Queen's Hospital

OBJECTIVE: To formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction. SETTING: Constipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term "opioid-induced bowel dysfunction." METHODS: A literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system. RESULTS: From a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction. CONCLUSIONS: In recent years, more insight has been gained in the pathophysiology of this "entity"; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.

Numerous factors need to be taken into account when implanting deep brain stimulation (DBS) systems into patients with Parkinson's disease. The surgical procedure itself can be divided into immediate preoperative, intraoperative, and immediate postoperative phases. Preoperative considerations include medication withdrawal issues, stereotactic equipment choices, imaging modalities, and targeting strategy. Intraoperative considerations focus on methods for physiological confirmation of a given target for DBS electrode deployment. Terms such as microelectrode recording, microstimulation, and macrostimulation will be defined to clarify inconsistencies in the literature. Advantages and disadvantages of each technique will be addressed. Furthermore, operative decisions such as staging, choice of electrode and implantable pulse generator, and methods of device fixation will be outlined. Postoperative issues include imaging considerations, including magnetic resonance safety, device-device interactions, and immediate surgical complications pertaining to the DBS procedure. This report outlines answers to a series of questions developed to address all aspects of the DBS surgical procedure and decision-making with a systematic overview of the literature (until mid-2004) and by the expert opinion of the authors. This is a report from the Consensus on Deep Brain Stimulation for Parkinson's Disease, a project commissioned by the Congress of Neurological Surgeons and the Movement Disorder Society. It outlines answers to a series of questions developed to address all surgical aspects of deep brain stimulation.

The guideline group regarding the diagnosis and management of myelofibrosis was selected to be representative of UK-based medical experts, together with a contribution from a single expert from the USA. MEDLINE and EMBASE were searched systematically for publications in English from 1966 until August 2011 using a variety of key words. The writing group produced the draft guideline, which was subsequently revised by consensus of the members of the General Haematology and Haemato-oncology Task Forces of the British Committee for Standards in Haematology (BCSH). The guideline was then reviewed by a sounding board of UK haematologists, the BCSH and the British Society for Haematology Committee and comments incorporated where appropriate. The criteria used to state levels and grades of evidence are as outlined in the Procedure for Guidelines commissioned by the BCSH; the 'GRADE' system was used to score strength and quality of evidence. The objective of this guideline is to provide healthcare professionals with clear guidance on the investigation and management of primary myelofibrosis, as well as post-polycythaemic myelofibrosis (post-PV MF) and post-thrombocythemic myelofibrosis (post-ET MF) in both adult and paediatric patients.

The joint line convergence angle (JLCA) has a normal range between 0° to 2°, which increases in magnitude depending on the severity and stage of osteoarthritis in the knee.The JLCA represents the interaction of the intra-articular deformity arising from the osteoarthritis and the surrounding soft tissue laxity. Therefore, the JLCA has become a vital parameter in analysing the long leg alignment views for corrective planning before osteotomy surgery. Recent studies have considered the influence on how the preoperative JLCA is measured and its influence on achieving accurate postoperative desired correction in high tibial osteotomy surgery.The JLCA also reflects the influence of soft tissue laxity in a lower limb malalignment and many surgeons encourage it to be taken into account to avoid non physiological correction and/or overcorrection with negatively impacted postoperative patient outcome.This present review addressed how to obtain an accurate preoperative measurement of the JLCA, its influence on postoperative deformity analysis and how to reduce errors arising from an elevated preoperative JLCA.We have proposed a formula to help determine the value to subtract from the planned correction in order to avoid an overcorrection when performing a corrective osteotomy.Level of clinical evidence IV, narrative review.

