účel studie Cílem studie bylo zhodnotit počet vyšetřených novorozenců a výsledky screeningu za dvanáct let (2008–2019) a posoudit účinnost zavedeného systému novorozeneckého screeningu sluchu. Design a metodika Studie byla navržena jako retrospektivní analýza dat. Údaje zahrnovaly všechny děti (19 043) narozené v nemocnici a také děti (74) přeložené z jiných zdravotnických zařízení. Do výzkumné skupiny bylo zařazeno celkem 19 117 dětí. Výsledky V prvních třech letech byl vyšší počet dětí, které screeningem sluchu neprošly, což mělo v dalších letech klesající tendenci. Po prvním roce screeningu (2008) došlo ke zlepšení diagnostiky a k poklesu falešně pozitivních výsledků screeningu (z 9,4 % na 6,4 %; p=0,002). Od roku 2008 do roku 2015 měl poměr dětí s pozitivním screeningem vůči negativnímu setrvalou nebo klesající tendenci. Závěr Výsledky ukázaly snížení falešně pozitivních výsledků po prvním roce screeningového programu, pravděpodobně kvůli lepšímu managementu péče a postupnému zvyšování dovedností sester provádějících screening. Důsledky pro praxi Základními kameny novorozeneckého screeningu sluchu je dostatečný počet proškolených neonatologických sester, jejich vzájemná zastupitelnost a dostupnost zařízení pro screening sluchu na novorozeneckém oddělení každý den. Výsledky naznačují důležitost pravidelného vyhodnocování získaných dat, což umožňuje včasné odhalení možných nedostatků v systému screeningu sluchu.

Background Uroliths are stones formed in the urinary tract. Analysis of stones helps to identify risk factors for their development and prevention of recurrence. Standard stone analysis using modern technology is not routinely done in Nigeria. This study sought to determine the chemical composition of urinary stones seen in Abuja, Nigeria. Methods This was a retrospective study on composition of uroliths. Urinary stones surgically removed from 155 patients through minimal access surgical procedures between January 2015 and August 2019 were analysed. Optical crystallography and infrared spectroscopy were used to determine the chemical composition of the urinary stones. Results A total of 155 urinary stones were assembled from the patients. More stones were removed from male patients and the male to female ratio was 1.9:1. Stones were rare in the extremes of age. The predominant location (89.7%) of stones was in the upper urinary tract. All stones were of mixed composition with calcium oxalate accounting for 93.55%. Calcium oxalate, calcium phosphate and uric acid stones were more common in the upper tract, while 2 of the 3 struvite stones were found in the lower tract. Conclusion Stones found in this study were of mixed composition with the most common constituent being Calcium oxalate and the least common, struvite.

Background Recent reports describe a high rate of premature lead failure in the St Jude/Abbott TendrilTM 2088 (St. Jude Medical Inc., St. Paul, MN, USA) pacing lead principally manifested by electrical noise. This finding awaits confirmation. Methods We performed a retrospective analysis of 2088 TendrilTM leads among 362 patients implanted from 2010 to 2018. Eligible leads were those with device interrogations beyond one month from lead implantation. Review of serial device interrogations was conducted for each lead, particularly focussing on electrical noise as a marker of premature lead dysfunction. Results Four hundred and eight (408) leads among 337 patients were included in this study, with an average patient age of 81±11 years at the time of lead implantation. Mean follow-up was 2.5±1.8 years. There were eight leads with electrical noise indicating premature lead failure. This reflects an overall 1.7% rate of lead dysfunction; the failure rate was 6.2% at 4 years. The majority of cases were detected during routine checks without adverse clinical consequences. Four (4) cases required device reprogramming to avoid interference or inhibition due to noise. Conclusion The rate of Tendril TM 2088 premature lead failure appears to be similar to recent local and international studies. This study reports a significantly higher rate of lead dysfunction at 4 years (6.2%) than the published Abbott product performance reports.

Aims Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue. Methods Between October 2010 and July 2018, 102 patients with a mean age of 43 years (19 to 67), including 101 males, underwent distal biceps tendon repair less than six weeks after the injury, using cortical button fixation. The primary short-term outcome measure was the rate of complications. The primary long-term outcome measure was the abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Secondary outcomes included the Oxford Elbow Score (OES), EuroQol five-dimension three-level score (EQ-5D-3L), satisfaction, and return to function. Results Eight patients (7.8%) had a major complication and 34 (33.3%) had a minor complication. Major complications included re-rupture (n = 3; 2.9%), unrecovered nerve injury (n = 4; 3.9%), and surgery for heterotopic ossification (n = 1; 1.0%). Three patients (2.9%) overall required further surgery for a complication. Minor complications included neurapraxia (n = 27; 26.5%) and superficial infection (n = 7; 6.9%). A total of 33 nerve injuries occurred in 31 patients (30.4%). At a mean follow-up of five years (1 to 9.8) outcomes were available for 86 patients (84.3%). The median QuickDASH, OES, EQ-5D-3L, and satisfaction scores were 1.2 (IQR 0 to 5.1), 48 (IQR 46 to 48), 0.80 (IQR 0.72 to 1.0), and 100/100 (IQR 90 to 100), respectively. Most patients were able to return to work (81/83, 97.6%) and sport (51/62,82.3%). Unrecovered nerve injury was associated with an inferior outcome according to the QuickDASH (p = 0.005), OES (p = 0.004), EQ-5D-3L (p = 0.010), and satisfaction (p = 0.024). Multiple linear regression analysis identified an unrecovered nerve injury to be strongly associated with an inferior outcome according to the QuickDASH score (p < 0.001), along with infection (p < 0.001), although re-rupture (p = 0.440) and further surgery (p = 0.652) were not. Conclusion Acute distal biceps tendon repair using cortical button fixation was found to result in excellent patient-reported outcomes and health-related quality of life. Although rare, unrecovered nerve injury adversely affects outcome. Cite this article: Bone Joint J 2021;103-B(7):1284–1291.

