Search

The aim of this study was to determine the rate of persistent pain following total TMJ replacement and to identify potential predictive risk factors. A retrospective review of case notes treated by a single surgeon in a tertiary unit was performed. For each patient a number of variables were recorded including visual analogue pain scores (0 to 10) and opioid usage pre surgery and at 12 months or last follow up beyond 12 months. Persistent pain scores of 5 to 7 were regarded as moderate and 8 to 10 as severe. The mean pain score at last follow-up was significantly lower than preoperatively (2.1 vs. 6.3, p 0.001) with a mean follow-up time of 40.1 months (range 12-44). 16.4% of the patients reported moderate to severe pain and 13.7% were still on regular opioids at the last follow-up. Therefore 15 patients (20.5%) suffered from chronic postoperative pain after TMJ replacement surgery. Patients reporting severe preoperative pain scores (p = 0.04), regular opioid use (p = 0.001) or multiple previous open TMJ surgeries (p = 0.03) were more likely to suffer from chronic persistent pain and these should be regarded as predictive risk factors. The identification of these factors allows for better risk stratification of patients, informed consent and the agreement of expected outcomes. Patients with true articular disease and a single failed surgery should be considered for early total TMJ replacement to minimise multifactorial persistent pain.

Background Management algorithms of pediatric blunt abdominal solid organ injury (BASOI) are evolving to include interventional radiology, but there are few studies documenting the application and clinical outcomes of cases in children. Methods A retrospective case note review of all paediatric BASOI at a single Paediatric Major Trauma Centre was completed. CT scans and injuries have been retrospectively graded according to AAST guidelines. Results In the period February 2012 - October 2019, there were 106 children (median age 10.6 years (range 10 days – 16 years)) with BASOI. Of these, 71% (n = 75) suffered liver injuries, 29% (n = 31) spleen, and 27% (n = 29) renal. 95 children (89.6%) were treated with non-operative management, of which 15% (n = 14) went on to require secondary operative management (surgery, n=1 & interventional radiology, n= 14). There were no deaths or loss of organ in the group which required secondary operative management, regardless of the grade of injury. Conclusion The majority of BASOI can be successfully treated conservatively, but IR is a useful additional tool in their management for all grades of injury and is complementary to open surgery.

Summary Background With the advent of new techniques, foot salvage is feasible following talus oncological resection. As the reconstruction aims to achieve a pain-free, stable ankle for ambulation, biological limb reconstruction is the best option. This case series will evaluate the primary indications, complications, and functional outcomes of the reconstructed talus and highlighting the technical aspects of the surgery with a novel technique of triangular double-barrel free fibula flap. Methods We performed a retrospective case note review of patients undergoing foot salvage surgeries and primary talus reconstruction with double-barrel free fibula flaps between 2009 and 2019. Patient demographics, aetiologies, operative details, complications, and outcomes were analysed. All patients underwent the same talar reconstruction technique whereby a wide-based triangular framework was created from two bony struts of the osteotomized fibula. The Musculoskeletal Tumour Society (MSTS) scoring system was used to analyse the short- to mid-term functional outcomes. Results Four consecutive patients with aggressive benign and malignant tumours were identified. They consist of three males and one female, with a median age of 32 (range 27–39). Patients were followed up for a median duration of 60 months (range 24–132). Two flaps were complicated with venous thromboses; however, all were salvageable following re-explorations. All patients achieved solid bony fusion with good functional and aesthetic outcomes. The median MSTS score was 74.5% (range 66–76). No donor site morbidity and local recurrence were reported. Conclusion The triangular double-barrel free fibular flap is a good option for limb salvage following total talus resection, with good short- to mid-term functional and aesthetic outcomes.

