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During a routine post-operative orthopaedic radiograph reading session, repeated unusual radiographic soft tissue and bone appearances became evident. It was discovered that these patients had received biodegradable magnesium implants which have recently been introduced into orthopaedic clinical practice. To the untrained eye, the combination of peri-metallic bone resorption with associated soft tissue gas, could easily be mistaken for post-operative infection. The aim of this study is to properly characterise the radiographic post-operative appearances of biodegradable magnesium orthopaedic hardware. We retrospectively evaluated radiographs of all patients who underwent magnesium screw implantation for fractures over a 6 month period. Four patients, mean age of 9.75 (range: 6-15) years who underwent magnesium screw fixation following fracture were included in the study. Follow up duration was 100 days (range: 75-122) with a mean of 2.5 postoperative radiographs being performed per patient during this period. All cases demonstrated post-operative peri-metallic radiolucency which developed around the magnesium screws on x-ray, which subsequently resorbed over time. Peri-metallic soft tissue gas was observed in all patients. In two cases, magnesium implants fractured. As the use of biodegradable metal implants becomes more common, it is important for radiologists to be aware of their imaging characteristics. Prior to reporting a case, it would be prudent to know if biodegradable screws have been utilised and whether there exists a clinical concern for post-operative infection in patients with these particular implants, in which case it would be critical not to dismiss peri-prosthetic radiolucencies and soft tissue gas as merely a sequela of the natural metal degradation process.

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Aim To examine the role of placental protein tyrosine nitration and p38-Mitogen-Activated Protein Kinase α (p38-MAPKα), Extra Cellular-Signal Regulated Kinase (ERK) and c-Jun NH2-Terminal Kinase (JNK) activity, in the pathogenesis of type 1 diabetic pre-eclampsia, and the putative modulation of these indices by maternal vitamin C and E supplementation. Methods Placental samples were obtained from a sub-cohort of the DAPIT trial: a randomised placebo-controlled trial of antioxidant supplementation to reduce pre-eclampsia in type 1 diabetic pregnancy. Placenta from placebo-treated: normotensive (NT) [n = 17], gestational hypertension (GH) [n = 7] and pre-eclampsia (PE) [n = 6] and vitamin-treated: NT (n = 20), GH (n = 4) and PE (n = 3) was analysed. Protein tyrosine nitration was assessed by immunohistochemistry in paraffin-embedded tissue. Catalytic activities of placental p38-MAPKα, ERK and JNK were measured by enzyme-linked immunosorbent assay (ELISA). Results Nitrotyrosine immunostaining was present in placebo-treated NT, GH and PE placentae, with no significant difference observed between the groups. There was a non-significant trend towards decreased p38-MAPKα activity in PE vs NT control placentae. ERK and JNK were similar among the three outcome placebo groups and vitamin supplementation did not significantly alter their activity. Conclusion Nitrotyrosine immunopositivity in normotensive diabetic placentae indicates some degree of tyrosine nitration in uncomplicated diabetic pregnancy, possibly due to inherent oxidative stress and peroxynitrite production. Our results suggest that p38-MAPKα, ERK and JNK are not directly involved in the pathogenesis of type 1 diabetic pre-eclampsia and are not modulated by vitamin-supplementation.

Thecondition results from T-cell medi-ated destr uction of pancreatic isletbeta-cells. Aetiological factorsinclude putative environmentaltriggers as well as geographical andgenetic components.T1D classically presents withpolyuria, polydipsia and weightloss; children with undiagnoseddiabetes may present with diabeticketoacidosis. Almost invariably insymptomatic patients randomplasma glucose concentration iselevated ( ≥11.1mmol per litre) andis sufficient for confirmation ofdiagnosis.As many as half those present-ing with neonatal diabetes ar e asso-ciated with mutations of the

Aim In view of the increased rates of pre-eclampsia observed in diabetic pregnancy and the lack of ex vivo data on placental biomarkers of oxidative stress in T1 diabetic pregnancy, the aim of the current investigation was to examine placental antioxidant enzyme status and lipid peroxidation in pregnant women with type 1 diabetes. A further objective of the study was to investigate the putative impact of vitamin C and E supplementation on antioxidant enzyme activity and lipid peroxidation in type 1 diabetic placentae. Methods The current study measured levels of antioxidant enzyme [glutathione peroxidase (Gpx), glutathione reductase (Gred), superoxide dismutase (SOD) and catalase] activity and degree of lipid peroxidation (aqueous phase hydroperoxides and 8-iso-prostaglandin F2α) in matched central and peripheral samples from placentae of DAPIT (n = 57) participants. Levels of vitamin C and E were assessed in placentae and cord blood. Results Peripheral placentae demonstrated significant increases in Gpx and Gred activities in pre-eclamptic in comparison to non-pre-eclamptic women. Vitamin C and E supplementation had no significant effect on cord blood or placental levels of these vitamins, nor on placental antioxidant enzyme activity or degree of lipid peroxidation in comparison to placebo-supplementation. Conclusion The finding that maternal supplementation with vitamin C/E does not augment cord or placental levels of these vitamins is likely to explain the lack of effect of such supplementation on placental indices including antioxidant enzymes or markers of lipid peroxidation.

