Daisy Hill Hospital

A 54-year-old lady was brought to our A+E after falling from a stepladder onto the metallic base of her artificial Christmas tree. The metallic rod impaled her through the right buttock. X-rays and a CT was performed prior to transport to a trauma centre causing delays to her surgery.

Colocolonic intussusception, caused by submucosal lipomas, is extremely rare. These benign soft tissue tumours comprise mature adipocytes of mesenchymal origin. While the majority of patients with lipomas remain asymptomatic, large or giant size lipomas (>4 cm) have been shown to cause debilitating abdominal pain, alternating bowel pattern, and anaemia secondary to gastrointestinal blood loss. This necessitates intervention in the form of surgical resection or endoscopic removal. However, once lipomas increase beyond 2 cm in size there is a significant risk of complications with an endoscopic approach, and open surgery or laparoscopic resection with bowel re-anastomosis is warranted. In this case put forth, the patient underwent a successful transverse colectomy and primary anastomosis.

A substantial proportion of arteriovenous fistulas fail to function adequately for hemodialysis. Existing studies on arteriovenous fistula failure prediction assess patency rather than the more clinically relevant outcome of arteriovenous fistula function. We hypothesized that preoperative demographic and ultrasound characteristics, and postoperative assessment by an experienced vascular access nurse would predict which arteriovenous fistulas will not function adequately for hemodialysis. Prospective cohort study of chronic kidney disease patients at a tertiary care center in Vancouver, Canada, with arteriovenous fistula creation between 2009 and 2013. Pre and postoperative clinical assessment and ultrasound blood vessel mapping were performed by an experienced vascular access nurse. The primary outcome was failure to achieve a fistula used successfully for hemodialysis (FUSH). Outcomes were assessed in 200 patients; 123 (61.5%) arteriovenous fistulas were radiocephalic. Overall, 26.5% of arteriovenous fistulas had FUSH failure (34.1% of lower arm vs 14.3% of upper arm, p = 0.002). Univariate predictors of FUSH failure included older age (p = 0.03), female sex (p = 0.05), smaller arterial diameter (p ⩽ 0.001), lower artery volume flow (p = 0.04), and smaller vein diameter (p = 0.01). In multivariable analysis, artery diameter (odds ratio: 0.44, 95% confidence interval: 0.28-0.68) most significantly predicted FUSH failure. Vascular access nurse assessment 6 weeks postoperatively correctly predicted outcome in 83.8% of FUSH and 65.0% of FUSH failure. Smaller artery diameter most strongly predicted FUSH failure. Early postoperative nursing assessment was more useful to predict FUSH than FUSH failure, and as such was insufficient in determining which arteriovenous fistulas should be abandoned as many predicted to fail could be salvaged with further intervention.

IntroductionContrast induced acute kidney injury (CI-AKI), defined as a delta rise in creatinine of >26.5 umol/L or a 50% relative rise within 48 hours following iodinated contrast, is associated with considerable mortality risk. Our previous study of 301 patients undergoing contrast coronary angiography/percutaneous coronary intervention (PCI) highlighted a CI-AKI rate of 9.3% at index procedure. Few studies have looked at long term prognosis, adverse events and mortality following CI-AKI. Our objective is to assess the 5 year mortality rate following contrast coronary angiography and to evaluate independent risk factors and presence of index CI-AKI on 5 year mortality.MethodsA prospective cohort study in a single cardiology centre in the UK was carried out from 2011–2013, the results of which have been previously published.1 In total 2,519 patients were screened, 321 (12.7%) of which had CKD, in total 301 (93.7%) patients were recruited. Written consent was obtained from all patients. Patient demographics, CI-AKI risk factors, CKD stage and contrast dose at initial contrast angiography were recorded. A Mehran risk score was calculated for each patient. Samples for plasma NGAL, serum L-FABP, serum KIM-1, serum IL-18 and serum creatinine were previously collected pre and post contrast angiography and statistically analysed to assess prediction of CI-AKI as previously described.1 At 5 years following index contrast procedure we analysed for MACE and mortality by accessing up to date electronic medical records. Patient consent was granted to access medical notes. Statistical analysis was performed to assess the predicative ability of CI-AKI risk factors and Mehran risk score on 5 year mortality risk.ResultsAt 5 years follow up data was available for 292 (97%) of the original 301 patients. Type 2 diabetes, contrast volume, Mehran risk score, lower glomerular filtration rate (GFR) and use of intravenous fluids at index procedure were independently associated with five year mortality, p <0.05, table 1. A Mehran score ≥10 had an AUC of 0.67, p <0.001, sensitivity 65%, specificity 67%, PPV 41%, NPV 85%, RR 2.7 and OR 3.9 for five year mortality. 62 Table 1Baseline characteristics of patients with 5 year mortality DemographicAt 5 year follow up 76 (26.0%) of the total cohort of patient had died. Out of the 28 patients who developed CI-AKI at index contrast procedure 17 (60.7%) of the 28 patients had died at 5 years versus 58 (22.0%) of the 264 non CI-AKI patients (p<0.001), table 2, figure 1. At 5 year follow up MACE occurred in 20 (71.4%) of the 28 CI-AKI patients versus 78 (29.5%) of the 264 non CI-AKI patients. 62 Figure 1Percentage of 5 year mortality and MACE in CI-AKI vs non CI-AKI patients 62 Table 2Comparison of 5 year mortality and MACE in baseline CI-AKI vs non CI-AKIBold - statistically significant (p<0.05)ConclusionThis study highlights that index CI-AKI is an independent risk factor for 5 year mortality and MACE. Several risk factors act independently as surrogate markers of CI-AKI prior to administration of iodinated contrast, many of which are incorporated in the Mehran CI-AKI risk score. Furthermore, these are associated with adverse incidents and mortality at five years following index contrast procedure. A combination approach of these findings, including novel biomarkers as previously demonstrated, will help to reduce risk and early identify CI-AKI to facilitate timely therapeutic intervention.ReferenceConnolly M, Kinnin M, McEneaney D, Menown I, Kurth M, Lamont J, et al. Prediction of contrast induced acute kidney injury using novel biomarkers following contrast coronary angiography. Quarterly Journal of Medicine - An International Journal of Medicine 2018:103–110.Conflict of Interestn/a

