Dr Gray's Hospital

INTRODUCTION: The SCARE Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case reports and are used and endorsed by authors, journal editors and reviewers, in order to increase robustness and transparency in reporting surgical cases. They must be kept up to date in order to drive forwards reporting quality. As such, we have updated these guidelines via a DELPHI consensus exercise. METHODS: The updated guidelines were produced via a DELPHI consensus exercise. Members were invited from the previous DELPHI group, as well as editorial board members and peer reviewers of the International Journal of Surgery Case Reports. The expert group completed an online survey to indicate their agreement with proposed changes to the checklist items. RESULTS: A total of 54 surgical experts agreed to participate and 53 (98%) completed the survey. The responses and suggested modifications were incorporated into the new 2020 guideline. There was a high degree of agreement amongst the SCARE Group, with all modified SCARE items receiving over 70% scores 7-9. CONCLUSION: A DELPHI consensus exercise was completed and an updated and improved SCARE Checklist is now presented.

INTRODUCTION: The development of reporting guidelines over the past 20 years represents a major advance in scholarly publishing with recent evidence showing positive impacts. Whilst over 350 reporting guidelines exist, there are few that are specific to surgery. Here we describe the development of the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery). METHODS AND ANALYSIS: We published our protocol apriori. Current guidelines for case series (PROCESS), cohort studies (STROBE) and randomised controlled trials (CONSORT) were analysed to compile a list of items which were used as baseline material for developing a suitable checklist for surgical cohort guidelines. These were then put forward in a Delphi consensus exercise to an expert panel of 74 surgeons and academics via Google Forms. RESULTS: The Delphi exercise was completed by 62% (46/74) of the participants. All the items were passed in a single round to create a STROCSS guideline consisting of 17 items. CONCLUSION: We present the STROCSS guideline for surgical cohort, cross-sectional and case-control studies consisting of a 17-item checklist. We hope its use will increase the transparency and reporting quality of such studies. This guideline is also suitable for cross-sectional and case control studies. We encourage authors, reviewers, journal editors and publishers to adopt these guidelines.

The PROCESS Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case series in order to increase reporting robustness and transparency, and are used and endorsed by authors, journal editors and reviewers alike. In order to drive forwards reporting quality, they must be kept up to date. As such, we have updated these guidelines via a DELPHI consensus exercise. The updated guidelines were produced via a DELPHI consensus exercise. Members from the previous DELPHI group were again invited, alongside editorial board members and peer reviewers of the International Journal of Surgery and the International Journal of Surgery Case Reports. An online survey was completed by this expert group to indicate their agreement with proposed changes to the checklist items. A total of 53 surgical experts agreed to participate and 49 (92%) completed the survey. The responses and suggested modifications were incorporated into the previous 2018 guidelines. There was a high degree of agreement amongst the PROCESS Group, with all but one of the PROCESS items receiving over 70% of scores ranging 7–9. A DELPHI consensus exercise was completed and an updated and improved PROCESS Checklist is now presented. • This was a DELPHI consensus exercise to update the PROCESS guidelines. • Of the invited surgical experts, 49 (92%) completed the survey. There was a high level of agreement in the PROCESS Group. • The survey responses were incorporated as modifications and an improved PROCESS Checklist is now presented for use.

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

The American Heart Association makes every effort to avoid any actual or potential

STUDY DESIGN: The influence of ketorolac on spinal fusion was studied in a retrospective review of 288 patients who underwent an instrumented spinal fusion. OBJECTIVE: To assess the effect of postoperative ketorolac administration on subsequent fusion rates. SUMMARY OF BACKGROUND DATA: Nonsteroidal anti-inflammatory drugs are widely used compounds, which are known to inhibit osteogenic activity and have been shown to decrease spinal fusion in an animal model. No previous studies have examined the influence of nonsteroidal anti-inflammatory drugs on spinal fusion in clinical practice. METHODS: The medical records of 288 patients who underwent instrumented spinal fusion from L4 to the sacrum between 1991 and 1993 were reviewed retrospectively. The 121 patients who received no nonsteroidal anti-inflammatory drugs were compared with the 167 patients who received ketorolac after surgery. The groups were demographically equivalent. RESULTS: Ketorolac had a significant adverse effect on fusion, with five nonunions in the nondrug group and 29 nonunions in the ketorolac group (P > 0.001). Ketorolac administration also significantly decreased the fusion rate for subgroups including men, women, smokers, and nonsmokers. The odds ratio demonstrated that nonunion was approximately five times more likely after ketorolac administration. Cigarette smoking also decreased the fusion rate (P > 0.01); smokers were 2.8 times more likely to develop nonunion. CONCLUSION: These data suggest that nonsteroidal anti-inflammatory drugs significantly inhibit spinal fusion at doses typically used for postoperative pain control. The authors recommend that these drugs be avoided in the early postoperative period.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist.