Background: The management of a difficult airway requires training in cricothyroidotomy (CT). The objectives of this study were: (i) to describe technical changes made to The REAL CRIC Trainer model in order to increase its realism, (ii) to assess the model by experts in comparison to a commercial dry model, (iii) to evaluate its performance in a realistic simulation scenario for training technical and behavioural skills, and (iv) to assess whether the model can help to identify anatomic structures by ultrasound (US). Methods: An observational prospective study was conducted in which an assembled modified model was assessed by five experts in CT and comparing it with a commercial dry model. The fidelity of US images obtained in the model was compared to those obtained from volunteers. The usefulness and realism of the model, attached to a high-fidelity simulator's neck in emergent CT clinical scenario, was assessed by the 11 ICU staff taking part. Results: Using a score out of 10, CT performance in our model and in a dry model was rated by the experts as 9 vs. 6, respectively in external appearance, 8.4 vs. 5.8 in tactile fidelity, and 8.6 vs. 4.1 in technical realism. Participants in the simulation gave a mean score of 7.7/10 to the fidelity parameters. Usefulness for training of the model integration into a simulation scenario was rated as 9.6. Ultrasound images were evaluated as high fidelity. Conclusions: Our modified REAL CRIC Trainer model was rated high by experts in CT and participants in a simulated clinical scenario, and may be useful for a complete emergent CT training closer to the clinical reality than the models currently available. Resumen: Introducción: El manejo de la vía aérea difícil comprende el entrenamiento en la cricotiroidotomía (CT). Los objetivos de este estudio fueron: describir los cambios técnicos realizados en el modelo REAL CRIC Trainer para aumentar el realismo, obtener su valoración por expertos respecto a un modelo seco comercializado, evaluar su rendimiento en un escenario de simulación para el entrenamiento de habilidades técnicas y conductuales de la CT emergente y determinar si el modelo permite identificar estructuras anatómicas mediante ecografía. Métodos: Estudio prospectivo y observacional, el modelo ensamblado fue evaluado por 5 expertos en CT que lo compararon con un modelo seco comercial. Se comparó también su fidelidad ecográfica con la de las imágenes obtenidas en voluntario. La utilidad y el realismo del modelo utilizado en un escenario de simulación clínica para CT emergente fue valorada por 11 participantes, personal de la UCI. Resultados: La evaluación por expertos de la CT en el modelo diseñado y en modelo seco comercial, obtuvo puntuaciones de 9 vs. 6 sobre 10, respectivamente en apariencia externa, 8,4 vs. 5,8 en fidelidad táctil y 8,6 vs. 4,1 en realismo de la técnica. Los participantes en la simulación otorgaron una puntuación media de 7,7/10 a los parámetros de fidelidad. La utilidad de integrar el modelo en un escenario de simulación de alta fidelidad fue evaluada en 9,6/10 y las imágenes de ultrasonido fueron consideradas como de alta fidelidad. Conclusiones: El modelo REAL CRIC Trainer modificado fue muy bien valorado tanto por los expertos como por los participantes en un escenario clínico de simulación, y puede ser útil para un entrenamiento completo en CT emergente más próximo a la realidad clínica que los modelos disponibles.

Introduction: Traumatic brain injury (TBI) is amongst the leading causes of morbidity and mortality worldwide. The unprecedented emergence of COVID-19 has mandated neurosurgeons to limit viral spread and spare hospital resources whilst trying to adapt management plans for TBI. We aimed to characterize how this affects decision-making on TBI management and drive strategies to cope with future expected waves.\ud \ud Methods: Retrospective TBI data collection from a single tertiary referral unit was performed between: 01/04/2019 – 30/06/2019 (‘Pre-Epidemic’) and 01/04/2020 – 30/06/20 (‘Epidemic’). Demographics, mechanism of injury, TBI severity, radiological findings, alcohol/anticoagulants/antiplatelets use, and management decisions were extracted.\ud \ud Results: 646 TBI referrals were received in ‘Pre-Epidemic’ (N = 317) and ‘Epidemic’ (N = 280) groups. There was reduction in RTA-associated TBI (14.8 vs 9.3%; p = .04) and increase in patients on anticoagulants (14.2 vs 23.6%; p = .003) in the ‘Epidemic’ group. Despite similarities between other TBI-associated variables, a significantly greater proportion of patients were managed conservatively in local referring units without neurosurgical services (39.1 vs 56.8%; p < .0001), predominantly constituted by mild TBI.\ud \ud Conclusion: Despite COVID-19 public health measures, the burden of TBI remains eminent. Increases in local TBI management warrant vigilance from primary healthcare services to meet post-TBI needs in the community.

Objectives:We present our experience and outcomes with the BeGraft in the treatment of aortic coarctation in a predominantly paediatric population.Methods:This study includes a retrospective analysis of patients who had Begraft aortic stent implantation between 2018 and 2020 from a single centre.Results:The BeGraft aortic stent was used in 11 patients (7 males, 4 females) with a median age of 14 (13–21) years and a median weight of 65 (46–103) kg. Coarctation was native in five patients and recurrent in six patients. Median stent diameter and length were 16 mm and 38 mm, respectively. The median peak-to-peak pressure was 30 (12–55) mmHg before the procedure and 5 (0–17) mmHg after the procedure. The stenting procedure was successful in 10 of the 11 patients. Stent migration to the abdominal aorta occurred on post-procedure day 1 in the 21-year-old patient, who had previously undergone surgical closure of the ventricular septal defect and balloon angioplasty for coarctation. After repositioning failed, the stent was safely fixed in the abdominal aorta. Strut distortion also occurred during balloon retrieval in one patient, but no aneurysm or in-stent restenosis was observed at 1-year follow-up. The patients were followed for a median of 14 (4–25) months and none required redilation.Conclusions:Our initial results demonstrated that the BeGraft aortic stent effectively reduced the pressure gradient in selected native and recurrent cases. Despite advantages such as a smaller sheath and low profile, more experience and medium- to long-term results are needed.

Introduction: Significant ventilator-associated pneumonia and mortality were found in COVID-19 patients who required mechanical ventilation which calls for non-invasive means in managing respiratory failure. Methods: We retrospectively reviewed patients admitted to the intensive care unit of Pamela Youde Nethersole Eastern Hospital in Hong Kong with severe acute respiratory syndrome coronavirus 2 infection from 28 November to 15 December 2020. Patients’ laboratory, respiratory parameters and outcome data were recorded and analysed. Results: Eleven received prone ventilation. The median age was 67 (inter-quartile range: 59–72) years, and median COVID-19 GRAM score was 151 (inter-quartile range: 133–181), representing a high-risk group. There were significant improvements 1 h after awake proning in SpO2 (95% vs 92%, p = 0.008), FiO2 (0.4 vs 0.5, p = 0.003), SpO2/FiO2 (240 vs 184, p = 0.005), respiratory rate (19 vs 26, p = 0.006) and respiratory rate – oxygenation index (13.22 vs 7.67, p = 0.003; Table 1). Although not reaching statistical significance, the median PaO2, PaCO2 and PaO2/FiO2 improved after proning. The overall intubation rate was 22% and intensive care unit mortality was 22%, which is in contrast to 65.5% and 27.6%, respectively, in the first three waves. Although did not reach statistical significance, those received prone ventilation tend to have a lower ICU mortality (9.1% vs 42.9%, p = 0.245) and hospital mortality (18.2% vs 42.9%, p = 0.326). Conclusion: Awake proning potentially minimizes complications from invasive ventilation and provides a low-cost low-risk treatment option in COVID-19 patients with respiratory failure. This is particularly important when healthcare resources are strained at times of a pandemic.

