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Metabolic characterization of deceased donor kidneys undergoing hypothermic machine perfusion before transplantation using c-enriched glucose.Background: The provision of a metabolic substrate is one mechanism by which hypothermic machine perfusion (HMP) of kidneys provides clinical benefit. This study aimed to describe de novo metabolism in ex vivo human kidneys undergoing HMP before transplantation using 13C-labeled glucose as a metabolic tracer. Methods: Cadaveric human kidneys were perfused with modified clinical-grade perfusion fluid (kidney perfusion solution [KPS-1], Organ Recovery Systems), in which glucose was uniformly enriched with the stable isotope 13C ([U-13C] glucose). The sampled perfusion fluid was analyzed using a blood gas analyzer, and metabolic profiling was performed using 1-dimensional and 2-dimensional nuclear magnetic resonance spectroscopy and mass spectrometry. Functional outcome measures included serum creatinine levels and the development of delayed graft function. Results: Fourteen kidneys were perfused with the modified KPS-1 and successfully transplanted. The mean duration of HMP was 8.7 h. There was a sustained increase in the conversion of glucose into de novo glycolytic end products, such as lactate, in donor kidneys during HMP. There was no significant association between functional outcomes and metabolism during the HMP. De novo anaerobic metabolism was indicated by continuing lactate production, as indicated by increasing concentrations of universally 13C-labeled lactate ([U-13C] lactate) in perfusion fluid from all kidneys. This was more evident in donation after circulatory death donor kidneys. Conclusions: Our study is the first to use [U-13C] glucose to describe the metabolism during HMP. The consequences of an initial warm ischemic insult on circulatory death in donor kidneys continue during the preservation period.
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The versatility of the supinator to posterior interosseus nerve (SPIN) transfer: indications and outcomes, a case series.Background: Transfer of the supinator motor branches to the posterior interosseous nerve (SPIN) was first described as a reliable method of restoration of digit extension in cases of paralysis when there is retained function in the 5th and 6th cervical nerve roots with loss of function in the 8th cervical nerve root. Methods: We performed a retrospective review of all the SPIN transfers that were performed in our unit which included 16 limbs in 14 patients over a 6-year period. The median age was 49 years (range 22-74). The average follow-up period was 15 months (range 6-24 m). Aetiology included spinal cord injury (SCI) in 5, plexus root avulsion in 3, degenerate spondyloradiculopathy in 3 and the final three patients had paralysis from oncological resection, inflammatory and compressive neuropathy respectively. Results: Functional digit extension (MRC grade 3 and above) was achieved in 12/16 limbs. Patients with degenerative spine lesions had the worst outcome with a median of MRC grade 2 with a median time to surgery of 20 months (average age of 67), compared to 13 months in the SCI group (average age 32.8) and four months in the BPI group (average age 34.6). Conclusions: The SPIN transfer may be safely performed in a wide spectrum of pathologies including brachial plexus injuries, spinal cord injuries and neuritis. However, in degenerative spondyloradiculopathy we report inferior outcomes, which may be due to late referral, chronic denervation, possible involvement of the donor nerve and an older age group and potentially diminished rehabilitation and neural plasticity potential.
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Test yourself question: a young male with right shoulder pain.No abstract available
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Accuracy of intraoperative diagnosis of appendicitis in laparoscopy. Should this affect decision for appendicectomyPoster presentation abstract 942 from the Association of Surgeons in Training (ASiT) Annual Conference 6th-8th March 2020, Birmingham International Convention Centre.