STUDY DESIGN: Thirty-seven patients who experienced visual loss after spine surgery were identified through a survey of the members of the Scoliosis Research Society and a review of the recent literature. OBJECTIVES: Records were reviewed in an attempt to identify preoperative and intraoperative risk factors and to assess the likelihood of recovery. SUMMARY OF BACKGROUND DATA: Postoperative blindness after spine surgery has been documented in case reports or small series. The authors report the largest group of such cases to date and the first to allow conclusions regarding risk and prognosis. METHODS: Letters were sent to members of the Scoliosis Research Society requesting copies of medical records concerning patients who experienced postoperative visual deficits after spine surgery. An additional 10 well-documented recent cases were identified from published reports. RESULTS: Patients with visual loss had a mean age of 46.5 years. Surgery included instrumented posterior fusion in 92% of the cases, with an average operative time of 410 minutes and blood loss of 3500 mL. Most cases had significant intraoperative hypotension, with a mean drop in systolic blood pressure from 130 to 77 mm Hg. However, comparison with a matched group of patients with no visual symptoms showed no differences in the hematocrit or blood pressure values. Visual loss occurred because of ischemic optic neuropathy, retinal artery occlusion, or cerebral ischemia. Eleven cases were bilateral, and 15 patients had complete blindness in at least one eye. Most deficits were permanent. CONCLUSIONS: The authors conclude that blindness after spine surgery is more common than has been recognized previously. Most cases are associated with complex instrumented fusions.

STUDY DESIGN: This study retrospectively reviewed instrumented lumbar fusions complicated by surgical wound infection and managed by a protocol including antibiotic impregnated beads. OBJECTIVE: To evaluate the potential for an acceptable clinical outcome in cases of instrumented lumbar fusion complicated by wound infection. SUMMARY OF BACKGROUND DATA: Initial studies of pedicle screw instrumentation suggested an increased infection rate versus noninstrumented fusion. The presence of a metallic implant also complicates wound management. METHODS: Eight hundred fifty-eight instrumented fusions were reviewed with 22 (2.6%) deep wound infections identified. Analysis included preoperative risk factors, surgical procedure, postoperative course, and clinical outcome. RESULTS: Nineteen patients (mean age, 55 years) were reviewed at a minimum of 1 year after surgery. Sixteen (83%) reported significant preoperative health problems. Forty-seven percent of the patients had three- and four-level fusions. Mean operative time was 342 minutes. Mean estimated blood loss was 1620 mL. Infection was diagnosed at an average of 16 days after surgery with wound drainage as the most common presenting feature. Patients underwent between two and 10 (mean, 4.7) irrigation procedures. Seven patients had other significant noninfectious complications. At follow-up evaluation, no patient had recurrence of infection. By comparison to preoperative symptoms, 15 patients were improved, three were unchanged, and one deteriorated. Fusion was apparently solid in 14 patients, probable in four patients, and nonunion occurred in one patient. CONCLUSION: Although wound infection is a significant complication, this study suggests that aggressive surgical management can result in preservation of an adequate fusion rate and maintenance of an acceptable postoperative outcome.

AIM: The aim of this review was to critically appraise the evidence on the impact of periodontal treatment of cardiovascular diseases (CVDs) biomarkers and outcomes. METHODS: A systematic search was performed in Cinhal, Cochrane, Embase and Medline for relevant articles up to July 2012. Duplicate screening and reference hand searching were performed. Data were then summarized and evidence graded in tables. RESULTS: The search resulted in: (a) no evidence on the effects of periodontal therapy on subclinical atherosclerosis, serum levels of CD40 ligand, serum amyloid A and monocyte chemoattractant protein-1, (b) limited evidence on the effects of periodontal therapy on arterial blood pressure, leucocyte counts, fibrinogen, tissue necrosis factor-a, sE-selectin, von Willebrand factors, d-dimers, matrix metalloproteinases, oxidative stress and CVD events, and (c) moderate evidence suggesting a negligible effect of periodontal therapy in reducing interleukin-6 and lipids levels, whilst a positive effect in reducing serum C-reactive protein levels and improving endothelial function. CONCLUSIONS: Periodontal therapy triggers a short-term inflammatory response followed by (a) a progressive and consistent reduction of systemic inflammation and (b) an improvement in endothelial function. There is however limited evidence that these acute and chronic changes will either increase or reduce CVD burden of individuals suffering from periodontitis in the long term.

