Oxford Hospitals Research Articles

Cardiovascular Risk Associated With White-Coat Hypertension: Con Side of the Argument.

Cardiovascular Risk Associated With White-Coat Hypertension: Con Side of the Argument.

A cross-sectional study exploring the incidence of and indications for second-stage cesarean delivery over three decades.

To observe the incidence of, indications for, and complications associated with second-stage cesarean delivery in 10-year intervals over 30years. The present analysis of prospectively collected data compared cesarean deliveries during 1976, 1986, 1996, and 2006 at John Radcliffe Hospital in Oxford, UK (n=3222). Pregnancy, delivery, and neonatal details were reviewed. The proportion of deliveries by cesarean in the second stage of labor increased from 0.5% (22/4464) in 1976 to 2.1% (124/5998) in 2006 (P<0.001). The proportion of cesarean deliveries during the second stage because of failed instrumental delivery also increased over the study period from 59.1% (13/22) in 1976 to 71.0% (88/124) in 2006. Compared with cesareans at other stages, uterine trauma (P<0.001), blood loss greater than 1000mL (P=0.002), and blood transfusion (P=0.001) were more frequent in second-stage cesarean delivery. Neonates delivered by second-stage cesarean had lower Apgar scores (P<0.001 for 1-min and 5-min scores) and cord arterial pH values (P<0.001) than did those delivered by cesarean earlier in labor. A trend towards an increase in neonatal trauma with second-stage cesarean compared with cesarean delivery before labor or during the first stage did not reach statistical significance. The proportion of deliveries by cesarean in the second stage of labor increased; these deliveries were associated with greater maternal and neonatal morbidity, but were not influenced by the indication for cesarean.

18 Mindfulness based interventions

Niels Detert is a Clinical Neuropsychologist in the Psychological Medicine service at the John Radcliffe Hospital in Oxford. He studied Philosophy and Psychology at St Anne’s College, Oxford, and went on to complete doctoral training as a Clinical Psychologist, also in Oxford. He has special interests in using Mindfulness training with people with Neurological conditions and psychotherapy with people with Functional Neurological Symptoms. Group Mindfulness based interventions (MBIs) such as Mindfulness Based Cognitive Therapy have received increasing interest as a cost-effective long-term treatment for recurrent depression and for symptoms of depression, anxiety and stress in health conditions, and more recently as potential first-line treatments for mild-moderate depression. In depression the literature in diverse patient groups reveals superiority over wait-list and treatment as usual, and equivalence with active controls. For anxiety symptoms the outcomes are similar in the literature as a whole, although one meta-analysis with a small number of studies showed no effect in studies with a primary diagnosis of anxiety disorder. In healthcare populations the evidence supports the use of MBIs as an adjunct for alleviation of mental and physical symptoms and for prevention. Evidence in neurological populations is of outcomes broadly consistent with the rest of the literature, in MS and epilepsy, with preliminary promising results in Parkinson’s disease, traumatic brain injury, stroke and other neurological conditions. Areas of ongoing research include psychological mechanisms, neural correlates, and alternative delivery models. Areas for further research include a need for high quality studies where there is preliminary evidence, and investigation of the specific characteristics of this treatment which may guide treatment selection. Pragmatically the resource efficiency of MBIs as group interventions and their generic applicability suggests their utility in the management of larger numbers of patients with diverse physical and psychological needs. Use of an MBI as a long-term coping strategy is a relevant option in the management of patients with long-term conditions who are also suffering with stress, anxiety and depression. References . Gotink RA, Chu P, Busschbach JJV, Benson H, Fricchione GL, Hunink MGM. Standardised Mindfulness-Based Interventions in Healthcare: An Overview of Systematic Reviews and Meta-Analyses of RCTs. Plos One2015:10(4);e0124344–17. http://doi.org/10.1371/journal.pone.0124344 . Grossman P, Kappos L, Gensicke H, D’Souza M, Mohr DC, Penner IK, Steiner C. MS quality of life, depression, and fatigue improve after mindfulness training: a randomised trial. Neurology2010;75(13):1141–1149. http://doi.org/10.1212/WNL.0b013e3181f4d80d

Christopher William Burke

After wide ranging experience of both general and especially endocrine medicine in three London hospitals, as well as a few months in general practice, Christopher William Burke was appointed consultant...