Objective Systemic juvenile idiopathic arthritis is one of the subtypes of juvenile idiopathic arthritis. This type of disease accounts for approximately 10–20% of all cases of juvenile idiopathic arthritis. It typically affects both sexes equally and is usually present in children under 5 years. This study aimed to evaluate the demographic and clinical features of patients who were followed up for the diagnosis of sJIA in a single centre, the treatments they received, the responses to the treatment and the course of the disease. Methods All patients with systemic juvenile idiopathic arthritis who were evaluated at Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, Department of Paediatric Rheumatology, between January 2017 and January 2020 were included in this study. Descriptive features, clinical information, medications, treatment responses and long-term prognosis of patients were evaluated retrospectively. Results The study included 40 patients. 60% (n=24) of the patients were female and 40% (n=16) were male. The diagnosis age of the patients was 7.77±4.82 years and the patients were followed up for an average of 48±41 months. All of the patients had fever at the time of diagnosis. The 3 most common clinical signs after fever were arthralgia, hepatomegaly and lymphadenopathy (65, 55 and 50%, respectively). Ten patients (32.5%) had macrophage activation syndrome at admission. No significant difference was detected between the groups with and without macrophage activation syndrome concerning age, gender and clinical findings. Leukocyte, haemoglobin, platelet and erythrocyte sedimentation rates were significantly lower in the macrophage activation syndrome group compared with the other group, and ferritin was significantly higher. The C-reactive protein value was higher in the group without macrophage activation syndrome, but the difference was not statistically significant. While all patients received corticosteroid therapy as the initial therapy, 87.5% of these patients were administered pulse methylprednisolone therapy. In the follow-up, 21 patients (52.5%) needed biological treatment. Twenty-seven patients (67.5%) had a monocyclic course, 3 patients (7.5%) had a polycyclic course and 10 patients (25%) had a persistent polyarticular course. Conclusion Early diagnosis and treatment of systemic juvenile idiopathic arthritis are important because of the risk of developing macrophage activation syndrome – the most lethal complication. In our evaluation, it was seen that laboratory parameters could provide more guidance than clinical findings. Although steroids are the cornerstone of therapy, biological agents are effective in patients who are not responsive to steroid therapy. Hintergrund Die systemische juvenile idiopathische Arthritis ist ein Subtyp der juvenilen idiopathischen Arthritis. Auf diesen Krankheitstyp entfallen etwa 10 bis 20% aller Falle von juveniler idiopathischer Arthritis. Er betrifft ublicherweise beide Geschlechter gleichermasen und tritt in der Regel bei Kindern unter funf Jahren auf. Ziel dieser Studie war die Bewertung der demografischen und klinischen Merkmale der in einem einzigen klinischen Zentrum mit sJIA diagnostizierten Patienten sowie deren Behandlungen, Reaktionen auf die Behandlung und Krankheitsverlauf. Methoden Alle zwischen Januar 2017 und Januar 2020 in der Abteilung fur padiatrische Rheumatologie des Dr.-Sami-Ulus-Kinderkrankenhauses untersuchten Patienten mit systemischer juveniler idiopathischer Arthritis wurden in diese Studie eingeschlossen. Deskriptive Merkmale, klinische Informationen, Medikamente, Ansprechen auf die Behandlung und die Langzeitprognose der Patienten wurden retrospektiv ausgewertet. Ergebnisse In diese Studie wurden 40 Patienten eingeschlossen. 60% (n=24) der Patienten waren weiblich und 40% (n = 16) waren mannlich. Das Diagnosealter der Patienten lag bei 7,77 ± 4,82 Jahren, und die Patienten wurden durchschnittlich 48 ± 41 Monate nachbeobachtet. Alle Patienten hatten zum Zeitpunkt der Diagnose Fieber. Die drei haufigsten klinischen Symptome nach Fieber waren Arthralgie (65%), Hepatomegalie (55%) und Lymphadenopathie (50%). Zehn der Patienten (32,5%) hatten bei Aufnahme ein Makrophagenaktivierungssyndrom. Es wurde kein signifikanter Unterschied zwischen den Gruppen mit und ohne Makrophagenaktivierungssyndrom in Bezug auf Alter und Geschlecht sowie klinische Befunde festgestellt. Die Erythrozytensedimentationrate von Leukozyten, Hamoglobin, Blutplattchen und Erythrozyten war in der MAS-Gruppe im Vergleich zur anderen Gruppe signifikant niedriger und der Ferritinspiegel war signifikant hoher. Die Konzentration des C-reaktiven Proteins war in der Gruppe ohne Makrophagenaktivierungssyndrom hoher, doch diese Erhohung war statistisch nicht signifikant. Laborparameter scheinen wichtiger zu sein als klinische Befunde. Alle Patienten erhielten als Ersttherapie eine Kortikosteroidtherapie, 87,5% von ihnen wurde eine Methylprednisolon-Stostherapie verabreicht. In der Nachuntersuchung benotigten 21 Patienten (52,5%) eine biologische Behandlung. 27 Patienten (67,5%) zeigten einen monozyklischen, 3 Patienten (7,5%) einen polyzyklischen und 10 Patienten (25%) einen persistierenden polyartikularen Verlauf. Schlussfolgerung Eine fruhzeitige Diagnose und Behandlung der systemischen juvenilen idiopathischen Arthritis ist wichtig, da das Risiko besteht, ein Makrophagenaktivierungssyndrom zu entwickeln – die todlichste Komplikation. In unserer Bewertung wurde festgestellt, dass Laborparameter richtungsweisender sein konnen als klinische Befunde. Obwohl Steroide den Eckpfeiler der Therapie darstellen, sind biologische Wirkstoffe bei Patienten wirksam, die nicht auf eine Steroidtherapie ansprechen.