STUDY DESIGN: This was a prospective study to determine the potential effects of indomethacin on spinal fusions in the rat. OBJECTIVES: To determine if indomethacin exerts a deleterious effect on spinal fusions in the rat model. SUMMARY OF BACKGROUND DATA: Nonsteroidal anti-inflammatory drugs are a class of compound that affect bone osteogenesis during fracture healing and heterotopic ossification. Spinal fusion is a process that occurs via osteogenesis and, therefore, may be similarly affected. METHODS: Thirty-nine adult, Sprague-Dawley rats underwent a three-level posterior spinal fusion. Fusion was performed using morselized autogenous vertebral bone graft obtained via caudectomy and stabilized using a cerclage wiring technique. The 39 rats were divided into two groups consisting of 17 study animals and 22 control animals. The control group was injected with 1.5 cc of 0.9 normal saline subcutaneously for 12 weeks, whereas the test animals were injected on an identical schedule using 3 mg/kg of indomethacin sodium salt. Two control animals died, and three animals in the treatment group died of drug-related complications. Twelve weeks after surgery, all animals were killed, and the involved spinal segments were evaluated by direct manual examination. A fusion was probable if the spinal segments exhibited decreased scaled micromotion. RESULTS: Sixty segmental levels in 20 control animals were assessed. Overall, 27 of 60 levels (45%) achieved fusion. In the indomethacin-treated group, 42 levels in 14 animals were evaluated. Overall, four of 42 levels (10%) achieved a fusion. Chi-square analysis demonstrated a significant difference (P < 0.001) between the control and indomethacin-treated groups. CONCLUSIONS: This study raises serious questions about the inhibitory effects of nonsteroidal anti-inflammatory drugs on spinal fusion. Clinically, the widespread use of nonsteroidal anti-inflammatory drugs in the postoperative period after spinal fusion may need to be avoided.

Although evidence suggests that primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in the majority of patients with ST-segment-elevation myocardial infarction (STEMI), only a minority of patients with STEMI are treated with primary PCI, and of those, only a minority receive the treatment within the recommended 90 minutes after entry into the medical system. Market research conducted by the American Heart Association revealed that those involved in the care of patients with STEMI recognize the multiple barriers that prevent the prompt delivery of primary PCI and agree that it is necessary to develop systems or centers of care that will allow STEMI patients to benefit from primary PCI. The American Heart Association will convene a group of stakeholders (representing the interests of patients, physicians, emergency medical systems, community hospitals, tertiary hospitals, and payers) and quality-of-care and outcomes experts to identify the gaps between the existing and ideal delivery of care for STEMI patients, as well as the requisite policy implications. Working within a framework of guiding principles, the group will recommend strategies to increase the number of STEMI patients with timely access to primary PCI.

The incidence of head and neck squamous cell carcinoma (HNSCC) has been gradually increasing over the last three decades. Recent data have now attributed a viral aetiology to a subset of head and neck cancers. Several studies indicate that oral human papillomavirus (HPV) infection is likely to be sexually acquired. The dominance of HPV 16 in HPV+ HNSCC is even greater than that seen in cervical carcinoma of total worldwide cases. Strong evidence suggests that HPV+ status is an important prognostic factor associated with a favourable outcome in head and neck cancers. Approximately 30 to 40% of HNSCC patients with present with early stage I/II disease. These patients are treated with curative intent using single modality treatments either radiation or surgery alone. A non-operative approach is favored for patients in which surgery followed by either radiation alone or radiochemotherapy may lead to severe functional impairment. Cetuximab, a humanized mouse anti-EGFR IgG1 monoclonal antibody, improved locoregional control and overall survival in combination with radiotherapy in locally advanced tumours but at the cost of some increased cardiac morbidity and mortality. Finally, the improved prognosis and treatment responses to chemotherapy and radiotherapy by HPV+ tumours may suggest that HPV status detection is required to better plan and individualize patient treatment regimes.