In-center hemodialysis (HD) has been the standard treatment for older dialysis patients, but reports suggest an associated decline in physical and cognitive function. Cross-sectional data suggest that assisted peritoneal dialysis (aPD), an alternative treatment, is associated with quality of life (QoL) outcomes that are comparable to in-center HD. We compared longitudinal changes in QoL between modalities. We enrolled 106 aPD patients, matched with 100 HD patients from 20 renal centers in England and Northern Ireland. Patients were assessed quarterly for 2 years using the Hospital Anxiety and Depression Scale (HADS), SF-12 physical and mental scores, symptom score, Illness Intrusiveness Rating Scale (IIRS), Barthel's score, and the Renal Treatment Satisfaction Questionnaire (RTSQ). Mixed model analysis was used to assess the impact of dialysis modality on these outcomes during follow-up. P values were adjusted for multiple significance testing. Multivariate analysis showed no difference in any of the outcome measures between aPD and HD. Longitudinal trends in outcomes were also not significantly different. Higher age at baseline was associated with lower IIRS and RTSQ scores during follow-up. One-hundred and twenty-five (60.6%) patients dropped out of the study: 59 (28.6%) died, 61 (29.6%) withdrew during follow-up, and 5 (2.5%) were transplanted. Quality of life outcomes in frail older aPD patients were equivalent to those receiving in-center HD. Assisted PD is thus a valid alternative to HD for older people with end-stage kidney disease (ESKD) wishing to dialyze at home.

Aims An increase in EEG waiting times prompted an audit of EEG referrals, using the NICE guideline, CG137, to define our audit criteria. We aimed to audit all paediatric EEG referrals made from our paediatric service, between January to December 2016. We aimed to audit the following: Was the referral appropriate i.e. was it being carried out for suspected epilepsy, or inappropriate i.e. probable syncope or non-epileptic event. Was the length of time between referral and EEG being performed within 4 weeks? In the case of suspected epilepsy with a normal first EEG, was a further sleep deprived EEG (SDE) requested. Patient diagnosis following investigation Methods This was a retrospective audit, using information gathered from the Northern Ireland Electronic Care Record. The local EEG department supplied a list of all EEG referrals made in 2016 from our paediatric department. For each referral, we recorded the following: indication for referral, referral waiting time, EEG type and patient diagnosis. Using this information, we were able to categorise referrals as appropriate or inappropriate. Results 131 patients were identified by the EEG department. We excluded 36 patients with known epilepsy and 4 patients who were under 3 months at the time of their seizure, leaving 91 patient records available for the audit. Of these, 5 patients were not counted; 1 patient’s information was unavailable and 4 patients did not attend for EEG or follow-up appointments. A total of 86 patient records were included in the final audit. 60.5% of EEG referrals were assessed as appropriate. 39.5% were deemed inappropriate. 29.8% of patients had an EEG carried out within 4 weeks. The average outpatient EEG waiting time was 66 days. 17 patients with suspected epilepsy with normal EEG, went on to have a SDE. 15 patients received a new diagnosis of epilepsy. Conclusion Our results show that EEGs are being requested for suspected non-epileptic events which leads to the risk of false positive results, increased waiting times and unnecessary tests being carried out. We recommend that further education is required to support clinicians in requesting tests judiciously.