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Test yourself answer: a young male with right shoulder pain.No abstract available
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Comparative effectiveness of different cystic duct ligation techniques in laparoscopic cholecystectomy: a systematic review and network meta-analysis.Background: Laparoscopic cholecystectomy is one of the most common surgical procedures. Several techniques of ligating the cystic duct have been compared in randomized trials, but data on comparative effectiveness are missing. Our aim was to systematically review the literature and, if appropriate, synthesize the available evidence. Methods: A systematic search of PubMed, Scopus, Ovid, and Cochrane Library was conducted to identify randomized studies comparing different ligation techniques of the cystic duct in laparoscopic cholecystectomy. Network meta-analysis synthesized evidence from all available techniques. Techniques compared were metal (MC), absorbable (AC), or polymer clips (PC), suture ligation (SL), and ultrasonic shears (US). Results: Twenty-three randomized studies with 2851 patients were included in our study. A well-connected network was formed for bile leak and a star-shaped network for operative time, with MC as the common comparator. No difference was found when SL, AC, US, or PC were compared for bile leak. Operative time was statistically significantly reduced when US were compared to MC (mean difference [MD] = -14.32 [-19.37, -9.28]), SL MD = -20.16 (-10.84, -29.47), and AC MD = -18.32 (-1.25, -35.39). The remaining techniques had similar operative times. PC had the highest probability of being the best technique P = 41.8, and SL had the highest probability P = 46.1 of being the second best for bile leak. US had a 98.1% chance of being the best technique for operative time. Conclusions: Given that all techniques demonstrate similar efficacy, the decision should be based on cost, familiarity with the technique, and environmental factors.
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Intraoperative neuromonitoring and mapping during spinal cord untethering surgery; a single-centre paediatric neurosurgery unit experience.Purpose: A review of intraoperative neuromonitoring (IONM) and mapping (IONMa) utility during paediatric tethered cord surgery with particular attention to feasibility, measures to prevent injury, and postoperative outcome. Methods: A retrospective analysis of spinal cord untethering surgery between 2015 and 2022 was carried out. Cohort demographics, IONM and IONMa data, and procedural details were summarised and associations between variables explored. Clinical outcome was assessed 3-months post procedure via review of medical records. Results: One hundred and twenty-two patients (median age: 3 years old: IQR: 2-9, 61% female) underwent surgery. The most common diagnosis was thickened filum (n = 59, 48%). Urological dysfunction was the most common presenting complaint (62%). Electromyography (EMG), motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), and bulbocavernosus reflexes (BCR) were successfully recorded in 100%, 99%, 90%, and 73% patients. Unsuccessful BCR monitoring only occurred in females (p < 0.001). The Triggered-EMG protocol identified nerve rootlets adhered to the filum or tethering structure in 16% of the cohort. Alert criteria breaches (> 30-50% reduction in SSEP, > 80% reduction in MEP amplitude, absent BCR) occurred in 13 patients (11%). These alert criteria breaches were reversed in 11 (85%) with no permanent neurological deficits. In 2 (15%), alerts were irreversible, and one developed a permanent neurological deficit. Signs and symptoms of tethered cord had either stabilised (≥ 64%), improved (≥ 20%), or worsened (≤ 4%) at 3-month postoperative review. Conclusion: IONM and IONMa are useful and effective tools in monitoring and identifying neural tissue, which can guide safe cord untethering and lipoma resection. Our results validate IONM and IONMa in surgery for cord untethering.
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A reproducible extended ex-vivo normothermic machine liver perfusion protocol utilising improved nutrition and targeted vascular flows.Background: Normothermic machine perfusion of donor livers has become standard practice in the field of transplantation, allowing the assessment of organs and safe extension of preservation times. Alongside its clinical uses, there has been expanding interest in extended normothermic machine perfusion (eNMP) of livers as a potential vehicle for medical research. Reproducible extended normothermic machine perfusion has remained elusive due to its increased complexity and monitoring requirements. We set out to develop a reproducible protocol for the extended normothermic machine perfusion of whole human livers. Methods: Human livers declined for transplantation were perfused using a blood-based perfusate at 36 °C using the Liver Assist device (XVIVO, Sweden), with continuous veno-venous haemofiltration in-parallel. We developed the protocol in a stepwise fashion. Results: Perfusion techniques utilised included: targeted physiological vascular flows, phosphate replacement (to prevent hypophosphataemia), N-acetylcysteine (to prevent methaemoglobin accumulation), and the utilisation of sodium lactate as both a nutritional source and real-time measure of hepatocyte function. All five human livers perfused with the developed protocol showed preserved function with a median perfusion time of 168 h (range 120-184 h), with preserved viability throughout. Conclusions: Livers can be reproducibly perfused in excess of 120 (range 121-184) hours with evidence of preserved hepatocyte and cholangiocyte function.
