Friarage Hospital

Abstract Objective : To investigate the role of sleeping arrangements as risk factors for the sudden infant death syndrome after a national risk reduction campaign. Design : Two year population based case-control study. Parental interviews were conducted for each infant who died and for four controls matched for age and date of interview. Setting : Three regions in England with a total population of 17 million people. Subjects : 195 babies who died and 780 matched controls. Results : Prone and side sleeping positions both carried increased risks of death compared with supine when adjusted for maternal age, parity, gestation, birth weight, exposure to smoke, and other relevant factors in the sleeping environment (multivariate odds ratio = 9.00 (95% confidence interval 2.84 to 28.47) and 1.84 (1.02 to 3.31), respectively). The higher incidence of side rather than prone sleeping led to a higher population attributable risk (side 18.4%, prone 14.2%). More of the infants who died were found with bed covers over their heads (21.58; 6.21 to 74.99). The use of a dummy had an apparent protective effect (0.38; 0.21 to 0.70). Bed sharing for the whole night was a significant risk factor for infants whose mothers smoked (9.25; 2.31 to 34.02). No protective effect of breast feeding could be identified on multivariate analysis. Conclusions : This study confirms the importance of certain risk factors for the sudden infant death syndrome and identifies others—for example, covers over the head, side sleeping position—which may be amenable to change by educating and informing parents and health care professionals. Key messages This large case-control study is the first after the national campaign to reduce the risk of the syndrome The risk of sudden infant death is increased by prone or side sleeping position; loose bedding (particularly duvets), which can slip over the baby's head; and bed sharing by mothers who smoke The risk may be reduced by supine sleeping position; placing the baby with feet at the foot of the cot (“feet to foot”); ensuring that bedding is securely tucked in; and avoiding the use of duvets

OBJECTIVE: To investigate the effects of exposure to tobacco smoke and of parental consumption of alcohol and illegal drugs as risk factors for the sudden infant death syndrome after a national risk reduction campaign which included advice on prenatal and postnatal avoidance of tobacco smoke. DESIGN: Two year population based case-control study. Parental interviews were conducted for each infant who died and four controls matched for age and date of interview. SETTING: Three regions in England with a total population of 17 million people. SUBJECTS: 195 babies who died and 780 matched controls. RESULTS: More index than control mothers (62.6% v 25.1%) smoked during pregnancy (multivariate odds ratio = 2.10; 95% confidence interval 1.24 to 3.54). Paternal smoking had an additional independent effect when other factors were controlled for (2.50; 1.48 to 4.22). The risk of death rose with increasing postnatal exposure to tobacco smoke, which had an additive effect among those also exposed to maternal smoking during pregnancy (2.93; 1.56 to 5.48). The population attributable risk was over 61%, which implies that the numbers of deaths from the syndrome could be reduced by almost two third if parents did not smoke. Alcohol use was higher among index than control mothers but was strongly correlated with smoking and on multivariate analysis was not found to have any additional independent effect. Illegal drug use was more common among the index parents, and paternal use of illegal drugs remained significant in the multivariate model (4.68; 1.56 to 14.05). CONCLUSIONS: This study confirms the increased risk of the sudden infant death syndrome associated with maternal smoking during pregnancy and shows evidence that household exposure to tobacco smoke has an independent additive effect. Parental drug misuse has an additional small but significant effect.

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.

BACKGROUND: Previous reviews have highlighted the benefit of loaded therapeutic exercise in the treatment of tendinopathy. Changes in observable structural outcomes have been suggested as a possible explanation for this response to therapeutic exercise. However, the mechanism for the efficacy of therapeutic exercise remains unclear. OBJECTIVE: To systematically review the relationship between the observable structural change and clinical outcomes following therapeutic exercise. DATA SOURCES: An electronic search of AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to June 2012. STUDY ELIGIBILITY CRITERIA: Any study design that incorporated observable structural outcomes and clinical outcomes when assessing the effect of therapeutic exercise on participants with tendinopathy. STUDY APPRAISAL AND SYNTHESIS METHODS: Included studies were appraised for risk of bias using the tool developed by the Cochrane Back Review Group. Due to heterogeneity of studies, a qualitative synthesis was undertaken. RESULTS: Twenty articles describing 625 patients were included. Overall, there is a strong evidence to refute any observable structural change as an explanation for the response to therapeutic exercise when treated by eccentric exercise training. Moderate evidence does exist to support the response of heavy-slow resistance training (HSR). CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: The available literature does not support observable structural change as an explanation for the response of therapeutic exercise except for some support from HSR. Future research should focus on indentifying other explanations including neural, biochemical and myogenic changes. REGISTRATION NUMBER: Registered with PROSPERO, registration number CRD42011001638.