Plexiform variants of neurofibromas and schwannomas are rare and typically arise in superficial soft tissues in the head and neck region. The treatment of these tumors is challenging and no generally accepted guidelines exist for their optimal management. The purpose of this study was to review the management and longterm prognosis of head and neck plexiform neurofibromas and schwannomas at 2 tertiary care academic hospitals in Finland over a 31-year period. The pathology files were searched for plexiform neurofibromas and schwannomas between the years 1990 and 2020. The case notes were reviewed for full management details. Two plexiform schwannomas and 6 plexiform neurofibromas were identified. Five of the 6 plexiform neurofibromas were managed operatively. All patients with a surgically managed plexiform neurofibroma underwent multiple operations. Sclerotherapy abolished 1 patient's cutaneous plexiform neurofibromas. The management of plexiform neurofibromas and plexiform schwannomas remains challenging. Sclerotherapy may offer a promising management option for cutaneous plexiform neurofibromas.

Facial feminisation surgery (FFS) is integral to the management of transgender adult females. Literature detailing the conduct and outcomes of FFS is lacking. The aim of this project was to review surgical practices in NHS Scotland. We identified Gender Identity Clinics throughout Scotland. These clinics were then contacted to discuss which services were available regarding FFS and to whom they refer patients. Retrospective review of electronic case notes between June 2014 and June 2019 was carried out and data was recorded on patient demographics, procedures employed, surgical complications, and postoperative outcome. FFS was carried out in two centres. Sixty patients received FFS during the study period, in 160 separate surgical procedures. Patients were all transitioning from natal biological male to female gender, with an average age of 36 years. The most common procedure was rhinoplasty (n = 36). Surgical complications occurred in eight procedures, and negative outcomes were recorded in 12/88 operating sessions. Increasing demand for surgery was noted throughout the study period. These results suggest that a wide variety of procedures are used, and that FFS is well accepted with relatively few surgical complications and negative outcomes. In depth understanding of patient's perceptions and views of their experiences, alongside objective measures, are essential to determine the impacts of FFS.

With its Judgment of 27 November 2019 in Case T-31/18 Luisa Izuzquiza and Arne Semsrott v European Border and Coast Guard Agency (Frontex), the Court of Justice of the European Union opened a new chapter in the elaboration of the two seemingly antagonistic interests enshrined in Regulation (EC) No 1049/2001 of 30 May 2001 regarding public access to European Parliament, Council and Commission documents: the public’s fundamental right to transparency versus the public’s interest as regards “public security”. Focusing on the evolution of “public security” in the EU since 1993, this case note analyses the CJEU’s balancing of these principles, its increased scrutiny of Frontex administrative decisions, and the extent to which Frontex had to justify its denial to grant access to documents through the lens of the management of sensitive operational information. This examination puts the judgment in the context of the ongoing situation in the central Mediterranean and, by providing detailed insights on the underlying operational considerations, shows that the fundamental and wide-reaching right to transparency has to be balanced with the need to protect crew and vessels and the implementation and enforcement of the Frontex mandate. While continuing established case law in its use of the public security exception (a so-called absolute exception that is not subject to an overriding public interest test), in this case the CJEU subsumed, for the first time, individual subjective rights and legal interests under public security. This article argues that this amounts to the individualisation of public security. As pointed out by Frontex in its written and oral defence, the CJEU thus opened the door to extending the scope of public security to also include other groups of people in the government’s continuous and exclusive de jure and de facto control. The conclusion from the Frontex Case is thus that protecting life at sea and ensuring effective border surveillance are two sides of the same medal as they have a common aim: combatting human smugglers, traffickers in human beings and other criminals and safeguarding life, safety and physical integrity of law-enforcement crew and migrants alike.

There currently exists little evidence on the effectiveness of case-managed programs targeting radicalised individuals. This paper provides results from an evaluation of two case-managed interventions implemented by police in Australia, referred to as Intervention 1 and Intervention 2. Drawing on client case note data and interviews, the paper provides quantitative and qualitative results. It examines client change using a five-point metric and details two individual case studies. Results provide data on radicalised behaviours, intervention goals and services offered to clients. Individual client progress is explored, and the overall effectiveness of both programs examined. The results show a positive relationship between client change and different measures of engagement. Limitations of the evaluation methodology and data sources are acknowledged and addressed. Lessons are highlighted relating to the assessment of client change, program evaluation and the role of interventions in supporting disengagement.