OBJECTIVE: To determine prognostic indicators for the surgical treatment of brachycephalic obstructive airway syndrome (BOAS) and to compare the prognosis of 2 multilevel surgical procedures. STUDY DESIGN: Prospective clinical study. SAMPLE POPULATION: Client-owned pugs, French bulldogs, and bulldogs (n = 50). METHODS: Noninvasive whole-body barometric plethysmography (WBBP) was used to assess respiratory function before, 1 month and 6 months after upper airway corrective surgery. Postoperatively, BOAS indices (ie, ascending severity score generated from WBBP data, 0%-100%) that equaled to or exceeded the cut-off values of BOAS in the diagnostic models were considered to have a "poor prognosis." A multivariate logistic regression was used to assess predictors for prognosis. RESULTS: The median BOAS indices decreased after surgery (from 76% to 63%, P < .0001), although dogs with indices in this range would still be considered clinically affected. Age (odds ratios [OR] = 0.96, 95% confidence interval [CI]: 0.93-0.99, P < .05), body condition (OR = 0.06, 95% CI: 0.01-0.39, P < .01), laryngeal collapse (OR = 6.1, 95% CI: 1-37.22, P < .05), and surgical techniques (OR = 7.94, 95% CI: 1.17-54.01, P < .05) were associated with postoperative prognosis. The multivariate model suggests modified multilevel surgery (MMS) may have a better outcome than traditional multilevel surgery (TMS) (P = .034). The positive predictive value of the logistic model was 84% (95% CI: 68-94%) and the area under the receiver operating characteristic (ROC) curve was 89% (95% CI: 78-99%, P <.0001). CONCLUSIONS: Younger age, normal body condition, presence of laryngeal collapse, and treatment with TMS were negative prognostic factors after surgical treatment of BOAS. MMS is recommended, particularly in dogs with a higher probability of poor prognosis.

OBJECTIVE: To assess the efficacy of corticosteroids in the treatment of severe hyperemesis gravidarum refractory to conventional management. DESIGN: Multicentre, double-blind, randomised, placebo-controlled trial. SETTING: Inpatient gynaecology wards in eight collaborating centres. POPULATION: Twenty-five women with severe hyperemesis of which 24 completed the one- week study period. METHODS: Twenty-five women were randomised to receive either 40 mg prednisolone daily in two divided oral doses, or equivalent placebo tablets. If, after three days, a woman was still vomiting, medication was changed to the equivalent intravenous alternative (hydrocortisone 100 mg twice daily or normal saline injections) MAIN OUTCOME MEASURES: Frequency of vomiting and the dependence on intravenous fluid replacement therapy after one week of treatment. RESULTS: There was a non-significant trend towards improved nausea and vomiting and reduced dependence on intravenous fluids. However, steroid therapy led to an improved sense of wellbeing (P = 0.021), improved appetite (P = 0.039) and increased weight gain (P = 0.025) compared with placebo. There was no difference in pregnancy outcome between the treatment and placebo groups. CONCLUSIONS: This study supports a beneficial role for steroids in severe hyperemesis, but did not validate the hypothesis that they lead to rapid and complete remission of symptoms. The study was not large enough to demonstrate a significant improvement in the primary outcome measures.

BACKGROUND: Cholecystectomy on index admission for acute cholecystitis is associated with improved patient outcomes. The timing of intervention is mainly driven by service provision. This population-based cohort study aimed to evaluate timing of emergency cholecystectomy in England. METHODS: Data from all consecutive patients undergoing surgery for acute cholecystitis on index admission in England from 1997 to 2012 were captured from the Hospital Episodes Statistics database. Data were analysed based on whether patients underwent surgery 0-3 days, 4-7 days or ≥ 8 days from admission. Outcome measures were rate of post-operative biliary complications, conversion to open and length of stay. RESULTS: Forty-three thousand eight hundred and seventy patients underwent emergency cholecystectomy. 64.6% of patients underwent surgery between days 0 and 3 of admission, 24.3% between days 4-7 and 11.0% had surgery after day 8. Patients undergoing early surgery had significantly reduced rates of intra-operative laparoscopic conversion to open (0-3 days: 3.6%; 4-7 days: 4.0%; ≥ 8 days 4.7%, p = 0.001), post-operative ERCP (0-3 days: 1.1%; 4-7 days: 1.5%; ≥ 8 days 1.9%, p < 0.001) and bile duct injury (0-3 days: 0.6%; 4-7 days: 1.0%; ≥ 8 days 1.8%, p < 0.001). Early cholecystectomy was also associated with a shorter post-operative length of stay (LOS) [0-3 days group: median post-operative LOS 3 days (IQR: 1-6); 4-7 days group: 3 days (IQR 2-6); ≥ 8 days group: 4 days (IQR 2-9) (p < 0.001)]. High-volume centres undertook a significantly greater proportion of cholecystectomies within 3 days of presentation (high-volume: 67.3%; medium-volume: 64.8%; low-volume: 61.2%). In multivariate analysis greater time to surgery was independently associated with increased risk of post-operative ERCP and bile duct injury. CONCLUSIONS: Early cholecystectomy within 3 days of admission reduces intra-operative conversion, post-operative biliary complications and length of stay. Centres undertaking the greatest numbers of emergency cholecystectomies perform a larger proportion within 3 days of admission.