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Can socioeconomic and psychosocial factors predict the duration of orthodontic treatment?Introduction and objectives: Very little is known about the role of socioeconomic and psychosocial factors in predicting orthodontic treatment duration. Thus, this study aimed to test whether socioeconomic position (SEP) and psychosocial factors, namely, family environment and resiliency can predict orthodontic treatment duration. Methods: Data were analysed from a hospital-based, prospective, longitudinal study that recruited 145 consecutively selected 12- to 16-year-old male and female adolescents. Baseline SEP and psychosocial data were collected by a validated child self-completed questionnaire before the placement of fixed appliances. Linear regression analysis was used. Results: The response rate was 98.6 per cent and the dropout was 8.2 per cent. Maternal emotional support was an important predictor of orthodontic treatment duration. Adolescents with high levels of maternal emotional support were more likely to have a shorter orthodontic treatment duration (by nearly four months) than those with low levels of maternal emotional support (P = 0.02). Parental SEP, paternal emotional support, maternal and paternal control, as well as resiliency were not significantly associated with orthodontic treatment duration (P > 0.05). The multivariable regression analysis (including age, gender, and malocclusion severity) confirmed the significance of maternal emotional support as a predictor of orthodontic treatment duration. Conclusions: Maternal emotional support is an important predictor of orthodontic treatment duration. This may be explained by a higher maternal involvement in the orthodontic treatment, which may have facilitated achieving the required orthodontic treatment outcome in a shorter treatment duration.
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Burns objective scar scale (BOSS): validation of an objective measurement devices based burn scar scale panelAims: Hypertrophic scars in burn survivors are a major cause of morbidity but the development of evidence based treatments is hampered by the lack of objective measurements of these scars. The objective of our study is to investigate the most accurate parameters for objective scar assessment and to create a combination score to facilitate the use of a panel of objective scar measurement tools. Methods: Three independent assessors evaluated fifty five scar sites on fifty five burn patients with both the subjective modified Vancouver Scar Scale (mVSS) and a panel of objective measurement tools including the DSM II Colormeter, Cutometer, Dermascan high frequency ultrasound. The sensitivity and specificity of the objective scar parameters in predicting a mVSS score of 6 or more using the Receiving Operator Characteristic Area under the curve (ROC AUC) was then calculated and the most accurate parameters were combined to create an objective global scar score. Results: The ROC AUC values were found to be highest for the Dermascan scar thickness (0.897), dermal intensity and intensity ratio (0.914 and 0.919), Cutometer R0 value (0.942), and R0 ratio (0.944). For colour measurements, ratios of scar to normal skin performed better than the single parameters for both erythema and pigmentation measurements: DSM II Erythema ratio vs Erythema (0.885 vs 0.818), DSM II a* ratio vs a* (0.848 vs 0.741); DSM II Melanin ratio vs Melanin (0.854 vs 0.761), DSM II L* ratio vs L* (0.862 vs 0.767). Analysis of the ROC AUC with chi-square test values showed that the highest AUC (0.786) was obtained with the combination of the Cutometer R0, Dermascan scar thickness, intensity and their respective scar to normal skin ratios. A total score of 5 and above (out of 6 parameters) had the highest combined sensitivity (69.0%) and specificity (83.3%). Conclusion: The objective parameters for the DSM II Colormeter, Cutometer and Dermascan high frequency ultrasound were all found to have moderate to strong ROC AUC values and combination of the Cutometer R0 and Dermascan scar thickness and intensity values can be used to create an objective global scar scale that can accurately differentiate patients with hypertrophic burn scarring from non-hypertrophic scars or normal skin.