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 13 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Paul T. HeathPaul T. HeathPaul T. Heath is a Professor and Honorary Consultant in Paediatric Infectious Diseases at St Georges NHS Trust and St George's, University of London, UK, where he is also the Director of the Vaccine Institute. His training in paediatrics and infectious diseases was at the Royal Children's Hospital, Melbourne, Australia, the John Radcliffe Hospital, Oxford, UK, and St George's Hospital, London. His particular research interests are in the epidemiology of vaccine preventable diseases, in clinical vaccine trials, particularly in at-risk groups, and in perinatal infections and he has published over 180 original or review papers in these areas. He sits on national committees concerned with neonatal infections, group B streptococcus prevention and on immunisation policies in children. He is a Fellow of the Royal College of Paediatrics and Child Health and a member of the research committee of the European Society of Paediatric Infectious Diseases. Dennis L. StevensDennis L. StevensDr Stevens received his PhD in Microbiology from Montana State University, USA, and his MD from the University of Utah College of Medicine, USA. Following a residency in internal medicine at the University of Utah, Dr Stevens completed an infectious disease fellowship at Brooke Army Medical Center in San Antonio, Texas, USA. Since 1979 he has been Chief of Infectious Diseases at the Veterans Affairs Medical Center in Boise, Idaho, USA. Dr Stevens is Professor of Medicine at the University of Washington School of Medicine, USA, and his major clinical interests have been in Staphylococcal and Streptococcal toxic shock syndromes and in skin and soft tissue infections, including necrotizing fasciitis and gas gangrene. His research interests are centered around gram positive bacteria and the role of extracellular toxins in the pathogenesis of severe soft tissue infection caused by Streptococcus pyogenes, Clostridium perfringens, and methicillin-resistant Staphylococcus aureus. His current research efforts investigate the mechanisms of toxin induced shock and organ dysfunction, including cardiomyopathy, the effects of toxins on endothelial cells, granulocytes, and platelets, and the importance of the mechanisms of action of antibiotics in treating gram positive infections. Dr Stevens has published over 170 original research papers, 89 book chapters, 143 abstracts and three books: Streptococcal Infections: Clinical Aspects, Microbiology and Molecular Pathogenesis (co-authored with Dr Edward Kaplan), An Atlas of Infectious Diseases: Skin and Soft Tissue, Bone and Joint Infections and Netter's Textbook of Infectious Diseases (co- authored with Dr Elaine Jong). Dr Stevens is a member of the American Society of Microbiology, a Fellow in the American College of Physicians, a Fellow in the Infectious Disease Society of America and a member of the Association of American Physicians. In 2000, Dr Stevens received the Infectious Disease Society of America's Society Citation Award, and in 2001 The William Altemier Award from the Surgical Infectious Disease Society. Dr Stevens has served as a consultant for the CDC Working Group on Invasive Group A streptococcal infections and for the WHO and NIH on similar matters. Dr Stevens is currently Chairman of the Infectious Disease Society of America Guidelines Committee on Skin and Soft Tissue Infections.

Patient perspective: life in the melanoma patient community and the emergence of the melanoma patient conference.

Imogen Cheese speaks to Sebastian Dennis-Beron, Commissioning Editor: Imogen was diagnosed with melanoma in June 2013 (currently stage 2C no evidence of disease monitored under Professor Mark Middleton at Oxford) and has since created and writes a website blog (www.melanomarollercoaster.co.uk) as well as founded the melanoma patient conference in 2015. As an impartial event, the patient conference brings together all stakeholders involved in melanoma diagnosis, treatment and care; this includes clinicians, charities and crucially, people living and dying with melanoma. This means the only end goal for the conference are the ongoing needs of patients and families. Imogen's blog has a readership of over 2000 people - many of whom are melanoma patients in the UK. She is prolific in her contact with these patients on social media and as a result of her blog, she has been asked to represent melanoma patients in the UK as their advocacy representative at numerous conferences and events across Europe (including ECC2015 and the MPNE annual events in Brussels). Patients reach out to Imogen on a daily basis asking for support and seeking a means to improve their knowledge and obtain access to better care and information on the latest drugs and trials in the UK. She is a member of the Melanoma Patient Network Europe and speaks daily to over 300 patients on an online support group on social media. Imogen was invited by the British Skin Foundation to support them in establishing a skin cancer specific arm of their charity called ITTakes7 and has worked directly with Melanoma UK on various projects for patient interaction and information gathering. She is connected with Cancer Research UK as a patient representative with the ECMC network and involved with the Oxford hospitals as an advisor for their public engagement and planning. Imogen can be found on twitter at @MelanomaBlog.