BACKGROUND: Desensitisation to alarms, or alarm fatigue, is a concern for healthcare staff. Little is known about how physiotherapists relate to, or are affected by clinical alarms. This pilot study aimed to explore physiotherapists’ attitudes and practices towards physiologic monitor alarms (PMA) in critical care. METHODS: An online survey of physiotherapists with critical care experience working at a Model 4 Irish Hospital. A sample of convenience was used with all eligible physiotherapists invited to complete the online survey via email (n = 33). Demographic information was captured, as well as information on experiences, practices, and barriers and facilitators to managing PMA. RESULTS: The response rate was 76% (25/33). All respondents worked on-call and weekends, with one respondent managing a current day-to-day critical care caseload. The majority of respondents (20/25, 80%) perceived all PMA as clinically important, but a workplace distraction (19/25, 76%). Negative emotions were commonly experienced by respondents on hearing PMA. All respondents (25/25, 100%) reported to notice their patient’s PMA, feeling they had a responsibility to respond. Respondents indicated varying levels of self-confidence in responding to PMA but commonly assessed the cause of the alarm (24/25, 96%) and checked the patient’s condition (24/25, 96%). Education and training was identified as a key barrier and facilitator for physiotherapists in terms of managing alarms in critical care. CONCLUSION: This study provides preliminary data on physiotherapists’ attitudes and practices towards PMA in critical care. Additional studies are necessary in order to verify the findings of this pilot study and further explore alarm fatigue amongst critical care physiotherapists.

Introduction:Our aim was to present the initial experience with a protocol-driven early extubation strategy and to identify risk factors associated with failed spontaneous breathing trials within 12 hours after surgery.Methods:A single institutional retrospective study of children up to 18 years of age was conducted in post-operative cardiac surgical patients over a 1-year period. A daily spontaneous breathing trial protocol was used to assess patients’ readiness for extubation. The study population (n = 129) was stratified into two age groups: infants (n = 84) and children (n = 45), and further stratified according to ventilation time: early extubation (ventilation time less than 12 h, n = 86) and deferred extubation (ventilation time more than 12 h, n = 43). Mann–Whitney U-test and binomial logistic regression were used for statistical analysis.Results:Early extubated infants had shorter ICU (4 versus 6 days, p = 0.003) and hospital length of stays (16 versus 19 days, p = 0.006), lower re-intubation rates (1 versus 7 patients, p = 0.003), and lower mortality (0 versus. 4 patients, p = 0.01) than deferred extubated infants. There was no significant difference in the studied outcomes in the children group. Malnourished infants and longer cardiopulmonary bypass times were independently associated with failed spontaneous breathing trials within 12 hours after cardiac surgery.Conclusions:Early extubated infants after cardiac surgery had shorter ICU and hospital length of stay, without an increase in morbidity and mortality, compared to infants who deferred extubation. Nutritional status and longer cardiopulmonary bypass times were risk factors for failed spontaneous breathing trial.

The aim of this study was to compare the safety and efficacy of transhepatic puncture tract embolization with n-butyl cyanoacrylate (n-BCA) versus coils after percutaneous transhepatic portal vein interventions in patients with hepatocellular carcinoma (HCC). It was also the aim of the study to evaluate the extent of artifacts in CT exams during FU. Single-center retrospective study from 2017–2019 in 190 patients who underwent percutaneous transhepatic portal vein interventions. The transhepatic puncture tracts were embolized with n-BCA in 88 patients (Group A) and with coils in 102 patients (Group B). Procedure-related complications and image noise around coils and n-BCA were compared between the groups. No significant differences were noted at baseline between both groups (platelets, coagulation, liver disease, types of procedures, liver function, liver tumors). All patients underwent transhepatic puncture tract embolization. Procedure-related complications were only observed in patients from Group B: subcapsular hemorrhage (n = 2; 1.96%), hepatic artery hemorrhage (n = 1; 0.98%), and pseudoaneurysms combined with hemobilia occurred (n = 1; 0.98%). In Group A, the distal part of the punctured portal vein branch was embolized with n-BCA in 1 patient (1.14%). Four major complications in Group B Vs 0 in Group A were observed, respectively (p

Introduction: Gaining intravenous (IV) access is vulnerable to errors and failure, and this study analysed IV procedures by paramedics in the federal state of Hesse in Germany to examine these. Methods: This was a single-centre, observational, pilot study survey on gaining vascular access. As well as identifying the success and failure rate of IV attempts, factors associated with a higher risk of failure were analysed using logistic regression, Χ2 or Fisher's exact test. Results: A total of 207 vascular access attempts were included in the analysis, of which 90.34% were successful. Significantly associated with higher risk of failure were patients' age (OR 1.05; 95% (CI 1.02–1.10); p=0.041), or when two (OR 3.94; 95% CI (2.39–6.20); p≤0.001) or more than three attempts (OR: 3.26 [95% CI: 1.35; 5.17]; p=0.003) were needed rather than one. In contrast, risk of failure was significantly lower when patients indicate a good (OR 0.02; 95% CI (0.00–0.15); p≤0.001) or moderate (OR 0.04 (95% CI 0.01–0.17); p≤0.001) vein status compared to a bad vein status. Failure rates were higher when paramedics were working a night shift (OR 0.06; 95% CI (0.00–0.98); p=0.005) rather then during the day. Conclusion: A proportion of IV access attempts by paramedics are unsuccessful and, if paramedics are to provide invasive interventions, non-IV options for drug administration should be available.

Objective: A surgical approach to the treatment of spinal defects and disorders has become more common because of the medical and technological advancements achieved in the last decade. This rising trend in spinal surgeries is associated with adverse events, most notably wound complications. From its introduction, negative pressure wound therapy (NPWT) has proved to be essential in the management of complex wounds and in speeding up wound recovery. The aim of this study is to investigate the use of incisional NPWT in patients undergoing spinal surgery and its role in the prevention of wound complications. Method: This study is a retrospective medical chart review conducted on patients who underwent spinal surgery and received incisional vacuum therapy as part of their treatment. The apparatus was applied intraoperatively following the spinal surgery for all patients included in this study. All surgical procedures were conducted between September 2019 and May 2020. Data entry and analysis were performed between September and October 2020. Results: A total of five patients' records were reviewed. In our healthcare centre, three patients developed seroma, one developed haematoma, four required revision surgery and one patient required re-operation. There was no wound dehiscence and none of the wounds became infected. Mean length of hospital stay was 11.2 days (standard deviation (SD): 9.5 days) and mean operation time was 333 minutes (SD: 86.4 minutes). Conclusion: There is a scarcity of data on the role of incisional vacuum therapy in the prevention of wound complications associated with spine surgeries. Our study showed promising results for the use of incisional NPWT in the management of spinal wounds. Further research is required in order to enhance wound care by exploiting this potentially beneficial approach.