This study was commissioned by GSK through the Farr Institute/SHIP/eDRIS single portal. DJM is a Clinician Scientist Fellow funded by the Health Foundation/Academy of Medical Sciences. Objectives: Acute pancreatitis (AP) can initiate systemic complications that require support in critical care (CC). Our objective was to use the unified national health record to define the epidemiology of AP in Scotland, with a specific focus on deterministic and prognostic factors for CC admission in AP. Setting: Health boards in Scotland (n=4). Participants: We included all individuals in a retrospective observational cohort with at least one episode of AP (ICD10 code K85) occurring in Scotland from 1 April 2009 to 31 March 2012. 3340 individuals were coded as AP. Methods: Data from 16 sources, spanning general practice, community prescribing, Accident and Emergency attendances, hospital in-patient, CC and mortality registries, were linked by a unique patient identifier in a national safe haven. Logistic regression and gamma models were used to define independent predictive factors for severe AP (sAP) requiring CC admission or leading to death. Results: 2053 individuals (61.5% (95% CI 59.8% to 63.2%)) met the definition for true AP (tAP). 368 patients (17.9% of tAP (95% CI 16.2% to 19.6%)) were admitted to CC. Predictors of sAP were pre-existing angina or hypertension, hypocalcaemia and age 30-39 years, if type 2 diabetes mellitus was present. The risk of sAP was lower in patients with multiple previous episodes of AP. In-hospital mortality in tAP was 5.0% (95% CI 4.1% to 5.9%) overall and 21.7% (95% CI 19.9% to 23.5%) in those with tAP necessitating CC admission. Conclusions: National record-linkage analysis of routinely collected data constitutes a powerful resource to model CC admission and prognosticate death during AP. Mortality in patients with AP who require CC admission remains high. Publisher PDF

Objective: The first aim of this study was to assess 25-hydroxy vitamin D (25OHD) concentrations in women with type 1 diabetes (T1DM) during pregnancy, post-delivery and also foetal (cord blood) 25OHD concentrations and to examine relationships between these. The second aim of the study was to investigate potential interactions between maternal body mass index (BMI) and foetal vitamin D status. A further study aim was to examine potential relationships between maternal 25OHD and glycosylated haemoglobin (HbA1c) throughout pregnancy.Research Design and Methods: This was an observational study of 52 pregnant controls without diabetes and 65 pregnant women with T1DM in a university teaching hospital. Maternal serum 25OHD was measured serially throughout the pregnancy and post-delivery. Cord blood 25OHD was measured at delivery. 25OHD was measured by liquid chromatography tandem mass spectrometry (LC-MS/MS).Results: Vitamin D deficiency (25OHD 2 vs. obese BMI >30 kg/m2 (nmol/L±SD); 19.93±11.15 vs. 13.73±4.74, p= 0.026]. In the T1DM group, HbA1c at booking was significantly negatively correlated with maternal 25OHD at all 3 trimesters (p= 0.004; p = 0.001; p= 0.05).Conclusion: In T1DM pregnancy, low vitamin D levels persist throughout gestation and post-delivery. Cord blood vitamin D levels correlate with those of the mother, and are significantly lower in obese women than in their normal weight counterparts. Maternal vitamin D levels exhibit a significant negative relationship with HbA1c levels, supporting a potential role for this vitamin in maintaining glycaemic control.

Transformational change, or reengineering, is a tough assignment for any organization. The pay-off, however, can be huge: happier patients, reenergized staff, and increased productivity. This article describes the team-based Apollo 11 project at Southeast Health Center in Indianapolis. Although this redesign effort took 7 months of extraordinary team effort, it resulted in a 54% reduction in patient encounter time, a decrease of more than 40% in per-visit cost, and improved patient and staff satisfaction. This article summarizes the background and dynamics of Apollo 11, shares some initial project results, and summarizes the lessons learned, so that other healthcare organizations can successfully tackle the reengineering challenge.