Introduction: Hospital Selayang started the liver transplant program in 2002. We report a total of 81 liver transplant cases until year 2015. Among these, paediatric cases constitute almost half. This report aims to review the demography and outcome of paediatric liver transplant cases. Methodology: Case notes of all paediatric patients underwent liver transplant from year 2002 to 2015 were retrospectively reviewed. Results: A total of 38 paediatric cases received liver transplantations from year 2002 to 2015. Age at transplantation ranged from 11 months to 16 years old (mean age 6 years) and weight ranged from 6.47 to 63 kilogram (mean 18kg). There were 20 males and 18 females, 20 of them were Malay, whereas Chinese and Indian were 13 and 4 respectively. Eighteen cases were living-related and 20 cases were cadaveric liver transplants. For recipient blood group, O+ is the commonest. Biliary atresia was the most common indication for liver transplant (22 cases; 58%), followed by intrahepatic cholestasis disorders (5 cases; 13%) and metabolic disease (4 cases; 10%). Post transplantation, there were 6 (16%) biliary complications, 12 (32%) vascular complications, 26 (68%) developed early onset infection, 13% had acute rejection and 2 graft failure. Out of the 38 transplants, 79% of them survive after 1 year, and 69.7% survive after 5 years. The common causes of mortality were sepsis and vascular complications. Conclusion: Despite limited resources, a successful paediatric liver transplant programme has been established in Hospital Selayang with good survival rate.

Background:With the high prevalence of HIV in Sub-Saharan Africa, screening for this viral infection is a routine in many health institutions prior to surgery, the world has recorded success story in the research of HIV especially with the advent of Highly Active Anti-Retroviral Therapy (HAART) this disease burden has been reduced globally. The prevalence of HIV in Nigeria is 1.4%. Aim:To determine the prevalence of HIV in surgical patients at the Rivers State University Teaching Hospital (RSUTH), Port Harcourt, Rivers State, Nigeria. Method:This was a cross sectional study of ANC attendees and surgical patients at the RSUTH, from January 1stto June 31st, 2019. They were surgical patients who were systematically selected, information was obtained from patients case notes with a structured proforma. The information obtained was coded and analyzed using SPSS version 25. Result:A total of 370 patients were attended to pre-operatively. There were 146 (39.5%) males and 224 (60.5%) females. The mean age was 31 years. One hundred and ninety four (52.4%) were obstetrics and gynaecological surgeries while 176 (47.6 %) were non-gynaecological surgeries. The commonest indication for surgery was caesarean representing 126 (34.1%) of the subjects.The prevalence of HIV in surgical patients was 8 (2.1%). Three (1.6%) of the obstetrics and gynaecological patients had HIV compared to 1(0.5%) non-obstetrics and gynaecological patient. Conclusion:The study revealed that prevalence of HIV in surgical patients at the RSUTH was high (2.1%). HIV infection was thrice as common in obstetrics and gynaecological patients compared with other surgical disciplines. There is need to step up surveillance amongst ANC attendees who are reflection of the populace in this region.

Displaced midshaft clavicle fractures have a non-union rate of 10–20%. Those who unite with conservative treatment have similar outcomes to those who undergo operative treatment; therefore, protocols to identify potential non-unions are important to avoid unnecessary surgery. The aim of this study is to report one such protocol. A protocol was introduced, where all isolated closed displaced midshaft clavicle fractures were initially managed non-operatively in a sling. At 2 weeks patients were assessed clinically and those who were struggling with their symptoms were offered surgery, with the remainder mobilised as comfortable. All cases treated at one centre over a three-year period, with a minimum follow-up of one-year underwent case note review. Between 2015 and 2017 613 clavicle fractures were managed through clinic. 347 were middle third (56%), 75% were male, mean age 41(range16–97). Forty-one middle third clavicle fracture patients underwent early fixation. Eleven patients required late fixation for symptomatic delayed, non- or malunion, 6 for symptomatic non-unions and 1 was a symptomatic malunion. For displaced fractures the early operative rate was 17.8%, and symptomatic non/malunion rate was 3.2%. This led to a total operative rate of 21%. A protocol for managing clavicle fractures has demonstrated an effective management of these injuries. It is cost-effective reducing the number of patients with displaced fractures requiring fixation with a fixation rate of 21% whilst reducing the rate of symptomatic non- and malunion (3.2%). The management pathway is simple and could be introduced into any orthopaedic outpatient department with ease.