Summary Cystic echinococcosis (CE) is a zoonotic disease caused by the larval stage of Echinococcus granulosus tapeworms. These parasites have a worldwide geographic distribution and pose a serious threat to livestock industry as well as human health in the endemic areas. CE is widely distributed in Pakistan. However, very few reports are available related to the regional transmission of E. granulosus. A retrospective analysis was conducted of surgically confirmed CE patients who were treated at Shoukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Punjab Province, Pakistan from 2007 – 2018. In total, 536 CE patients were evaluated during the study period. Cases originated from the provinces of Khyber Pakhtunkhwa (n=336), Punjab (n=147), Baluchistan (n=18), Sindh (n=3), Islamabad (n=2), Gilgit Baltistan (n=1), and Azad Jammu and Kashmir (n=1). An additional 28 cases were from Afghanistan. The highest number of CE cases was reported in 2013 (n=90). Females made up a larger proportion of cases (n=310; 57.8 %) than males (n=226; 42.2 %). Most patients were members of the Pashtun (n=197; 36.7 %), Hindku (n=142; 26.5 %), and Punjabi (n=118; 22.0 %) ethnic groups. The largest number of cysts was obtained from the liver (137/536; 25.6 %). This study showed that CE is likely present throughout Pakistan. In order to control the disease, a comprehensive control program and regional surveillance are needed.

Background A multidisciplinary team responsible for the management plan of prosthetic joint infections (PJI) was founded in January 2008. The aim of this study was to investigate whether a decrease in the number of surgeries and length of stay (LOS) was seen in the management of PJI with the aid of the multidisciplinary team. Methods This retrospective cohort study consisted of a total of 154 postoperative PJIs from three time periods: 21 PJIs from 2005 to 2007 (Group 1), 65 PJIs from 2011 to 2013 (Group 2), and 68 PJIs from 2015 to 2016 (Group 3). Successful outcome was classified as the retention of the original implant or revised implant and no infection-related death. Results The median number of operations decreased from 2.0 operations (Group 1) to 1.0 operation (Group 3) (p = .023), and the median LOS was shortened from 49.0 days (Group 1) to 17.0 days (Group 3) (p = .000). The number of PJIs treated with two-stage exchange decreased from 52.4% (11/21, Group 1) to 16.2% (11/68, Group 3) (p = .004). Simultaneously, debridement, antibiotics, and implant retention (DAIR) as primary surgical treatment increased from 42.9% (9/21, Group 1) to 89.7% (61/68, Group 3) (p = .000). The successful outcome of DAIR improved from 55.6% (5/9, Group 1) to 85.2% (52/61, Group 3) (p = .077). Conclusions Treatment of PJI in a specialized centre with the aid of a multidisciplinary team lead to fewer surgeries and reduced LOS. Successful outcome of DAIR improved over time.

Purpose Breast protontherapy efficiently limits cardiac, lung and contralateral breast exposure, which may clinically translate into better late tolerance profile compared with classic photon techniques. While breast protontherapy is already implemented in the United States and in some European countries, clinical experience of breast cancer protontherapy is currently limited in France. The aim of this study is to evaluate the clinical practice of breast cancer protontherapy at the Institut Curie in order to implement this technique at a larger scale. Materials and methods Data from all breast cancer patients that have been addressed to the protontherapy centre of Orsay (CPO, Institut Curie) for adjuvant breast protontherapy were retrieved. We analysed why these patients were ultimately treated with protontherapy or not. Results Between November 2019 and November 2020, eleven breast cancer patients have been evaluated for adjuvant protontherapy at the CPO. Two of them were ultimately treated with proton beams; adjuvant breast protontherapy therapy was well tolerated. The nine other patients were not treated with protontherapy due to lack of availability of protontherapy treatment rooms in acceptable time limits, at the time of patient evaluation. Conclusion Despite dosimetric advantages and excellent clinical tolerance, lack of availability of protontherapy machines currently limits wider implementation of breast protontherapy.

In this single centre cohort study we assessed BNT162B2 vaccine uptake and effectiveness among UK healthcare workers (HCWs) during a time of high community COVID-19 prevalence. Early uptake among HCWs was 62.3% (1409/2260), however there were significant differences in uptake between age groups, ethnic origins, and job roles. Uptake increased to 72.9% after a vaccine hesitancy working group implemented specific measures. In the 42 days after vaccination, 49 new cases of COVID-19 were identified, of which 7 (14.3%) occurred in HCWs who were beyond 10 days of vaccination. Kaplan–Meier curves for partially vaccinated and unvaccinated groups were congruent until day 14 and continued to diverge up to 42 days. Cox regression analysis showed a 70.0% (95%CI 6.0–91.0; p=0.04) risk reduction for COVID-19 infection in partially vaccinated HCWs. Here we report early vaccination rates among HCWs are generally high although uptake is lower in certain groups. It is possible to improve vaccine uptake and efforts should focus on this, however, significant resource is required. The BNT162B2 vaccine is effective from 14 days post-vaccination in a frontline clinical setting and protection continues beyond 21 days post 1st dose without a 2nd dose, being given., Several vaccines for COVID-19 have received emergency approval. Here, the authors describe BNT162B2 vaccine uptake and effectiveness among UK healthcare workers in a single centre cohort study during a time of high community COVID-19 prevalence.

Background: Diverticular associated colitis (DAC) has become increasingly appreciated as a form of inflammatory disease, localized mainly in the sigmoid, and defined as chronic inflammation of the interdiverticular mucosa with sparing of rectum, right colon and diverticula themselves. Methods: A retrospective case identification from January 2005 to December 2016 was performed. Patients with a diagnosis of DAC based on clinical, endoscopic and histological findings were enrolled. We analyzed their characteristics and response to therapy, and performed a review of literature. Results: Out of 377 pathology reports, 37 cases of DAC were identified, with a median age of 73 years and followed during 1-13 years. Six patients (16.22%) were refractory to conservative treatment and required surgery. In three patients (8.11%) evolution to ulcerative colitis (UC) was observed. Patients were divided into four endoscopic patterns, with a more benign course for type A “crescentic fold disease” compared to the other subtypes. Patients with type B “mild to moderate ulcerative colitis-like” were at significantly higher risk of persistent disease activity or relapse (p < 0.01). Conclusion: DAC is a multifaceted disease and considered to be a relatively benign condition. However, a subset of patients requires surgery and/or may progress to develop UC.