While electronic medical records (EMRs) have long held the promise of improved efficiency and quality, they have not yet made significant inroads into ambulatory care. One reason may be attempted EMR implementation in "old paradigm" clinic models. Southeast Health Center (SEHC) in Indianapolis, Indiana, began by reengineering its clinic procedures; only then did staff look for a computerized record. Because the new clinic model meshed nicely with the design of a relatively new EMR, a joint project was undertaken to test this EMR in SEHC's unique environment. This article details the reengineering, EMR implementation, project dynamics, results, and lessons learned.

Nigel Lawson once confided that he finds it difficult to smile. The shape of his mouth, which droops at the edges like Zapata moustaches, forms a permanent scowl. It remains even as he distributes his newly discovered largesse. Last week we could discern a Herculean effort from the Chancellor to produce at least a self satisfied grin. He was in a position, at last, to give money away, to invest in public utilities without stoking up inflation. The National Health Service is to be one of the beneficiaries of the melting of Nigel's heart. For next year there is an extra ?250 million over and above spending increases already planned to meet inflation. The following year a further ?300 million will be injected, bringing total spending to ?16*5 billion by 1988. Health authorities are also to be allowed to keep the benefits of their efficiency drives, estimated at ?150 million this year. In the cold light of dawn, however, the spending spree seemed to fall short of its billing. The cash increases will be more than that required by inflation, but only 1% more. The local health authori? ties still have to meet the recent pay rises and price increases from within these resources. This will consume half the extra money next year. More is needed, members of parliament pointed out, to allow some growth in the service, to allow room for some improvements, cover new technology, and cope with the increasing number of elderly patients. Mr Lawson may indeed be throwing money around in a fashion unusual by his standards, but not enough to remove the incentive from the health authorities to find extra necessary funding else? where. The government is expecting "a very substantial increase" in the receipts from the sales of surplus land and buildings, now running at ?50 million a year. Mr Lawson said that the extra cash he had released "should enable health authorities to meet demographic pressures and to deliver improvements in services as well." And he was not smiling when he said it, either.

The dust had only just settled last week after the government's shock second reading defeat on the Shops Bill when the detectable stirrings of another backbench Tory revolt could be seen at Westminster. It will not be as cataclysmic in its consequences as the Sunday trading reversal; in fact, the government will hardly notice it. But there is a mood of militancy among Conservative back? benchers that has sent many of them in search of an issue on which they can rebel. To digress slightly, it was precisely this sort of eventuality about which former Cabinet minister Francis Pym warned during the last general election campaign. As the Labour vote disintegrated before the nation's eyes he began to express concern that the government could win a massive Commons majority. As a former chief whip and leader of the House, he was keenly aware of the trouble that that could bring; when the chips are down and a government is clinging to a small majority MPs think long and hard about walking through the division lobbies with the Opposition, and then don't. But when a government is cushioned by the 140 vote margin enjoyed by Mrs Thatcher MPs can indulge themselves in the luxury of defying their whips. It may, and invariably will, mean that they can whistle goodbye to a job in the administration, but with so many backbenchers, and competition for posts so intense, there is little chance of getting one anyway. But the prophecies of the seer Pym are now being realised; even he probably did not conceive of the government actually losing a Bill on its second reading, an almost unheard of setback. No such fate is likely to befall the latest blockbuster legislation to emerge from the DHSS, the National Health Service (Amendment) Bill. The main reason is that it is supported by the Opposition, so the votes are in the bag. But the aforementioned Conservative awkward squad is already beginning to flex its muscles over one provision in the complex Bill, which was ostensibly the wherewithal to remove crown immunity enjoyed by NHS hospitals in the wake of the food poisoning outbreak at the Stanley Royd Hospital. Ministers found themselves with an extremely timely and useful method of introducing two other legislative changes, which had been outstanding for months and for which a parliamentary slot could not be found (at that stage they did not realise that a huge gap was about to open up in the programme with the disappearance of the Shops Bill). These were, firstly, to introduce the new pharmacists' contract, which had been successfully challenged in the courts last year and eventually withdrawn after the House of Lords had rejected its implementation in Scotland alone; and, secondly, to clarify the mechanism for correcting past payments to the four NHS con? tractor professions if they have been inadequate or excessive. Legislation introduced in 1984 to do just that was found to be deficient when two opticians organisations successfully challenged in the courts government attempts to recover ?11 million over reimbursed for NHS spectacles. During last week's second reading for the new Bill Health Minister Barney Hayhoe was in a generous mood. He pledged, "I think it is right the opticians should not be deprived of the fruits of their court victory and I give the clear undertaking on behalf of the government that no further attempt to recover the ?11 rnillion will be made." As an aside, he added: "I can also give the assurance that there is no intention whatsoever to change the current system for determin? ing the pay of medical and dental practitioners, which is based on the recommendations of their independent review body." He did not, by the way, say when it would report this year, but on past precedent the professions will have to wait until the middle of May to hear the bad news. So the new Bill is a many tendrilled thing, and much of it found favour on both sides of the House.