The existence of "benign hereditary chorea" (BHC), a rare disorder of childhood-onset familial chorea without other neurologic features or progression, has increasingly been questioned, because many patients with this disorder were subsequently diagnosed with different conditions. We therefore analyzed all published reports of families with BHC and contacted their authors to obtain follow-up information. In addition, we reviewed all patients in whom at least one of the authors had at some stage considered a possible diagnosis of BHC. Of 42 families reported to have BHC in the literature, we obtained follow-up information on 11 families, three of which had been seen by us. An additional seven new, unreported families and four sporadic cases, in which this diagnosis was suspected by at least one of us at one point, were reviewed and videotaped. On reviewing the videotapes of the 11 families in the literature, the diagnosis of BHC was changed in nine. In the remaining two families, atypical features suggesting different diagnoses were present in the original reports. In none of our own previously unreported patients (seven familial and four sporadic) was BHC diagnosed unequivocally by all evaluators after review of their video recordings. In three of these families and all four sporadic patients the diagnosis was changed; in one family multifocal myoclonus could not be differentiated from chorea by any author, and in the remaining three families no consensus between the raters was found. Apart from the 11 families in whom we obtained follow-up information, analysis of the remaining 31 reports on families with BHC also revealed atypical features in the majority. We conclude that BHC is not a diagnosis, but a syndrome that requires further investigation. Whether there is a distinct entity "BHC" with a single gene abnormality remains to be proven.

OBJECTIVE: To assess the variables associated with the complications of total hip replacement (THR) and report owner-assessed outcomes, through surgeon-based registration of cases via an online database, informed owner consent, and prospective outcomes assessment using a client-administered clinical metrology instrument. STUDY DESIGN: Prospective case series ANIMALS: Dogs (n = 170) METHODS: Entries into the British Veterinary Orthopaedic Association-Canine Hip Registry (BVOA-CHR) between January 2010 and August 2011 were reviewed. Variables evaluated included dog age, body weight, breed, and indication for THR and prosthesis. Associations between each variable and the incidence of complications were assessed using logistic regression. Additionally, an on-line, owner-administered outcomes assessment questionnaire (modified from the Liverpool Osteoarthritis in Dogs (LOAD) questionnaire) was used to collect data from owners. RESULTS: One hundred and seventy cases met the inclusion criteria. Surgical indications included hip dysplasia and coxofemoral osteoarthritis (n = 150), Legg-Calves-Perthes disease (7), coxofemoral luxation (6), fracture (4), slipped capital physis (2), and femoral head and neck ostectomy revision (1). Surgical implants were from 4 systems. The incidence of surgeon-reported complication was 9.4%. No significant association was identified between weight, age, sex, breed, indication for THR, surgical technique and prosthesis, and the incidence of complications. In 82% of the cases, owners described their satisfaction with the outcome of THR as "very good" and a total of 20% complication rate was reported. There was a statistically significant improvement in owner-assessed questionnaire score before and after THR (P < .001). CONCLUSIONS: The BVOA-CHR offers a novel framework for the prospective studies on THR and on a national/international scale. Initial complication rates from the BVOA-CHR are similar to previous studies.

Research on the pedunculopontine nucleus (PPN) has identified this structure as a potential new target for deep brain stimulation (DBS) in patients with axial movement disorders refractory to other forms of treatment (Pahapill and Lozano, 2000; Jenkinson et al ., 2004). Stefani et al . recently presented their surgical approach for DBS of the PPN (Stefani et al ., 2007). Although they describe their anatomical target as the PPN, Figure 2 of their paper and sections of the text clearly show that they have actually targeted the peripeduncular nucleus (PPD). The pedunculopontine nucleus (PPN) and the peripeduncular nucleus (PPD) are distinct anatomical structures with different configurations and very different anatomical boundaries at different levels of the brainstem. The PPN is an …

AIM: The aim of the present study was to analyze our experience with a new liquid embolic agent, Squid, for the treatment of cerebral vascular lesions. MATERIAL AND METHODS: We present 28 patients who were treated with two formulations of Squid (Squid 18 and Squid 12). The lesions included 16 arteriovenous malformation (AVM)s (Spetzler-Martin grade 2 in 8, 3 in 6 and 4 in 2), 9 arteriovenous (AV) fistulas, 2 tumors (glomus tumor and angiofibroma) and 1 AICA aneurysm. Of the 9 patients presenting with hemorrhage, 6 were AVM, 2 were AVF and 1 was aneurysm. RESULTS: The total obliteration rate of the AVMs was 37.5%. Fistulas were closed completely after combined treatment with surgery in 6 out of 9 patients, and one was sent to radiotherapy. There was no mortality. Two reported hemorrhages and thromboembolic complications resulted in permanent deficits in 3 patients. Pathologic examination revealed mild inflammatory reaction with infiltration of polymorphonuclear cells in 5 patients in whom surgery was performed immediately after embolization. Technical problems such as rupture, inability to remove or premature occlusion of the microcatheter related to the embolic agent were not recorded. CONCLUSION: Squid is a safe and effective embolic agent for treatment of cerebral AVMs, AV fistulas, tumors and aneurysms with satisfactory obliteration rate.