Aims To determine the role of early MRI in the management of suspected scaphoid fractures. Methods A total of 337 consecutive patients presenting to an emergency department (ED) following wrist trauma over a 12-month period were prospectively included in this service evaluation project. MRI was not required in 62 patients with clear diagnoses, and 17 patients were not managed as per pathway, leaving a total of 258 patients with normal scaphoid series radiographs who were then referred directly from ED for an acute wrist MRI scan. Patient demographics, clinical details, outcomes, and complications were recorded at a minimum of a year following injury. Results The median time from injury to ED presentation was one day and the median number of positive clinical signs was two out of three (snuffbox tenderness, tubercle tenderness, pain on telescoping). Of 258 patients referred for acute MRI, 208 scans were performed as 50 patients either did not tolerate (five patients) or did not attend their scan (45 patients). MRI scans demonstrated scaphoid fracture (13%), fracture of another bone (22%), scaphoid contusion (6%), other contusion/ligamentous injury (20%), or solely degenerative pathology (10%). Only 29% of scans showed no abnormality. Almost 50% of those undergoing MRI (100 patients) were discharged by ED with advice, with only one re-presentation. Of the 27 undisplaced occult scaphoid fractures, despite prompt cast immobilization, two experienced delayed union which was successfully treated with surgery. Conclusion The use of MRI direct from ED enables prompt diagnosis and the early discharge of a large proportion of patients with normal radiographs following wrist trauma. Cite this article: Bone Jt Open 2021;2(6):447–453.

Background Many studies have corroborated the association of dipeptidyl peptidase-4 inhibitors (DPP4i) use with bullous pemphigoid (BP). It has been speculated that this drug-induced variant presents with a different clinical spectrum than conventional BP. Objective To determine the prevalence of DPP4i-induced cases of BP and to evaluate whether gliptin-related BP has specific clinicopathological and immunological features. Methods We conducted a retrospective, observational study of BP cases attended at our centre between January 2000 and June 2020. Epidemiological, clinical, histopathological and laboratory data were collected. Results A total of 257 cases of BP were collected; 51 (24.3%) were on treatment with DPP4i. When analysing DPP4i-induced BP cases, generalized BP was the predominant pattern and scalp/mucosal involvement was found in 13 patients. Gliptin-related BP cases were associated to a decrease in the eosinophilic infiltrate (p = 0.000) and both the detection rate and concentration of anti-BP180 IgG were lower (p = 0.004, p = 0.001, respectively) than non-DPP4i cases. Limitations Retrospective, single-centre study. Conclusion Our large DPP4i-induced BP case series has highlighted that DPP4i-induced BP is characterized by generalized lesions and scalp involvement. Lower titres of anti-BP180 antibodies and a decrease in eosinophils infiltrating into the skin may be distinct features of DPP4i-related BP.

The efficacy and safety of super-mini percutaneous nephrolithotomy (SMP, 14 Fr) was compared with mini percutaneous nephrolithotomy (MPCNL, 16 Fr) for the treatment of upper urinary tract stones in children (

Congenital haemangioma (CH) is a rare benign vascular tumour presenting at birth with excellent prognosis. Usually, CH regresses without treatment within the first few months of life. Kaposiform Haemangioendothelioma (KHE) is another type of vascular tumours that has been described as benign with locally aggressive potential. Although the diagnosis of vascular tumours is usually straightforward based on typical clinical presentation, yet some confusing similarities may exist with congenital sarcomas.Conclusion: Data of cases managed at the vascular anomaly clinic during the period 2015 through 2019 were retrospectively analysed. The study included three groups of patients: cases diagnosed as congenital haemangioma (9 cases), cases of Kaposiform Haemangioendothelioma who presented in the neonatal period (7 cases), as well as cases of congenital fibrosarcoma (4 cases) that were referred to the vascular anomaly clinic because of apparent similarity with vascular tumours. The hallmark of the study was to compare clinical and imaging features in the three groups to facilitate differentiation and remove diagnostic confusion when managing these rare cases in the future. What is Known: • Congenital haemangioma is a rare benign vascular tumour presenting at birth. • Kaposiform Haemangioendothelioma is another type of vascular tumours that has been described as benign with locally aggressive potential. What is New: • Confusing similarities may exist between vascular tumours and congenital sarcomas.

Background: Breast cancer is the most common cancer globally and in Nigeria, it constitutes about 12% of all new cancers and 25% of all cancers in women. In Nigeria, the majority of patients present with late disease and globally, advanced breast cancer is associated with a low survival rate among patients. This study seeks to review the presentation of advanced breast cancer as seen in the University of Port Harcourt Teaching Hospital, Southern Nigeria. Patients and Methods: This is a 5-year retrospective study conducted at the University of Port Harcourt Teaching Hospital. Records of patients that presented to the hospital within the study period with histologically proven breast cancer (stages 3 and 4) were retrieved, and relevant data extracted and analysed using SPSS version 22. Results: There were 47 patients with advanced breast cancer and they were all females. Their ages ranged from 25 to 72 years with a mean of 43.9 ± 4.7 and peak age of 31–50 years. Majority of the patients (72.3%) had stage 3 disease while 13 (27.7%) of them had stage 4. The lung was the commonest metastatic site and this was seen in 7 (14.9%) patients, followed by the liver in 1 (2.1%). Conclusion: Advanced breast cancer remains a dreaded disease that reduces patients’ quality of life significantly and may also be rapidly fatal. Community-based efforts in collaboration with Non-Governmental Organizations (NGOs) targeted at information dissemination to the public, and offering breast cancer screening and subsidized cancer treatment are essential to reduce the mortality associated with this deadly disease.

The prognosis of acute kidney injury (AKI) varies in children with nephrotic syndrome (NS), data on factors predicting the recovery and recurrence of AKI in children with NS are limited. This study aimed to explore the possible factors predicting the recovery from and recurrence of AKI in children with primary NS. Children with primary NS complicated with AKI from 1993 to 2017 in a single centre were reviewed retrospectively. The clinical pictures and possible factors predicting the recovery from and recurrence of AKI in children with primary NS were investigated. Sixty-eight episodes of AKI in 59 children with NS were analysed: 88.2% of AKI recovered within 3 months, and 2.9% of AKI did not recover after 3 months. Survival analysis revealed that leucocyturia is significantly related to the AKI recovery time (P = 0.001), and children with leucocyturia [22 (4, 79) days] recovered significantly slower than did children without leucocyturia [12.0 (2, 39) days]. Renal tubular and interstitial injury were prominent in children with leucocyturia, and 11.9% of children with index AKI experienced the recurrence of AKI. Most episodes of AKI that occurred in children with NS recovered completely. Leucocyturia is a significant factor predicting the recovery time of AKI.