The government is facing virtually irresistible political pressure to remove the crown immunity enjoyed by National Health Service hospitals. The scandal uncovered by the inquiry into the food poisoning outbreak at the Stanley Royd psychiatric hospital in Wakefield (p 348) has added new momentum to a campaign that was already in full swing at Westminster. Ironically, the inspectors, who took more than a year to complete their report, are adamant that in the case of Stanley Royd the evidence did not support the need for the abolition of crown immunity. All the environmental health officers questioned by the inquiry team agreed that the conditions at the hospital, though sometimes far from ideal, at no time would have justified a prosecution under the food and drugs legislation. Nevertheless, in the months to come, members of parliament will cite the tragedy in Wakefield as proof of the urgent need to abolish crown immunity. Conservative backbencher Mr Richard Shepherd, the member for Hereford, is soon to launch a private Bill in the Commons, which would make those employed in kitchens on crown premises subject to the health and safety laws. His supporters acknowledge the inquiry team's opinion that crown immunity did not contribute to the food poisoning at Stanley Royd hospital; but they believe strongly that this does not affect the principle of the matter. Indeed, the Wakefield outbreak, in which 19 people died and a total of 355 patients and 106 members of staff were affected, was the most extreme consequence of a general level of hygiene in NHS hospital kitchens that seems to be nothing short of scandalous. The inquiry team referred to "comments made frequently to us that the Institute of Environmental Health Officers regarded many hospital kitchens throughout the country as being unsatisfactory, a view publicly reiterated many times since our hearings concluded." Stripped of the ultimate sanction of bringing criminal charges against crown servants, the health officers regard themselves as visitors and advisers. The government, not wishing to abolish crown immunity for a variety of reasons, wants hospitals to act on this advice to bring their kitchens up to acceptable hygiene standards without recourse to the law. The report, however, seems to question this approach; the inquiry team uncovered a difference between the way that health inspectors carry out their duties on hospital premises compared with other establishments. "This difference is difficult to define but was appreciated by all the officers who gave evidence before us. The only reason that we were able to discern for this difference was that the environmental

Should tobacco companies be banned from sponsoring sporting events? The BMA thinks they should; so does the Labour party, though not some of its MPs. The government disagrees, but some Conservatives favour the idea. Such is the division of opinion that the chances of pushing a private member's Bill through the Commons to prohibit the cigarette companies from pumping an estimated ?8 million a year into sport are next to none. And so it proved when Conservative backbencher Roger Sims (Chislehurst) tried his luck recently. The procedures of the House require a vote to be taken on the second reading of a private member's Bill before 2 30 pm on the Friday that it is debated. If the discussion is still going on at that time it is adjourned until some future date, in the case of Mr Sims's Bill, 14 March. In practice, however, the measure goes to the back of a long queue of private members' legislation and is, to all intents and purposes, killed off. Mr Sims's Bill suffered such fate. It is doubtful that this came as a surprise to Mr Sims or his supporters. The uninitiated who do not follow parliamentary proceedings closely, however, must be increasingly bemused by the plethora of proposed smoking legislation, which receives sub? stantial publicity in the press and broadcasting media and then seems to sink without trace. What, for instance, happened to George Foulkes's Bill to restrict smoking in public places? The original was withdrawn on 3 February after a revised version, the Tobacco Smoking (Public Places) (No 2) Bill was tabled. But shortly after the debate on Mr Sims's measure had been adjourned a list of private Bills still awaiting a second reading was read out by the deputy speaker, Ernest Armstrong. If any of the measures are uncontroversial they are usually passed through on the nod. If contentious an MP or government whip can object, whereupon a specific date can be named for the second reading. But in the case of Mr Foulkes's Bill no day was named so it is unlikely to see the light of day again. You could be forgiven for thinking that many MPs are less than committed to the measures that they put before the Commons, but that is to do the majority of them an injustice. The old hands are fully aware that certain pieces of private legislation have about as much chance of getting past their colleagues as Ferdinand Marcos has of owning a holiday home in the Philippines. The Commons, however, is not just a legislative chamber; it is also a forum for debate. And there are few better ways of generating public interest in a subject close to an MP's heart than to enshrine it in a Bill, however unlikely it is to succeed.