Introduction: We studied the pharmacokinetics and pharmacology of intravenously administered CNB-001, a pleiotropic anti-inflammatory molecule with neurotrophic properties in two rabbit neuro-ischemia models. Hypothesis: In vitro, we have found that CNB-001 can significantly reduce cell death mediated by glutamate, iodoacetic acid, ATP depletion, oxidative stress (glutathione depletion) and oxygen-glucose depletion. We tested the hypothesis that CNB-001 would attenuate ischemia-induced behavioral deficits in vivo. Methods: Abiding by RIGOR guidelines, the study was randomized and the neuro-examiners were naive (blinded) to treatment. CNB-001 (10mg/kg) was administered IV 45 minutes prior to balloon of occlusion of the infrarenal aorta, which reliably produces spinal cord ischemia (SCI) depending upon the occlusion time. Using TARLOV scores and quantal analysis, we quantified the ischemia duration (P50 in minutes) producing SCI in 50% of study rabbits. Second, using a rabbit embolic stroke model (RSCEM), CNB-001(1-25mg/kg) was applied IV 1 hour post-ischemia and behavioral function measured. We calculated the effective stroke clot dose (P50 in mg) producing neurological deficits in 50% of embolized rabbits. Control groups and positive-control drugs were also studied in parallel in both rabbit ischemia models. All behavioral endpoints were measured 2days after ischemia. Results: Pharmacokinetic analysis of CNB-001 in normal male rabbits indicated that the t1/2 was 3.37 ± 0.52 hours and clearance rate was 44.2 ml/min/kg in rabbits. In the SCI model, CNB-001 (10mg/kg) significantly increased P50 values to 19.38 ± 2.03 min (n=16) from 13.58 ± 0.90min (n=14; p&lt;0.05); the positive control, memantine (IV 10mg/kg) increased P50 to 22.52 ± 2.98 min (n=23; P&lt;0.05). In the RSCEM, 10mg/kg CNB-001 significantly improved behavior: P50 2.15 ± 0.09 mg (n=18, p&lt;0.05) compared to vehicle 1.11± 0.08 mg (n=20), when the drug was administered 1 hour after embolization; tPA (IV 3.3mg/kg) also increased P50 2.69 ± 0.29mg (n=20). Conclusions: CNB-001 can be provided to patients prior to cardiaovascular surgery to reduce the probability of SCI. Moreover, CNB-001 can reduce behavioral deficits associated with brain ischemia when given after an embolic stroke.

Electron backscatter diffraction is a scanning electron microscopy technique used to obtain crystallographic information on materials. It allows the nondestructive mapping of crystal structure, texture, and strain with a lateral and depth resolution on the order of tens of nanometers. Electron backscatter diffraction patterns (EBSPs) are presently acquired using a detector comprising a scintillator coupled to a digital camera, and the crystallographic information obtainable is limited by the conversion of electrons to photons and then back to electrons again. In this article we will report the direct acquisition of energy-filtered EBSPs using a digital complementary metal-oxide-semiconductor hybrid pixel detector, Timepix. We show results from a range of samples with different mass and density, namely diamond, silicon, and GaN. Direct electron detection allows the acquisition of EBSPs at lower (≤5 keV) electron beam energies. This results in a reduction in the depth and lateral extension of the volume of the specimen contributing to the pattern and will lead to a significant improvement in lateral and depth resolution. Direct electron detection together with energy filtering (electrons having energy below a specific value are excluded) also leads to an improvement in spatial resolution but in addition provides an unprecedented increase in the detail in the acquired EBSPs. An increase in contrast and higher-order diffraction features are observed. In addition, excess-deficiency effects appear to be suppressed on energy filtering. This allows the fundamental physics of pattern formation to be interrogated and will enable a step change in the use of electron backscatter diffraction (EBSD) for crystal phase identification and the mapping of strain. The enhancement in the contrast in high-pass energy-filtered EBSD patterns is found to be stronger for lighter, less dense materials. The improved contrast for such materials will enable the application of the EBSD technique to be expanded to materials for which conventional EBSD analysis is not presently practicable.

Salmonella infection can cause four predominant clinical syndromes: enteric fever, acute gastroenteritis, bacteraemia with or without metastatic infection, and the asymptomatic carrier state. Salmonella as an aetiological agent in osteomyelitis is essentially rare and salmonella osteomyelitis in itself is predominantly seen in patients with haemoglobinopathies such as sickle cell disease or thalassemia. There are very few cases reported in the literature in which salmonella osteomyelitis is seen in otherwise healthy individuals. We describe here a case of salmonella osteomyelitis in a young gentleman with no significant comorbidities who presented with fever and severe back pain, having returned from recent foreign travel. It is therefore important to consider uncommon pathogens in the differential diagnosis of travellers with prolonged fever and insidious symptoms.