BACKGROUND: Given the high prevalence of coronavirus disease 2019 (COVID-19) globally, and the increased number of patients being discharged, it is necessary to understand the health consequences of COVID-19 to formulate and manage public policy concerning convalescent patients. METHODS: A longitudinal follow-up investigation of 25 patients from a tertiary hospital in Henan provincial was conducted 8 weeks after discharge. Of these patients, 15 attended a second follow-up appointment 8 weeks after that. A throat swab reverse transcription-polymerase chain reaction (RT-PCR) analysis for SARS-CoV-2 and chest computerized tomography (CT) scans were implemented at the first follow-up appointment, and a total of 40 blood samples (25 from the first and 15 from the second follow-up appointment) were collected. Patients’ levels of Immunoglobulin G (IgG) antibody against S-Receptor binding domain (S-RBD) and Nucleocapsid Protein (NP) of SARS-CoV-2 and the subpopulation of lymphocytes were evaluated using an enzyme-linked immunoassay (ELISA) test and flow cytometry, respectively. RESULTS: At the first follow-up appointment, 10 of the 25 patients (40.0%) showed complete radiological resolution. Of these patients, 80.0% were classified as moderate, and 80.0% were younger (those whose age was ≤ the median age of all the patients). The predominant patterns of abnormalities included an irregular line (12/25, 48.0%), ground-glass opacity (GGO) (44.0%), and multiple GGOs (28.0%). At the first follow-up appointment, 40.0% (10/25) of patients still had lymphopenia. Of the 15 patients who were followed-up with twice, the ratio of lymphopenia was 80% (12/15), 60.0% (9/15), and 46.7% (7/15) at 0, 8, and 16 weeks after discharge, respectively. This was mainly due to a decrease in the cluster of differentiation (CD) 4+ T lymphocyte, which was observed in 60% (9/15), 60% (9/15), and 46.7% (7/15) of total patients at 0, 8, and 16 weeks after discharge, respectively. All of the patients were S-RBD and NP IgG antibody positive at the first follow-up appointment. 40.0% (6/15) and 66.7% (10/15) of patients showed a decrease over 50.0% in the level of NP and S-RBD IgG antibodies, respectively, at the second follow-up appointment. The NP and S-RBD IgG antibodies’ levels declined to 44.6% (P=0.044) and 28.1% (P=0.18), respectively. 0 and 26.7% (4/15) of patients turned from NP and S-RBD IgG antibody positive to negative, respectively. CONCLUSIONS: About half of the patients still showed at least 1 abnormality in chest CT scans 8 weeks after discharge and lymphopenia 16 weeks after discharge. The level of the IgG antibody had declined by the follow-up appointment. Notably, the S-RBD IgG antibody declined more dramatically than that of NP. These results may have implications in the making of policies related to disease prevention, the long-term management of discharged patients, and vaccines’ development.

Background In our study, we sought to analyse the mid-term results after interventional aortic coarctation (CoA) stenting with sequential dilation of the stent. Methods The data of all 218 patients, who are above the age of 6 years and underwent CoA-stent implantation in our hospital, were retrospectively analysed on the rate of re-interventions, complications and arterial hypertension at a follow-up time of 31 months. To avoid any aortic complications, stents were deployed primarily not in full size and a second cardiac catheterisation for further dilatation was scheduled within 6–12 months after the stent implantation. Results The median peak invasive systolic pressure gradient declined significantly from 26.2 mmHg to 2.7 mmHg after stenting. There was one procedure related death due to an aortic rupture after stent implantation. There were in total 33 (15.1%) procedure-related complications including femoral artery complications, stent fracture and stent dislocation (in 9, 9 and 7 patients, respectively). In 85 patients a re-dilatation and in 25 patients a second stent-implantation was necessary at the first re-intervention. The systolic blood pressure declined significantly from 144 mmHg to 131 mmHg after stenting. The number of patients being normotensive changed from 18% before stenting to 78.5% after stenting with adjusted antihypertensive medication. Conclusion Aortic stenting is an effective means for CoA treatment. With sequential dilation of the stent, a very low rate of life-threatening procedural complications and mortality can be achieved. CoA stenting with proper antihypertensive medications results in better control of blood pressure.

Synovial sampling can be used in the diagnosis of peri-prosthetic joint infection (PJI). The purpose of this study was to establish the role of simultaneous image-guided synovial aspiration and biopsy (SAB) during an initial 2-year experience at our institution. Retrospective review of consecutive SABs performed during 2014–2016 at a tertiary referral musculoskeletal centre. Radiological SAB microbiology culture results were compared with intra-operative surgical samples or multidisciplinary team (MDT) meeting outcome at 1-year follow-up if surgery was not undertaken. Sensitivity, specificity and accuracy of synovial aspiration (SA), synovial biopsy (SB) and simultaneous SAB were calculated. 103 patients (46 male, 57 female) totalling 111 procedures were analysed with mean age 65 years (range 31–83). Image-guided synovial procedures were performed on 52 (46.9%) hip and 59 (53.1%) knee joint prostheses. The mean combined sensitivity, specificity and accuracy for the entire cohort was 72.6%, 96.9% and 90%, respectively. When only SB was obtained, diagnostic accuracy (92.5%) was similar to SA alone (94.1%). In total, there were 21 (18.9%) true-positive, 80 (72.1%) true-negative, 2 (1.8%) false-positive and 8 (7.2%) false-negative cases (PPV 91.3% and NPV 90.9%). No post-procedural complications were recorded at 1-year follow-up. Percutaneous image-guided SAB is a valuable technique in assessing suspected PJI, with most samples indicative of infective status and causative organisms when validated against intra-operative results and specialist MDT evaluation. Image-guided SB is a safe and useful additional procedure following failed SA with equivalent levels of diagnostic accuracy.