Recurrent dislocation, subluxation and functional instability due to patellofemoral pain might be present in 30 % to 60 % of patients managed non-operatively for posttraumatic patella instability. Disruption of the capsule, medial patella retinaculum and/or vastus medialis obliquus have been associated with recurrent patella instability but recently the medial patellofemoral ligament (MPFL) has been recognised as the most important ligamentous stabiliser preventing lateral dislocation of the patella. Many nonanatomical surgical techniques for the treatment of recurrent patellar dislocation have been described in the literature. These procedures alter the pre-morbid patella mechanics by several principles, including the release of tight lateral ligaments, tensioning of loose medial structures and distal realignment of the extensor mechanism or a combination of these. Very few address the principle site of pathology in patella dislocation, i.e., the torn MPFL. The outcomes are inconsistent and many studies have reported recurrent dislocations and patellofemoral pain and arthritis in up to 40 %. We describe a simple technique of MPFL reconstruction using a single hamstring tendon graft which is passed through the medial intermuscular septum at the adductor's magnus insertion and is fixed to the superomedial pole of the patella. A comprehensive review of the existing techniques of MPFL reconstruction using semitendinosus tendon autografts is also provided.

OBJECTIVES: The ongoing conflict in Afghanistan continues to generate a large number of complex trauma injuries and provides unique challenges to military anesthetists working in forward field hospitals. We report successful use of ultrasound-guided continuous transversus abdominis plane (TAP) block in two Afghan war casualties who sustained major trauma with coagulopathy. The use of bilateral continuous TAP blocks following major thoracoabdominal trauma in a combat environment is unique in the literature. DESIGN: Case report. RESULTS: The acute perioperative outcomes of two Afghan civilian patients were improved with bilateral continuous TAP blocks. Multiple benefits shared by both patients included early extubation, excellent analgesia, and minimal post-operative morphine requirements despite the setting of a massive blood transfusion and coagulopathy. CONCLUSIONS: A continuous TAP block technique can be utilized to provide excellent analgesia following major abdominal surgery when neuraxial anesthesia is contraindicated. The TAP block's ease of placement under ultrasound guidance makes this technique particularly useful in the austere battlefield hospital environment.

Objective: To use principal-components analysis to obtain a shorter and therefore more clinically useful version of the Coping Strategies Questionnaire (CSQ). Subjects: A British sample of 214 chronic back pain patients attending outpatient spinal assessment. Results: A 4-factor solution was discovered that incorporates Catastrophizing, Diversion, Cognitive Coping, and Reinterpreting factors. Apart from the absence of a Praying and Hoping factor, this solution is similar to those previously found by researchers in this field. Conclusions: The new questionnaire (the CSQ24) is a valid utilitarian version of the CSQ that is easy to score and is appropriate for clinical use. In recent years, the effective management of chronic musculo-skeletal pain, especially chronic low back pain (CLBP), has be-come a topical area of research. This is primarily because of a significant increase in the number of people seeking treatment for this condition (Clinical Standards Advisory Group, 1994) and a realization that the majority of common treatment options are unsuccessful (Barton, 2000; Clinical Standards Advisory Group, 1994; Evans &amp;amp; Richards, 1996). Specifically, the observation that

Diurnal patterns of variation in peak expiratory flow rate were studied in patients with all types of airway obstruction. Most regular patterns fall into one of two types: morning dip (M) with the lowest reading in the morning and (P) or double dip with the lowest readings morning and evening. Regular patterns were most frequently seen in asthmatics, but occurred also in bronchitis, particularly those with a history of wheeze. Treatment with bronchodilators reduces the prevalence of all regular patterns but does not abolish them. M pattern is characteristic of asthma but P pattern is the most frequent regular pattern seen in bronchitis. Amplitude of variation is greater in asthmatics than in simple bronchitis. It is reduced by about 20% with bronchodilators. Random observation of magnitude of response of peak flow rate to a bronchodilators is not a good indicator of amplitude of variation over the day. Because of the occurrence of a peak pattern in many patients the magnitude of diurnal variation may be underestimated by twice-daily peak flow rate readings. Treatment with corticosteroids does not appear strongly to influence either characteristic patterns or amplitude of variation.