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Proximal humerus fractures : a review of anatomy, classification, management strategies, and complicationsProximal humerus fractures are prevalent in older adults, particularly women, primarily due to osteoporosis and increased fall risk. These fractures often result from low-energy falls in elderly patients, while in younger individuals, they are more likely to occur with high-energy trauma, which may involve additional injuries to soft tissue and neurovascular structures. Proper anatomical understanding, including key structures and blood supply, is crucial for effective management and to prevent complications. Several classification systems assist in guiding treatment for proximal humerus fractures, including Codman's, Neer's, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) system, and the Codman-Hertel system, which helps predict ischemia risk. Evaluation of proximal humerus fractures begins with Advanced Trauma Life Support (ATLS) protocols, emphasizing a thorough shoulder assessment, particularly focusing on skin integrity in elderly patients. Neurological and vascular examinations are essential due to the common occurrence of nerve injuries, especially involving the axillary nerve. Imaging typically includes multiple standard views, with advanced imaging reserved for complex cases and for assessing associated soft tissue injuries. Treatment options range from conservative management for stable fractures to surgical intervention for more complex cases. Surgical choices include techniques like fixation, nailing, and various arthroplasty options, with some procedures potentially offering advantages for older adults with bone quality or soft tissue challenges. Rehabilitation is a vital component of recovery, with emphasis on early mobility and gradual strengthening to restore function, especially in older patients. Complications following open reduction and internal fixation (ORIF) for proximal humerus fractures can include issues such as non-union, malunion, osteonecrosis, infection, joint stiffness, and fixation failure. In cases where non-union or fixation failure occurs, revision surgery or arthroplasty may be necessary. Joint stiffness may require further intervention if physical therapy is insufficient, while symptomatic osteonecrosis might also need surgical management. Malunion is generally better tolerated in older patients but may require correction in younger individuals. Other surgical options, such as hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA), share similar risks, including infection, fractures, complications at the tuberosity, stiffness, and instability. RSA may be favored when there are tuberosity or rotator cuff issues. Closed reduction with percutaneous pinning carries a high risk of pin migration and malunion, which can result in deformities, pain, and dysfunction. Proper anatomical knowledge is essential to avoid neurovascular injury and to manage common issues such as pin-site infections effectively.
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Evaluation of Patient-Initiated Follow-Up (PIFU) service in a Fracture clinic : a comprehensive service evaluation and patient satisfaction auditBackground Outpatient clinics are increasingly challenged by high patient volumes and rising "did not attend" (DNA) rates, leading to extended wait times and declines in patient satisfaction. Traditional follow-up (FU) models with routinely scheduled appointments contribute to inefficiencies, as stable patients may attend unnecessary visits, thus straining clinic resources. The patient-initiated follow-up (PIFU) model offers an alternative where patients schedule appointments only when necessary. This study evaluates PIFU's efficacy in improving outpatient services and patient satisfaction by reducing routine appointments and prioritizing patient-driven follow-up. Methods This service evaluation and patient satisfaction audit was conducted at the fracture clinic of Royal Shrewsbury Hospital over three months (December 2023-March 2024). Out of 3828 patients seen, 203 were assigned to PIFU based on criteria indicating stable conditions with minimal follow-up requirements. The remaining patients were either scheduled for routine follow-ups or discharged. Data were collected retrospectively from clinic records, and a structured questionnaire assessed patient satisfaction with the PIFU service. Results Among the 203 patients assigned to PIFU, 183 (90.15%) patients received an informational leaflet, with all respondents finding it easy to understand. However, only 41 (20.2%) of patients utilized the PIFU service, primarily for concerns about pain, healing, or complications. Satisfaction among PIFU users was high, with 163 (80.3%) patients rating the service 5/5. Non-users mostly cited no perceived need for follow-up. Demographic analysis indicated that patients aged 40-60 were predominant (n=132; 65.02%) among the PIFU cohort. Conclusion The PIFU model demonstrated the potential to alleviate clinic workload by reducing routine follow-ups while maintaining high patient satisfaction. Although utilization rates were low, those who engaged found the service beneficial, suggesting PIFU's value for patients comfortable with self-management. Improved patient education may enhance engagement, supporting the broader implementation of PIFU in outpatient settings. Further research is warranted to explore barriers to patient-initiated follow-up and refine eligibility criteria for optimal outcomes.