OBJECTIVE: To determine whether serum concentrations of long chain n-3 polyunsaturated fatty acids (LCn3PUFAs) contribute to the difference in the incidence rate of coronary artery calcification (CAC) between Japanese men in Japan and white men in the USA. METHODS: In a population based, prospective cohort study, 214 Japanese men and 152 white men aged 40-49 years at baseline (2002-2006) with coronary calcium score (CCS)=0 were re-examined for CAC in 2007-2010. Among these, 175 Japanese men and 113 white men participated in the follow-up exam. Incident cases were defined as participants with CCS≥10 at follow-up. A relative risk regression analysis was used to model the incidence rate ratio between the Japanese and white men. The incidence rate ratio was first adjusted for potential confounders at baseline and then further adjusted for serum LCn3PUFAs at baseline. RESULTS: Mean (SD) serum percentage of LCn3PUFA was >100% higher in Japanese men than in white men (9.08 (2.49) vs 3.84 (1.79), respectively, p<0.01). Japanese men had a significantly lower incidence rate of CAC compared to white men (0.9 vs 2.9/100 person-years, respectively, p<0.01). The incidence rate ratio of CAC taking follow-up time into account between Japanese and white men was 0.321 (95% CI 0.150 to 0.690; p<0.01). After adjusting for age, systolic blood pressure, low density lipoprotein cholesterol, diabetes, and other potential confounders, the ratio remained significant (0.262, 95% CI 0.094 to 0.731; p=0.01). After further adjusting for LCn3PUFAs, however, the ratio was attenuated and became non-significant (0.376, 95% CI 0.090 to 1.572; p=0.18). CONCLUSIONS: LCn3PUFAs significantly contributed to the difference in the incidence of CAC between Japanese and white men.

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OBJECTIVES: To determine the value of inhaled corticosteroids in the management of chronic inflammatory airway disease in dogs. METHODS: Medical records of dogs that were presented for the investigation of respiratory disease were reviewed retrospectively. Criteria for inclusion were knowledge of previous medical treatment including side effects, diagnosis of the underlying disease, use of inhaled corticosteroids and at least two-months follow-up data. RESULTS: Thirteen dogs that fulfilled the criteria were identified. Ten dogs were diagnosed with chronic bronchitis and three with eosinophilic bronchopneumopathy. Four dogs had not previously received corticosteroid treatment for their respiratory disease, and all these showed a reduction or a resolution of clinical signs without obvious side effects after inhaled corticosteroid therapy. Nine dogs had previously received oral or parenteral corticosteroids for treatment of their respiratory disease, and all had exhibited side effects. Five of these dogs were treated with inhaled corticosteroids alone, and all exhibited an improvement in clinical signs without observable side effects. The remaining four dogs were treated with a combination of inhaled and oral corticosteroids, and all showed improvement in clinical signs and reduction in side effects. Inhaled medication was well tolerated in all dogs. CLINICAL SIGNIFICANCE: Inhaled corticosteroids were used for the management of chronic bronchitis and eosinophilic bronchopneumopathy in 13 dogs, and these may have the advantage of reducing side effects associated with oral corticosteroids.

Immediately sequential bilateral cataract surgery (ISBCS) is currently a "hot topic" in ophthalmology. There are well-documented advantages in terms of quicker visual rehabilitation and reduced costs. The risk of bilateral simultaneous endophthalmitis and bilateral blindness is now recognized to be minuscule with the advent of intracameral antibiotics and modern management of endophthalmitis. Refractive surprises are rare for normal eyes and with the use of optical biometry. Where a general anesthetic is indicated for cataract surgery, the risk of death from a second anesthetic is much higher than the risk of blindness. A widely recognized protocol from the International Society of Bilateral Cataract Surgeons needs to be adhered to if surgeons wish to start practicing ISBCS.

