Background: Transforaminal epidural steroid injections (TFESI) and interlaminar epidural steroid injections (ILESI) are commonly performed procedures for the management of unilateral lumbosacral radicular pain (LSRP) due to intervertebral disc herniations. Thus, corticosteroids are commonly used to reduce inflammation in the epidural space. Data from multiple studies and systematic reviews of the published data support the utility of TFESI and have shown that lumbar TFESI are effective for reducing pain, improving functionality, preventing spine surgery and for treating radiculopathy pain. Methods: This is prospective study consist of 60 patients of 18 to 60 years of age are enrolled suffering with symptomatic lumbar Intervertebral disc herniation at BGS Global Institute of Medical Sciences, Bangalore over a period of 1 year. In Group IL (interlaminar approach), with the patient in pronel position, under strict aseptic precautions, 18G Tuohy needle is placed in epidural space by loss of resistance technique and confirmed using iohexol dye and 80 mg (2 Ml) of methylprednisolone with 2 Ml of normal saline is injected. In group TF (transforaminal approach), with the patient in prone position, under strict aseptic precautions, 23 G Quinke needle is placed in epidural space under C-arm guidance and confirmed by using Iohexol dye and 80 mg (2 Ml) of methylprednisolone with 2 Ml of normal saline is injected. Results: In Group IL, NRS decreased from 7.77±1.2 (pre-procedure) to 4.73±1.1 and 4.27±1.5 at the end of 2^nd and 3^rd week respectively. In Group TF, NRS decreased from 7.8±1.3 (pre-procedure) to 2.77±1.7 and 2.63±1.7 at the end of 2^nd and 3^rd week respectively. This difference in NRS was statistically significant both at the end of 2^nd week and 3^rd week with a P value of 0.001 with Group TF having better pain relief. There was no statistically significant difference among the 2 groups with respect to SLRT, improvement in walking tolerance, reduction in analgesic use and reversal of paranesthesia at the end of 3^rd week. Conclusions: Epidural steroid injection by transforaminal route provides better subjective pain relief in the short term.

Chronically ill patients with neurodegenerative and neurobehavioral and psychiatric diseases commonly have systemic and central nervous system bacterial and viral infections. In addition, other chronic illnesses where neurological manifestations are routinely found, such as fatiguing and autoimmune diseases, Lyme disease and Gulf War illnesses, also show systemic bacterial and viral infections that could be important in disease inception, progression or increasing the types/severities of signs and symptoms. Evidence of Mycoplasma species, Chlamydia pneumoniae, Borrelia burgdorferi, human herpesvirus-1, -6 and -7 and other bacterial and viral infections revealed high infection rates in the above illnesses that were not found in controls. Although the specific roles of chronic infections in various diseases and their pathogeneses have not been carefully determined, the data suggest that chronic bacterial and/or viral infections are common features of progressive chronic diseases. Abbreviations: Ab Beta Amyloid; AD Alzheimer’s Disease; ADHD Attention-Deficit Hyperactivity Disorder; ALS Amyotrophic Lateral Sclerosis; ASD Autism Spectrum Disorders; EBV Epstein-Barr Virus; CFS Chronic Fatigue Syndrome; CFS/ME Chronic Fatigue Syndrome/Myalgic Encephalomyopathy; CI Confidence Interval; CMV Cytomegalovirus; CSF Cerebrospinal Fluid; CNS Central Nervous System; ELISA Enzyme Linked Immunoabsorbant Assay; GS Guillain- Barré Syndrome; GWI Gulf War Illnesses; HHV Human Herpes Virus; HSV Herpes Simplex Virus; MDD Major Depressive Disorder; ME Myalgic Encephalomyelitis; MRI Magnetic Resonance Imaging; MS Multiple Sclerosis; OCD Obsessive-Compulsive Disorder; PANDAS Paediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococci; PCR Polymerase Chain Reaction; PD Parkinson’s Disease; QOL Quality Of Life; TS Tourette’s Syndrome

Methods to assess cosmesis following breast-conserving surgery are varied and assumed to yield similar results. The aim of this study was to compare three different methods of cosmetic assessment following breast-conserving surgery and to assess the impact of certain factors on cosmetic outcome. One hundred and fifteen patients undergoing breast-conserving surgery had 3 view digital photographs taken for assessment of cosmesis at one-year post- surgery. Subjective cosmetic assessment was performed by a 5-member panel and objective assessment by Breast Retraction Assessment (BRA) and Nipple Deviation (ND). Factors including tumour size, percentage breast volume excised, location of tumour and number of breast operations performed was correlated with final cosmetic outcome. The majority of patients undergoing breast-conserving surgery demonstrated satisfactory cosmetic results. Inter-observer variation assessed using a kappa statistic for panel assessment gave a value of 0.42 with a 95% confidence interval (CI) of 0.37 to 0.47, indicating moderate agreement between observers. The kappa statistic for agreement between the three methods used for assessing cosmesis was -0.23 with 95% CI of -0.35, -0.11 indicating poor concordance between the three methods used. These methods however, may be complementary to each other and therefore these observations merit further investigation. Tumour location, tumour size and the number of operations performed did not influence cosmetic outcome. However, cosmetic outcome was related to percentage breast volume excised.