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Brief O2 uploading during continuous hypothermic machine perfusion is simple yet effective oxygenation method to improve initial kidney function in a porcine autotransplant modelWith oxygenation proposed as a resuscitative measure during hypothermic models of preservation, the aim of this study was to evaluate the optimal start time of oxygenation during continuous hypothermic machine perfusion (HMP). In this porcine ischemia-reperfusion autotransplant model, the left kidney of a ±40 kg pig was exposed to 30 minutes of warm ischemia prior to 22 hours of HMP and autotransplantation. Kidneys were randomized to receive 2 hours of oxygenation during HMP either at the start (n = 6), or end of the perfusion (n = 5) and outcomes were compared to standard, nonoxygenated HMP (n = 6) and continuous oxygenated HMP (n = 8). The brief initial and continuous oxygenated HMP groups were associated with superior graft recovery compared to either standard, nonoxygenated HMP or kidneys oxygenated at the end of HMP. This correlated with significant metabolic differences in perfusate (eg, lactate, succinate, flavin mononucleotide) and tissues (eg, succinate, adenosine triphosphate, hypoxia-inducible factor-1α, nuclear factor erythroid 2-related factor 2) suggesting superior mitochondrial preservation with initial oxygenation. Brief initial O2 uploading during HMP at procurement site might be an easy and effective preservation strategy to maintain aerobic metabolism, protect mitochondria, and achieve an improved early renal graft function compared with standard HMP or oxygen supply shortly at the end of HMP preservation.
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Bony cystic lesion with associated submandibular lymphadenopathy on a background of breast carcinoma: an unexpected case of cervicofacial actinomycosisActinomycosis is an uncommon, chronic suppurative granulomatous infection and needs to be considered as a differential diagnosis. A 56-year-old woman with a background of type 2 diabetes mellitus and breast carcinoma was referred to the Oral and Maxillofacial Surgery 2-week wait clinic, regarding a tender sublingual mass and firm erythematous swelling in the right submandibular and submental region. This was slowly progressive and had not responded to oral co-amoxiclav. An orthopantomogram showed a well-defined radiolucency and smaller radiolucent lesions throughout the edentulous right body of the mandible. A contrast-enhanced CT confirmed a right submandibular abscess communicating with cavitating lesions. The differentials included osteomyelitis, bony metastases, multiple myeloma or other cystic lesions. The patient underwent incision and drainage of the abscess, alongside biopsies, and intravenous co-amoxiclav was given. Microbiology cultures confirmed the presence of Actinomyces israelii and a diagnosis of cervicofacial actinomycosis with mandibular osteomyelitis. The patient was successfully treated with prolonged antibiotics.
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Blood pressure monitoring in kidney transplantation: a systematic review on hypertension and target organ damageBackground: Sparse studies show that ambulatory blood pressure monitoring (ABPM) is superior to office BP (oBP) measurements to predict target organ damage and cardiovascular (CV) events in kidney transplant recipients (KTRs). We performed a systematic review aimed at determining the potential associations between BP recordings by different methods and renal and CV outcomes in this population. Methods: Major medical databases were searched for studies enrolling adult KTRs undergoing 24h ABPM compared to office or home BP measurements. Main outcomes were: associations between different BP recordings and renal and CV outcomes. Additionally, any association between the circadian BP pattern (dipping/non-dipping status) and outcomes was assessed. Results: Twenty-two studies (2078 participants) were reviewed. Amongst 12 studies collecting data on renal endpoints, ten studies found that BP assessed by ABPM was a stronger predictor of renal function decline, assessed by serum creatinine (SCr) and/or creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR), than traditional office measurements. Twelve studies analyzed the relation between different BP recordings and CV target organ damages and reported robust correlations between echocardiographic abnormalities [i.e. left ventricular mass index (LVM/LVMI)] and 24h ABPM, but not with office BPs. Furthermore, 24h ABPM correlated better than oBP with markers of vascular damage, such as carotid intima-media thickness (IMT), diffuse thickening, and endothelial dysfunction. Additionally, abnormal circadian BP pattern (non-dippers and reverse dippers) identified a group of kidney recipients at risk for kidney function loss and CV abnormalities. Conclusions: In our systematic review, ABPM reflected target organ damage more closely than oBP in KTRs. Furthermore, altered circadian BP profile associated with renal and CV target organ damages.