Mutations in the gene (GJB2) encoding connexin 26 (cx26) have been linked to sensorineural hearing loss either alone or as part of a syndrome. Here we compare the properties of four cx26 mutants derived from point mutations associated with dominantly inherited hearing loss, either non-syndromic (W44S, R75W) or with various skin disorders (G59A, D66H, R75W). Since cx26 and cx30 are co-localized within the inner ear the effect of the dominant cx26 mutations on both of these wild-type proteins was determined. Communication-deficient HeLa cells were transiently transfected with the various cDNA constructs by microinjection. Dye transfer studies using the gap junction permeant tracer Cascade Blue demonstrated a disruption to the intercellular coupling for all four of the mutant proteins. Immunostaining of the transfected cells revealed that for the G59A and D66H mutants this correlated with impaired intracellular trafficking and targeting to the plasma membrane, as both proteins had a perinuclear localization. The impaired trafficking was rescued by oligomerization both with cx26 and with cx30, suggesting that cx26 and cx30 can form heteromeric connexons. Significantly reduced dye transfer rates were observed between cells co-expressing either cx26 or cx30 together with W44S or R75W compared with the wild-type proteins alone. The dominant actions of the G59A and D66H mutants were only on cx30 and cx26, respectively. We suggest that cx26 and cx30 form heteromeric connexons in vivo, within the inner ear, with particular properties essential for hearing. Disruption of these heteromeric channels by certain mutations may underlie the non-syndromic nature of the deafness.

STUDY DESIGN: Fifty-six residents with cerebral palsy and significant scoliosis or kyphosis at the Hazelwood Center in Louisville, Kentucky were studied periodically using radiographs to assess the degree of scoliosis, kyphosis, and pelvic obliquity and by clinical evaluation to assess functional status and skin condition. OBJECTIVES: This study followed the natural history of untreated scoliosis to determine whether a decline in functional status is related to curve progression and whether the development of decubiti is associated with the degree of pelvic obliquity. Identifying the factors that affect functional decline may help develop treatment plans to minimize it. SUMMARY OF BACKGROUND DATA: Significant structural deformities of the spine often accompany cerebral palsy. Despite the relatively large number of cases, little is known about the natural history of untreated scoliosis in the adult cerebral palsy population. Theoretically, curve progression will lead to pain, loss of ambulation or sitting balance, or even cardiopulmonary compromise, but few studies have been done to verify this. METHODS: Single-factor analysis of variance was used to compare the curve progression rate within groups based on the structure of the curve, and the two-sample student t test was used to compare the average initial curve, the average final curve, the progression rate, and the amount of progression between groups based on functional decline. The two sample t test also was used to correlate the average pelvic obliquity and the size of the final curve with the presence or absence of decubiti. RESULTS: Functionally, 10 patients (18%) declined during the course of the study. In these 10 patients, the average initial curve was 41.1 degrees, the average final curve was 80.6 degrees, and the average progression rate was 4.4 degrees per year. For the stable patients, the average initial curve was 33.9 degrees, the average final curve was 56.5 degrees, and the average progression rate was 3.0 degrees per year. The differences between the final curve and the absolute amount of progression were statistically significant (P = 0.018 and P = 0.03, respectively). Three patients developed decubiti. Their curve averaged 106 degrees, and their pelvic obliquity measured 45 degrees, both of which were significantly higher than those of the patients without decubiti. CONCLUSIONS: The results of the present study demonstrate that in the adult patient with cerebral palsy and scoliosis, a definite correlation exists between deformity size and functional decline and decubiti. Progression rate also seems to be a factor in functional decline. Additional studies are needed to determine whether surgical intervention will halt or reverse the decline.

Transient receptor potential (TRP) channels TRPC3 and TRPC6 are expressed in both sensory neurons and cochlear hair cells. Deletion of TRPC3 or TRPC6 in mice caused no behavioural phenotype, although loss of TRPC3 caused a shift of rapidly adapting (RA) mechanosensitive currents to intermediate-adapting currents in dorsal root ganglion sensory neurons. Deletion of both TRPC3 and TRPC6 caused deficits in light touch and silenced half of small-diameter sensory neurons expressing mechanically activated RA currents. Double TRPC3/TRPC6 knock-out mice also showed hearing impairment, vestibular deficits and defective auditory brain stem responses to high-frequency sounds. Basal, but not apical, cochlear outer hair cells lost more than 75 per cent of their responses to mechanical stimulation. FM1-43-sensitive mechanically gated currents were induced when TRPC3 and TRPC6 were co-expressed in sensory neuron cell lines. TRPC3 and TRPC6 are thus required for the normal function of cells involved in touch and hearing, and are potential components of mechanotransducing complexes.