A unique disorder is described in seven members of two families in whom dystonia was variably associated with subacute visual loss or asymptomatic optic atrophy, and striking bilateral symmetrical lucencies on CT scan, especially involving the putamen. It is possible that this is a variant of Leigh's disease. However, there were considerable differences between these patients and those with pathologically proven Leigh's disease. This condition must be excluded in all patients thought to have idiopathic dystonia, subacute visual failure similar to Leber's optic neuropathy, or a combination of these disorders.

PURPOSE: Collecting reference values in subpopulations such as infants and children can pose a daunting challenge to gather through epidemiologic studies. The authors propose to evaluate a method the authors refer to as extrapolated norms (e-norms) to derive Stimulated Single Fiber EMG jitter reference values from the laboratory data of pediatric and adult cohorts. Single Fiber EMG studies are considered the gold standard test for evaluation of neuromuscular transmission disorders. METHODS: Data that lie in the plateau part of an inverted S curve derived from sorted jitter data were used to calculate descriptive statistics for pediatric and adult e-norms jitter. RESULTS: The e-norms derived jitter was 22 ± 2.83 μs for our pediatric and 21 ± 2.79 μs for our adult cohort. Our adult e-norms values compared favorably with the 22 ± 1.99 μs published jitter range derived from a healthy adult cohort. CONCLUSIONS: The e-norms method the authors describe seems to be useful in recovering reference ranges when such values are difficult to obtain, such as in a pediatric subpopulation.

Objective: analyze trends in fertility rates and associations with perinatal outcomes for adolescents in Santa Catarina, Brazil. Methods: a population-based study covering 2006 to 2013 was carried out to evaluate associations between perinatal outcomes and age groups, using odds ratios, and Chi-squared tests. Results: differences in the fertility rate among female adolescents across regions and time period were observed, ranging from 40.9 to 72.0 per 1,000 in mothers aged 15-19 years. Adolescents had fewer prenatal care appointments than mothers ≥20 years, and a higher proportion had no partner. Mothers aged 15-19 years were more likely to experience preterm birth (OR:1.1; CI:1.08-1.13; p<0.001), have an infant with low birthweight (OR:1.1; CI:1.10-1.15; p<0.001) and low Apgar score at 5 minutes (OR:1.4; CI:1.34-1.45; p<0.001) than mothers ≥20 years, with the odds for adverse outcomes greater for those aged 10-14 years. Conclusion: this study provides evidence of fertility rates among adolescents remaining higher in regions of social and economic deprivation. Adolescent mothers and their infants more likely to experience adverse perinatal outcomes. Nurses, public health practitioners, health and social care professionals and educators need to work collaboratively to better target strategies for adolescents at greater risk; to help reduce fertility rates and improve outcomes.

An apparently well baby girl born at term was presented with signs and symptoms suggestive of acute onset of generalised floppiness at the age of 3 months. Clinically, the baby had lower motor neuron type of muscle weakness; detailed investigation lead to the diagnosis of neuromuscular junction disorder secondary to botulism toxicity. Further tests confirmed the botulism toxicity secondary to honey ingestion. The baby was treated with specific anticlostridium antibodies; she recovered remarkably, now growing and developing normally.

BACKGROUND AND PURPOSE: Stronger magnetic fields have the potential to improve fetal image resolution. Our objective was to detect whether there was better anatomic resolution of brain structures in fetuses imaged with a 3T magnet compared with a 1.5T magnet. MATERIALS AND METHODS: Multiple cerebral and facial anatomic structures were retrospectively assessed in 28 fetal MR imaging scans with normal findings (12 at 3T and 16 at 1.5T) with a 0-3 grading score. Fetuses were assessed during the second trimesters (gestational age, 20-24 weeks). The association between the quality ratings and magnetic field strengths (1.5T versus 3T) was evaluated by a linear mixed-effects model. A quantitative assessment of the signal intensity was also performed in the different layers of the developing brain. Comparative log-ratios were calculated across the different layers of the fetal brain. RESULTS: < .001). The cerebral structures of the cerebellum, pons, venous system, semicircular canal, and cochlea showed statistically significant higher values on the 3T magnet. Similarly, statistical significance was also obtained on the quantitative assessment of the multilayer appearance of the brain; the 3T magnet had a median factor of 8.38 higher than the 1.5T magnet (95% CI, 4.73-14.82). Other anatomic structures assessed in the supratentorial compartment of the brain showed higher values on the 3T magnet with no statistical significance. CONCLUSIONS: Both magnets depict cerebral and facial normal anatomic structures; however, our data indicates better anatomic detail on the 3T than on the 1.5T magnet.