BACKGROUND: Working for the UK National Health Service (NHS) requires working for organisations under financial pressures and frequent restructures, which can lead to anxiety over continuing employment and income. There are currently no studies to date that have examined the influence of personal resilience across all professions and demographics in the NHS. This study aims to quantify resilience within an NHS trust and explore the contribution of demographic variables of gender, age, years of service, pay grade, hours worked, job role, and division worked to the resilience response of employees. The study also explores the relationship between resilience levels and absence rates, as a marker for health and well-being amongst NHS staff. METHODS: This study consists of a cross-sectional on-line survey of staff employed in an NHS Trust. All trust employees were asked to complete a Resilience Scale (RS-25), and demographic questions including age, sex, length of service, NHS pay grade (banding), division, job role and number of hours worked per week. Trust level sickness absence rates were also collected during this period. Results were analysed using descriptive statistics, bivariate comparisons and chi-squared tests. RESULTS: Data was gained from 845 employees; a significant association between gender and resilience found females scoring higher on the resilience scale; x (2)(5) =18.30, p < 0.05. A weak positive correlation between age and resilience found older employees displaying a higher level of resilience; r = 0.11, p <0.05. Results also suggest employees working between 18.75-37.5 hours a week have higher levels of resilience. Ancillary staff scored low on resilience compared to all other staff groups which showed moderate resilience. Clinical staff scored lower on resilience compared to both administrative staff and clinical staff with line management responsibilities. No correlations were found between absence rates and resilience. CONCLUSION: This study gives a snapshot of the resilience of employees in a NHS trust. It is the first of its kind to take into consideration all job roles, divisions and the banding system within a trust. The results also indicate that resilience levels may not be a mediating factor for the health and well-being of NHS staff.

Key content Torsion of the ovary, tube or both is estimated to be responsible for only a small number of all gynaecological emergencies, but is a common diagnostic challenge in the emergency setting. Diagnosis can be difficult and is mainly based on clinical symptoms and imaging techniques such as ultrasound and MRI. A normal ultrasound scan does not exclude adnexal torsion and the decision to operate should be made on clinical grounds if symptoms are severe. Treatment is traditionally surgical removal of the ovary or adnexum, however, there is increasing evidence for conservative surgery, such as de‐torsion and oophoropexy, particularly in younger women. This article provides an overview of the symptomatology, ultrasound diagnosis and classification, as well as treatment options for ovarian torsion. Learning objectives To understand the clinical presentation and ultrasound characteristics associated with ovarian torsion. To review the literature on the available surgical options. Ethical issues Oophorectomy is commonly performed for adnexal torsion with a possible negative impact on fertility in women of reproductive age. De‐torsion is a more conservative surgical approach that should be considered in all younger women with ovarian torsion.

<h3>Introduction:</h3> Malignant mesothelioma is a fatal neoplasm, which is rapidly increasing in incidence throughout Western Europe. To date there have been no studies reporting on the natural history and interventional practices on a comprehensive unselected population, as opposed to reports from referral institutions or compensation claimants. We present a population based study capturing data on all patients with mesothelioma presenting within a defined geographical area over a 4 year period in the UK. <h3>Method:</h3> Data of all cases occurring in Leeds with a population of 750 000 were collected retrospectively from 2002 to 2003 and prospectively from 2004 to 2005. All patients’ hospital records and the Trust histology database were reviewed, as well as coroner’s reports on all patients with a post mortem diagnosis of mesothelioma. <h3>Results:</h3> Over the 4 year study period, there were a total of 146 cases in Leeds; 77% were male. Median age was 74 years (range 36–93). Median survival from diagnosis was 8.9 months. 92% and 8% had histological or cytological confirmation, respectively. 85% had documented evidence of definite or probable exposure to asbestos. 110/146 (75%) had symptomatic pleural effusions at presentation. Twice the number of patients (42 vs 17) were managed with surgical rather than bedside pleurodesis and these had a lower recurrence rate (14% vs 47%; p = 0.02). 122 patients had video assisted thoracoscopic surgery/cutting CT biopsies or chest drains. 73/122 (60%) had prophylactic radiotherapy to these sites. There were seven cases (5%) of tract invasion by tumour and six of these had received prophylactic radiotherapy. Median time to seeding was 174 days. 92/146 (63%) had a performance status of 2 or better at diagnosis but only 54/146 were considered fit for chemotherapy. Of these, 28 (52%) declined chemotherapy; the overall uptake of chemotherapy or entry into a trial was 18%. No patient had radical surgery. <h3>Conclusion:</h3> This comprehensive population based audit has shown that the median age at presentation of malignant mesothelioma is increasing and baseline performance status and survival is worse than in selected series. 37% of patients were considered suitable for palliative chemotherapy but less than 20% accepted this offer. Thorascopic pleurodesis appears to be associated with fewer recurrences. The role of prophylactic radiotherapy to chest drain and biopsy sites needs reappraisal.