Introduction: The gold standard treatment for high risk upper tract urothelial cancers is radical nephroureterectomy. Little evidence exists specifically directed for octogenarians with this disease, therefore we highlight our centre’s outcomes and compare to current literature. Methods: Demographic, operative and postoperative data were collected on all octogenarian patients who underwent minimally invasive radical nephroureterectomy between 2010 and 2018 in a single centre. Outcomes including intraoperative and postoperative complications, disease recurrence rates and survival data were analysed. A literature search was performed, with six included articles of cases series and retrospective cohort studies after screening of full manuscripts. Results: Twenty-three patients of average age 82.6 years (range 80–85) were included. Length of stay was median 10 days (range 5–53). Six patients (25%) had postoperative complications ranging from Clavien–Dindo classification 2–3. Eight patients were found to have recurrence, with median time to recurrence of 18 months. Of the 13 patients who died during a follow-up of median 38.4 months, five patients (22%) died of disease related to their original diagnosis (median survival 20 months). Conclusions: From this single centre case series results combined with a review of current literature, radical nephroureterectomy is safe for octogenarian patients for upper tract urothelial cancers when appropriately selected. Further work will need to be carried out to assess the role of lymphadenectomy and adjuvant chemotherapy in the older patient cohort. Level of evidence Level 4

Lung resection in patients aged ≥80 years is considered high risk and contributes to the low rates of resection in this population. This review of 79 octogenarians who underwent curative surgery for non-small-cell lung cancer demonstrated no intraoperative mortality, 30-day mortality of 1.3% and 12-month mortality of 10%. In this selected cohort of octogenarians, surgery resulted in acceptable short- to medium-term outcomes.

Aim: In developing countries like our country, the frequency of breast cancer is gradually increasing. There are several risk factors of breast cancer. Besides that there can be some unrevealed risk factors. The aim of our study is to reveal demographic data of patients with breast cancer followed up in our hospital and the risk factors of breast cancer. Material and Methods: 237 female patients treated with the diagnosis of breast cancer between 2005 and 2015 were included in the study. Demographic information, familial features, type of breast cancer, histology, stage-grade, hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status of the patients were recorded from the files of the patients.The patients diagnosed with breast cancer were grouped in terms of risk factors, prognostic factors, and the characteristics of breast cancer. Results: A significant correlation was detected between early menarche and PR+ (p=0.034). It was observed that the disease occurred earlier in patients with early menarche (p=0.004). A high positive correlation was detected between TNBC and tumor size (p=0.019 r=0.581). Breast cancer was occuring in early ages in nulliparous patients and there was a moderate positive correlation between them (p=0.024 r=0.284). Conclusions: We revealed that breast cancer might occur in early ages in females with early menarche or both with early menarche and nulliparity. Understanding the etiopathogenesis of this common disease is necessary to determine the content of early diagnosis, treatment, and screening programs. Each society should have their unique screening programmes as distinct from Western societies.

Introduction: According to the Urology guidelines, in selected cases of distal upper tract urothelial carcinoma (UTUC) segmental ureterectomy (SU) can be offered. There is no consensus in the surgical technique of preference. Robot-assisted SU could be an option to overcome all the limitations of open and laparoscopic techniques. We describe our first experience of robot assisted SU with psoas hitch ureteral reimplantation (RAPHUR). Materials and methods: 11 patients underwent RAPHUR for distal UTUC between 2013 and 2017 in a single centre. Pre-, intra-, and postoperative outcomes were assessed. Conventional imaging was performed after 1, 3, 6 months and 1 year from surgery as follow up protocol. We retrospectively evaluated the technical feasibility, oncological and functional outcomes. Results: Median age was 71 years (57-91). The median length of the ureteral defect was 23 mm (10-40). Median preoperative creatinine level was 1.22 mg/dl (0.7-1.85) and median eGFR was 57.5 ml/min/1.73m2 (31-80). Five (45.5%) patients were symptomatic and 7 (63.6%) had hydronephrosis. Median operative time was 185 min (120-240), with a median blood loss of 100 ml (50-300). No case required conversion to open surgery. Overall, only 1 (9%) patient developed Clavien Dindo ≥ 3 postoperative complications. Average hospital stay was 7 (2-9) days. Mean postoperative creatinine was 1.05 mg/dl (0.8-1.85) and mean postoperative eGFR was 72 (36-83). During a median follow up time of 25.5 months (12-53), 4 (36.4%) patients experienced recurrence of urothelial cancer at conventional imaging follow up and 2 (18.2%) died due to its progression. Conclusions: In our initial experience RAPHUR can be proposed to selected cases of distal ureteral carcinoma with optimal perioperative and functional outcomes. However, cancer control may be undermined compared to nephroureterectomy. Thus, further prospective studies are needed to confirm our findings.

Introduction Central venous access devices (CVAD) are used to facilitate intravenous treatment with coagulation factor concentrates (CFCs) in haemophilia A (HA). Guidelines for perioperative CFC replacement therapy are based on single centre experiences, and the length of replacement therapy varies. Aim The aim of this study was to evaluate whether haemostasis coverage under four days is as effective and safe as a longer period of haemostatic coverage. Methods We identified patients with severe HA without inhibitors or major bleeds within one month of the surgery who received their first CVAD. We compared the CFC consumption and bleeds between children with ≤4 and those who received 5-7 perioperative treatment days including the day of surgery. Bleeds were recorded up to 4 days after the end of perioperative haemostatic coverage. Results In total, 144 children met the eligibility criteria and were included in the study cohort: 34 had received haemostatic coverage for ≤4 days, while 110 had received 5-7 days of haemostatic coverage. One bleed related to the surgery occurred in both groups. Conclusion Overall, the bleeding complications were rare. Haemostatic coverage with CFCs under ≤4 days with elective CVAD insertions was as effective as coverage for ≥5 days.

Spasticity is a common and disabling symptom in patients with multiple sclerosis (PwMS): as highlighted by many epidemiological studies, it is often a severe and not well treated. Despite the availability of evidence-based spasticity management guidelines, there is still great variability in everyday therapeutic approach, especially for the most complex cases. In our single-centre study, we retrospectively evaluated PwMS-treated nabiximols and botulinum toxin injections (BTI) from July 2015 to April 2019. Clinical and demographic data were collected. The severity of spasticity and spasms was recorded by modified Ashworth Scale (mAS) and Penn Spasm Frequency Scale (PSFS) at baseline and after 1 month of treatment. We evaluated 64 treatments for MS-related spasticity: 28 patients were treated with BTI and 36 patients with nabiximols. We found that both BTI and nabiximols are effective in reducing mAS (nabiximols, BTI: p < 0.001), PSFS frequency (nabiximols: p = 0.001, BTI: p = 0.008) and intensity (nabiximols: p = 0.001, BTI p = 0.016). No differences were found when directly comparing the efficacy of the two treatments, except for a statistical trend favouring BTI on spasms intensity (p = 0.091). Eleven patients were treated with both BTI and nabiximols, and only four patients continued both treatments. All dropouts were due to inefficacy of at least one of the two therapies. Our single-centre experience highlights that both BTI and nabiximols are effective in treating multiple sclerosis-related spasticity; however, BTI treatment may be more effective on spasms intensity. Combined nabiximols and BTI treatment could represent a therapeutic option for severe spasticity.