Airway assessment is the most important aspect of anaesthetic practice as a difficult intubation may be unanticipated. A prospective study was done to compare the efficacy of airway parameters to predict difficult intubation. Parameters studied were degree of head extension, thyromental distance, inter incisor gap, grading of prognathism, obesity and modified Mallampati classification. 600 Patients with ASA I& ASA II grade were enrolled in the study. All patients were preoperatively assessed for airway parameters. Intra-operatively all patients were classified according to Cormack and Lehane laryngoscopic view. Clinical data of each test was collected, tabulated and analyzed to obtain the sensitivity, specificity, positive predictive value & negative predictive value. Results obtained showed an incidence of difficult intubation of 3.3 % of patients. Head and neck movements had the highest sensitivity (86.36%); high arched palate had the highest specificity (99.38%). Head and neck movements strongly correlated for patients with difficult intubation

The Foundation Programme details the first two years of training for UK doctors in the UK. Thereafter, trainees are expected to apply for highly competitive specialist training posts. Our study aimed to clarify and quantify the educational activities currently used by Foundation doctors during this two-year period, and to assess their motivational and deterring factors towards such educational activities. Method: A fourteen-point questionnaire was posted at random to 100 Foundation Year 1 and 2 (50 FY1 and 50 FY2) doctors across five Trent Deanery hospitals. The questionnaire assessed involvement in the following voluntary educational activities: courses, conferences, higher qualifications, e-learning packages and personal reading. It also sought their underlying attitudes. Results: Response rate was 49.0% (49/100), comprising 34 (68%) FY1 and 15 (30%) FY2. Overall, 89.8% of respondents engaged in voluntary educational activities. The most common (89.8%) was the e-learning package (FY1 85.3%, FY2 100%) followed by society membership (73.5% (FY1 64.7%, FY2 93.3%), courses (69.4%) (FY1 55.9%, FY2 100%), sitting higher qualifications (36.7%) (FY1 14.7%, FY2 86.7%) and attending conferences (14.3%) (FY1 14.7%, FY2 13.3%). The mean total cost incurred by doctors for these activities was £581 in FY1 and £1842 in FY2. The most common deterrents to pursuing voluntary education were a lack of study leave (42.9%) (FY1 38.2%, FY2 53.3%), lack of annual leave (22.4%) (FY1 23.5% FY2 20.0%) and expense (20.4%) (FY1 17.6%, FY2 26.7%). The most common motivating factor was the belief they would help candidates achieve a specialist training post (67.3%) (FY1 58.8%, FY2 86.7%). Only 8.2% (FY1 11.8%, FY2 0.0%) engaged primarily to improve their medical competence. Discussion: Our study is the first to quantify the voluntary educational activities of Foundation doctors. Most popular are e-learning packages — outstripping courses, higher qualification revision and conferences — highlighting their increasing popularity as a viable and accessible educational tool. The primary deterrent to pursuing voluntary educational activities is lack of study leave, of concern as entitlements to this continue to decrease. Interestingly, Foundation doctors are not motivated primarily by the educational benefits of these activities, but rather by their perceived ability to help attain a specialist training post. This highlights the concerning potential for voluntary educational activities to become a badge of attendance, undermining their intrinsic educational value and outcome.

Introduction: The Exeter Trauma Stem (ETS) is a new monoblock unipolar prosthesis with no independent published series using this implant. This study prospectively evaluates the first 50 ETS hemiarthroplasties performed as a primary treatment for fractured neck of femur at Norfolk and Norwich University Hospital. Methods: Patient demographics and operative details were recorded from the patient notes. Radiographic evaluation involved the Barrack cementation grading system, Dorr’s criteria and leg length measurement. All patients were sent an Oxford Hip Score questionnaire between two and four months postoperatively with 100% response rate. Results: Two thirds of cement mantles were Barrack grade A and B. Twenty-eight patients had lengthening of the operated limb with a mean of 12mm (5- 30) including one irreducible prosthesis. Further complications included three deaths and one deep infection. The average Oxford Hip Score was 27.2. Discussion: Patient demographics were similar to previous studies. There was no statistical difference between the cement mantles and those of another published study using the Exeter stem. The major difficulty evident from this study was correct positioning of the prosthesis with regards to leg-length. Post-operative hip scores were similar to other studies as was the mortality rate. Conclusion: Post-operative functional and radiographic scoring of the ETS prosthesis were encouraging but care is needed with regards to correct positioning of this prosthesis to attain equal leg lengths. Subsequent to the results of this study, a trialling system has been added to the instrumentation which the authors recommend in conjunction with pre-operative templating.

The question of whether these fractures are causally linked to bisphosphonate therapy is widely debated but as yet unresolved. Consequences of long-term suppression of bone turnover include increased mineralization of bone, alterations in the composition of its mineral/matrix composite and increased micro damage, all of which may reduce bone strength. Whilst these lend biological plausibility to a causal association, however, they do not constitute direct evidence. The bilateral fractures seen in many patients corroborate the suspicion that patients with bisphosphonate-associated stress fractures carry some   other   risk   factor   in   addition   to   taking    the drug. Microfractures, inadequate mineralization, and outdated collagen are some of the candidate causes. However, until further studies can provide definitive evidence of bisphosphonate-associated fractures, it is premature to attribute atypical fractures to over-suppression of bone turnover alone, while disregarding secondary and patient-related factors. Many experts believe that prolonged suppression of bone remodeling with alendronate may be associated with a new form of insufficiency fracture of the femur. Studies have not shown if the entire class of medications produce a similar result, but patients who have been treated with any bisphosphonate for an extended period of time should be considered at risk.