Frostbite is a thermal injury that can occur when temperatures drop low enough for tissue to freeze. On rewarming the tissues, an inflammatory process develops which is often associated with tissue loss. The extent of the tissue loss reflects the severity of the cold exposure and includes factors such as temperature, duration, wind chill, altitude, and systemic hypothermia. This review discusses the epidemiology, the pathophysiological processes involved, and the clinical management of frostbite injuries. Practical advice is given on both the field and hospital management and how to seek expert advice from remote situations. The review also discusses newer developments in frostbite treatment such as intra-vascular thrombolysis and adjunctive treatments such as the use of intravenous vasodilators.

A collection of Streptococcus zooepidemicus strains from human and animal infections was examined for DNA banding patterns after nuclease digestion and agarose gel electrophoresis. The large variety of DNA fingerprints found revealed the complexity of the species but showed that isolates from clusters of outbreaks had identical prints. The results confirmed the specificity of bacteriocin and bacteriophage typing of S. zooepidemicus; the technique also gave useful profiles on untypable strains. Strains with common bacteriocin and biotyping patterns from sporadic infections could be differentiated by their DNA fingerprints. In several outbreaks and incidents, more than one strain of S. zooepidemicus were encountered, and the importance of carefully interpreting typing data is stressed. Chromosomal DNA fingerprinting is a very efficient technique for demonstrating differences between strains of S. zooepidemicus, and its use is recommended for future epidemiological studies of this infectious agent.

Patients facing operation need good information. This is implicit in informed consent but it is often lacking. A solution is a comprehensive set of leaflets covering 65 different general surgical operations. The leaflets describe the illness, operation, exact management regimen, some complications and outlook, in a deliberately simple style. Master copies are stored on a wordprocessor to allow unlimited expansion and updating. A retrospective survey of 200 patients showed that those receiving leaflets were significantly more satisfied with information (72 per cent overall) than those not receiving leaflets (42 per cent overall) (P less than 0.01). This was especially apparent for information about postoperative progress, both in hospital (92 per cent versus 52 per cent) and after discharge from hospital (88 per cent versus 39 per cent). The system is effective, cheap and popular with patients and medical and nursing staff. The wordprocessor allows extensive modifications of the information to suit other surgeons' requirements.

PURPOSE: To assess the diagnostic test accuracy of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and computed tomography arthrography (CTA) for the detection of chondral lesions of the patellofemoral and tibiofemoral joints. METHODS: A review of published and unpublished literature sources was conducted on 22nd September 2011. All studies assessing the diagnostic test accuracy (sensitivity/specificity) of MRI or MRA or CTA for the assessment of adults with chondral (cartilage) lesions of the knee (tibiofemoral/patellofemoral joints) with surgical comparison (arthroscopic or open) as the reference test were included. Data were analysed through meta-analysis. RESULTS: Twenty-seven studies assessing 2,592 knees from 2,509 patients were included. The findings indicated that whilst presenting a high specificity (0.95-0.99), the sensitivity of MRA, MRI and CTA ranged from 0.70 to 0.80. MRA was superior to MRI and CTA for the detection of patellofemoral joint chondral lesions and that higher field-strength MRI scanner and grade four lesions were more accurately detected compared with lower field-strength and grade one lesions. There appeared no substantial difference in diagnostic accuracy between the interpretation from musculoskeletal and general radiologists when undertaking an MRI review of tibiofemoral and patellofemoral chondral lesions. CONCLUSIONS: Specialist radiological imaging is specific for cartilage disease in the knee but has poorer sensitivity to determine the therapeutic options in this population. Due to this limitation, there remains little indication to replace the 'gold-standard' arthroscopic investigation with MRI, MRA or CTA for the assessment of adults with chondral lesions of the knee. LEVEL OF EVIDENCE: II.