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Birmingham mandible and midface rules: determining variables for inclusion in a clinical predictor ruleStaff in emergency departments often rely on heuristics and algorithms to make clinical decisions on a wide range of problems. Clinical predictor rules such as the Ottawa ankle rules serve to reduce the need for unnecessary radiographs and help to give frontline staff the confidence to make a diagnosis. The current study aimed to achieve consensus on the variables to test for inclusion in a set of predictor rules for suspected fractures of the mandible and midface. A three-stage modified Delphi study was conducted of members and fellows of the British Association of Oral and Maxillofacial Surgeons (BAOMS). At the third stage, there was agreement of more than 51% to retain 11/35 of the suggested predictors for mandibular fractures and 14/28 of the midface predictors. To develop and validate clinical predictor rules for use by frontline staff, these variables will now form part of a prospective data gathering exercise at a major trauma centre.
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Biomarkers of liver injury during transplantation in an era of machine perfusionLiver ischaemia-reperfusion injury (IRI) is an intrinsic part of the transplantation process and damages the parenchymal cells of the liver including hepatocytes, endothelial cells and cholangiocytes. Many biomarkers of IRI have been described over the past two decades that have attempted to quantify the extent of IRI involving different hepatic cellular compartments, with the aim to allow clinicians to predict the suitability of donor livers for transplantation. The advent of machine perfusion has added an additional layer of complexity to this field and has forced researchers to re-evaluate the utility of IRI biomarkers in different machine preservation techniques. In this review, we summarise the current understanding of liver IRI biomarkers and discuss them in the context of machine perfusion.
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Bile duct injury during cholecystectomy: necessity to learn how to do and interpret intraoperative cholangiographyIntroduction: Biliary duct injury (BDI) is a serious complication during cholecystectomy. Perioperative cholangiography (POC) has recently been generating interest in order to prevent BDI. However, the current literature (including randomized controlled trials) cannot conclude whether POC is protective or not against the risk of BDI. The aim of our study was to investigate whether POC could demonstrate earlier BDI and which criteria are required to make that diagnosis. Methods: We performed a retrospective study between 2005 and 2018 in our French tertiary referral center, which included all patients who had presented following BDI during cholecystectomy. Results: Twenty-two patients were included. Nine patients had POC, whereas 13 did not. When executed, POC was interpreted as normal for three patients and abnormal for six. In this latter group, only two cases had a BDI diagnosed intraoperatively. In other cases, the interpretation was not adequate. Conclusion: BDIs are rare but may reduce patients' quality of life. Our study highlights the surgeon's responsibility to learn how to perform and interpret POC in order to diagnose and manage BDIs and potentially avoid catastrophic consequences.
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Basiliximab with delayed tacrolimus improves short-term renal outcomes post-liver transplantation - a real-world experienceBackground: Acute kidney injury (AKI) is common after liver transplantation (LT). Induction with interleukin-2 receptor antagonists is often used as a "renal-sparing" strategy. The aim of this study was to assess this approach in a real-world setting in an LT center. Methods: A retrospective cohort analysis of LTs between 2011 and 2018 was performed to assess the impact of a renal-sparing strategy using basiliximab in conjunction with mycophenolate mofetil and corticosteroids from day 0 post-LT along with delayed introduction of tacrolimus. This was compared with a group receiving tacrolimus, mycophenolate mofetil, and corticosteroids from the outset. Results: The renal-sparing regimen was associated with significantly lower incidence of all-stage AKI at day 7 post-LT (36% vs 55%, P = .006) and less decline in renal function at 3 months (39% vs 57%, P = .01). No further significant differences in renal outcomes were observed at other time points on follow-up to 1 year post-LT. There was no significant difference in the incidence of acute cellular rejection, inpatient length of stay or graft survival. The decision to adopt a renal-sparing regimen was predominantly made on a clinically reactive basis within the first 24 hours post-LT in 77%, and was preordained in 23%. Cost-effectiveness analysis did not find evidence of a significant cost saving when using a renal-sparing strategy. Conclusion: This study provides real-world analysis of the use of a renal-sparing immunosuppression regimen in LT. Although improvements in incidence of AKI in the short term were demonstrated, this did not translate to cost savings or improved renal outcomes after 3 months.
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Right sided shoulder pain in an adolescent: answerNo abstract available.