This article surveys Tony Weir's case notes and book reviews for the Cambridge Law Journal between 1963 and 2002 in order to illuminate Tony's unique genius as a legal academic and thinker. Reading Tony's case notes and book reviews reveals that he cannot be characterised as either a “lumper” (someone who seeks to reduce the law down to a few elemental ideas and concepts) or as a “splitter” (someone who resists such a reduction). Instead, Tony's genius lay in his possessing the Keatsian quality of “negative capability”. This quality allowed Tony to be both a lumper and a splitter at the same time, refusing to identify himself definitively with either way of thinking about the law.

Background The concept of entrustable professional activities (EPAs) as an assessment framework is new to undergraduate physiotherapy training in Singapore. The physiotherapy community was tasked to develop EPAs to reflect the core professional activities of an entry-level physiotherapist for its undergraduate programme. Methods A qualitative participatory approach was used to develop entry-level EPAs for undergraduate physiotherapy students. Four phases occurred; (1) formation and training of the EPA writing workgroup from different sectors of the physiotherapy industry in Singapore; (2) conceptualization of the framework; (3) writing EPAs and; (4) iteration of EPAs through reflection, revision and consensus building. Results Five core activities were identified for undergraduate physiotherapy students to perform upon graduation and were developed into entry-level EPAs. These entry-level EPAs were subsequently termed as core EPAs to reflect the core practices expected at entry level across specialties and sectors in Singapore. These EPAs were mapped to five competency domains and 12 competency descriptors. The sources of information to support entrustment decisions were (1) short practice observation, (2) entrustment-based discussion and (3) case notes evaluation. Remote supervision was selected as the level of entrustment that physiotherapy students must attain at graduation. Conclusion The development of EPAs utilized a ground-up and cross-sector approach to define entry-level EPAs as core physiotherapy activities expected to be performed and assessed during clinical training by undergraduate physiotherapy students. Future research is needed to validate the use of EPAs as an assessment framework for undergraduate physiotherapy education.

Objectives To investigate the population pharmacokinetics of posaconazole gastroresistant tablets in children with cystic fibrosis (CF) and perform simulations to recommend optimal doses. Patients and methods Children from a paediatric CF centre who had received posaconazole tablets and underwent therapeutic drug monitoring were identified from pharmacy records. Relevant clinical data were collated from case notes and electronic patient records and used to develop an allometrically scaled population pharmacokinetic model. A stepwise covariate model-building exercise evaluated the influence of interacting medicines and liver function. Results One hundred posaconazole serum concentrations were collected from 37 children with a median age of 14 years (range 7–17). Posaconazole pharmacokinetics were adequately described by a one-compartment model with inter-individual variability on clearance. Dose simulations demonstrated a 77%–83% probability of attaining a trough target of 1 mg/L with a dose of 300 mg every 12 h for two doses then 300 mg once daily (OD) in children aged 6–11 years; and 86%–88% with a dose of 400 mg every 12 h for two doses then 400 mg OD in adolescents aged 12–17 years. This dose scheme also yielded a 90% probability of achieving an AUC of 30 mg·h/L. AUC and trough concentration were highly correlated (r2 = 0.98). Simulations showed that trough concentrations of >0.75 mg/L would exceed an AUC of 30 mg·h/L in 90% of patients. Conclusions A starting dose of 300 mg OD in those aged 6–11 years and 400 mg OD in those aged 12–17 years (following loading doses) yields a 90% probability of attaining an AUC of 30 mg·h/L.