The aetiopathogenesis of haemorrhagic shock encephalopathy syndrome (HSES) remains unclear and after concern that a novel environmental agent was the cause, the British Paediatric Association and the Public Health Laboratory Service Communicable Disease Surveillance Centre in 1983 initiated surveillance of this condition in the British Isles. After 1986 cases were ascertained via the British Paediatric Surveillance Unit 'active' reporting scheme; this report presents the findings for 1985-8. Sixty five patients were reported, of whom 52 satisfied the criteria for inclusion. Of those whose outcome was known, 24 (46%) died, 18 had severe neurological damage, and six survived apparently intact. Epidemiological features of note were: the median age of 15 weeks (range 3-140); statistically significant clustering of admission times suggesting a peak onset period at night; lack of geographic clusters, of secular trends and, except for a slight excess in winter months, of seasonality. Clinical and pathological features followed a highly consistent pattern, suggesting that HSES is an individual clinical entity distinguishable from conditions with similar presentations, such as septicaemia and Reye's syndrome. There was no microbiological or epidemiological evidence to support the emergence of a novel environmental agent. Many of the features of HSES were, however, the same as those described in heat stroke and we suggest that the two conditions are the same even though there is usually no history of overt overheating.

A major contribution to the burden of Tuberculosis (TB) comes from latent Mycobacterium tuberculosis infections (LTBI) becoming clinically active. TB and LTBI probably exist as a spectrum and currently there are no correlates available to identify individuals with LTBI most at risk of developing active disease. We set out to identify immune parameters associated with ex vivo mycobacterial growth control among individuals with active TB disease or LTBI to define the spectrum of TB infection. We used a whole blood mycobacterial growth inhibition assay to generate a functional profile of growth control among individuals with TB, LTBI or uninfected controls. We subsequently used a multi-platform approach to identify an immune signature associated with this profile. We show, for the first time, that patients with active disease had the greatest control of mycobacterial growth, whilst there was a continuum of responses among latently infected patients, likely related to the degree of immune activation in response to bacillary load. Control correlated with multiple factors including inflammatory monocytes, activated and atypical memory B cells, IgG1 responses to TB-specific antigens and serum cytokines/chemokines. Our findings offer a method to stratify subclinical TB infections and the future potential to identify individuals most at risk of progressing to active disease and benefit from chemoprophylaxis.

Compartment syndrome is characterised by an increase in the interstitial pressure within a closed osseofascial compartment. This may be due to a decrease in compartment volume, an increase in compartment content or external pressures. We report 4 patients who required surgical decompression for gluteal compartment syndrome that developed after joint arthroplasty. Gluteal compartment syndrome is rare, has high morbidity, and can be life threatening if not detected early. We emphasise the importance of identifying patients at risk, frequent monitoring of patients with continuous epidural infusions, reporting of motor blockade, and regular changing of the patient's position postoperatively.

BACKGROUND: Hemorrhage remains the main cause of preventable death on the modern battlefield. As Improvised Explosive Devices in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the windlass tourniquet to control distal hemorrhage after mid-thigh application. To evaluate the efficacy of the Combat Application Tourniquet (CAT) windlass tourniquet in comparison to the newer Emergency and Military Tourniquet (EMT) pneumatic tourniquet. METHODS: Serving soldiers were recruited from a military orthopedic outpatient clinic. Participants' demographics, blood pressure, and body mass index were recorded. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid-thigh level, and the presence or absence of the popliteal pulse on Doppler was recorded. The process was repeated on the contralateral leg with the CAT now applied by a trained researcher. Finally, the EMT tourniquet was applied to the first leg and popliteal pulse change Doppler recorded again. RESULTS: A total of 25 patients were recruited with 1 participant excluded. The self-applied CAT occluded popliteal flow in only four subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in two subjects (8.3%). The EMT prevented all popliteal flow in 18 subjects (75%). This was a statistically significant difference at p < 0.001 for CAT versus EMT. CONCLUSION: This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid-thigh level. The EMT was successful in a significantly larger number of participants.

We assembled an international collection of strains from sporadic and epidemic human infection with Streptococcus zooepidemicus (Lancefield group C) for laboratory study. Cultural and physiological characteristics of the isolates were determined, including biotyping with the API 20 STREP test kit and susceptibility testing with penicillin, erythromycin and tetracycline. The strains were examined for bacteriocin production and sensitivity and typed with a specially developed group-C streptococcal bacteriophage system incorporating a panel of 14 phages. Results of these tests gave useful discrimination between many of the strains: differences were shown between each of the major outbreak strains, including those complicated by post-streptococcal glomerulonephritis. Serious group C streptococcal infection may be caused by S. zooepidemicus and isolates should be identified to species level; the application of a typing scheme such as this may help to distinguish epidemiological patterns of infection.