Thirty-three patients were diagnosed by hysterosalpingography and laparoscopy as having septate uteri, which were assumed to be responsible for their infertility, recurrent abortions, or premature labor. Fourteen of these had Tompkins metroplasty (group 1) while the other 19 had their repairs done by hysteroscopic metroplasty (group 2). Post-operative hysterosalpingography for patients in group 1 revealed normal uterine cavities in 72%, incomplete septum excision in 14%, and intrauterine filling defects in 14%. The corresponding figures in group 2 were 88, 12, and 0%. In group 1, 71.0% became pregnant; of these, 70% continued to term (with delivery by cesarean section), 20% aborted, and 10% were tubal pregnancies. In group 2, 84% became pregnant; of these, 87% had term vaginal deliveries, and 13% miscarried. Patients in group 2 had less operative time, less blood loss, and shorter hospital stays. These findings demonstrate that hysteroscopic metroplasty may be preferable to the transabdominal procedure based on cost and morbidity considerations as well as on anatomic and reproductive outcome.

Thallium-201 (201Tl) redistribution scintigraphy might differentiate reversibly from nonreversibly asynergic myocardial segments and thus predict the response of these segments to coronary artery bypass grafting (CABG). To test this hypothesis, 25 consecutive patients undergoing CABG, preoperative stress-redistribution 201Tl scintigraphy, and both pre- and postoperative resting equilibrium radionuclide ventriculography were evaluated. For both types of scintigraphic study, each patient was imaged in the same three views. Because of the effects of CABG on septal motion, this region was considered separately. Postoperative improvement was noted in 54% of 72 preoperative asynergic segments. Improvement was common not only in hypokinetic but also in akinetic and dyskinetic segments, and occurred in a similar proportion of studies performed early (less than 2 weeks) or late (3-6 months) after CABG. Thallium-201 redistribution scintigraphy was highly predictive of the pattern of postoperative asynergy: The redistribution pattern was normal in 90% of segments with reversible asynergy and abnormal in 76% of segments with nonreversible asynergy. The presence or absence of pathologic Q waves was less sensitive in this differentiation. Septal segments, however, frequently demonstrated abnormal wall motion postoperatively, despite normal 201Tl redistribution scintigraphy. Resting left ventricular ejection fraction (LVEF) was generally unchanged postoperatively, but in some patients with multiple areas of reversible asynergy it did improve. Thus, 201Tl redistribution scintigraphy appears to reliably distinguish viable from nonviable asynergic myocardial zones, and predicts the response of these segments to CABG.

BACKGROUND: Tacrolimus has been shown to have a less adverse effect on the lipid profiles of transplant patients when the drug is started as induction therapy. In order to determine the effect tacrolimus has on lipid profiles in stable cyclosporine-treated renal transplant patients with established hyperlipidemia, a randomized prospective study was undertaken by the Southeastern Organ Procurement Foundation. METHODS: Patients of the 13 transplant centers, with cholesterol of 240 mg/dl or greater, who were at least 1 year posttransplant with stable renal function, were randomly assigned to remain on cyclosporine (control) or converted to tacrolimus. Patients converted to tacrolimus were maintained at a level of 5-15 ng/ml, and control patients remained at their previous levels of cyclosporine. Concurrent immunosuppressants were not changed. Levels of total cholesterol, triglycerides, total high-density lipoprotein, low-density lipoprotein (LDL), very-low-density lipoprotein, and apoproteins A and B were monitored before conversion and at months 1, 3, and 6. Renal function and glucose control were evaluated at the beginning and end of the study (month 6). RESULTS: A total of 65 patients were enrolled; 12 patients failed to complete the study. None were removed as a result of acute rejection or graft failure. Fifty-three patients were available for analysis (27 in the tacrolimus group and 26 controls). Demographics were not different between groups. In patients converted to tacrolimus treatment, there was a -55 mg/dl (-16%) (P=0.0031) change in cholesterol, a -48 mg/dl (-25%) (P=0.0014) change in LDL cholesterol, and a -36 mg/dl (-23%) (P=0.034) change in apolipoprotein B. There was no change in renal function, glycemic control, or incidence of new onset diabetes mellitus in the tacrolimus group. CONCLUSION: Conversion from cyclosporine to tacrolimus can be safely done after successful transplantation. Introduction of tacrolimus to a stable renal patient does not effect renal function or glycemic control. Tacrolimus can lower cholesterol, LDL, and apolipoprotein B. Conversion to tacrolimus from cyclosporine should be considered in the treatment of posttransplant hyperlipidemia.

This cephalometric study was undertaken to compare and contrast the errors involved in taking linear and angular measurements using three different methods; hand instruments on tracings, digitization of tracings, and direct digitization of the radiographs. Of the three methods direct digitization of the radiographs proved to be the most reproducible particularly with angular measurements, although statistically significant differences were rarely found. Tracings were advantageous only with linear measurements involving constructed points such as Gonion and Articulare. Traditional methods of measurement using a ruler and protractor compared well with computer based methods involving the digitizer.