Books Received

Books Received Mark I. West Approaches to Teaching the Works of Jack London. Edited by Kenneth K. Brandt and Jeanne Campbell Rees-man. New York: Modern Language Association, 2015. Although Jack London is not known primarily as a children's author, he regularly published short stories in children's magazines, and a few of his works are often classified as children's books, including The Call of the Wild (1903) and White Fang (1906). Several of the contributors to this volume provide insights into teaching these two novels as well as some of London's other works that appeal to child readers. Left to Themselves: Being the Ordeal of Philip and Gerald. By Edward Prime-Stevenson. Edited by Eric L. Tribunella. Richmond, VA: Valancourt, 2016. In this critical edition, Eric L. Tribunella provides a scholarly introduction, explanatory notes, and five appendices. As Tribunella explains in his introduction, the original publication of Left to Themselves in 1891 marked the beginning of gay literature for young adults. Roald Dahl's Marvellous Medicine. By Tom Solomon. Liverpool: Liverpool University Press, 2016. Tom Solomon is a physician and a professor of neurological science. He and Roald Dahl met in 1990 when Dahl was one of his patients at the John Radcliffe Hospital in Oxford. The two became friends and often discussed their shared interest in medical science. In this memoir, Solomon recounts his relationship with Dahl and discusses the latter's fascination with the medical world. South African Young Adult Literature in English, 2000-2014. By Sandra Stadler. Heidelberg: Universitätsverlag Winter, 2017. Sandra Stadler places South African young adult literature within the country's contemporary cultural, social, and political context. She explores how issues related to race, gender, and class are reflected in South African novels for adolescent readers. [End Page 345] Copyright © 2017 Children's Literature Association

Editorial introductions

Current Opinion in Allergy and Clinical Immunology was launched in 2001. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of allergy and clinical immunology are divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Stephen JollesStephen JollesStephen Jolles is Consultant Clinical Immunologist and Honorary Senior Lecturer at the University Hospital for Wales and is Clinical Lead in the Immunodeficiency Centre for Wales. He trained in Immunology and Allergy at the Royal Free Hospital and Great Ormond Street Hospital in London, the John Radcliffe in Oxford and Westmead Hospital in Sydney. His PhD in Cellular Immunology at NIMR, Mill Hill was on Langerhans cell migration and he has a particular interest in the use of immunoglobulin and its mechanism of action both in primary immunodeficiency and at high dose as an immunomodulator. His research interests involve clinical trials, the laboratory diagnosis and management of primary and secondary immunodeficiency and allergy involving the development of new diagnostic tools, screening for immunodeficiency, and the development of molecular testing for primary immunodeficiency diseases. Maite de la MorenaMaite de la Morena(M Teresa Maite) de la Morena is a Professor of Pediatrics and Internal Medicine at the University of Texas, Southwestern Medical Center, Dallas, Texas, USA. She graduated from medical school at the Complutense University, Madrid, Spain, in 1982. This was followed by postgraduate research training in Immunology, followed by Pediatric residency and Allergy & Immunology subspecialty training at the University of South Florida, St. Petersburg, Florida, USA. Dr. de la Morena is a clinician with over twenty years of experience in the diagnosis and care of patients with primary immunodeficiency disorders. In collaboration with basic scientists at UT Southwestern Medical Center her current research interests include the discovery of novel genes associated in primary immunodeficiency syndromes, the role of microRNAs in primary immunodeficiency disorders, and longitudinal clinical outcomes of patients with immunodeficiency disorders such as the X-linked form of hyper IgM and chronic granulomatous disease. Giovanni PassalacquaGiovanni PassalacquaDr Giovanni Passalacqua was born in Genoa in 1964. He graduated in 1990 from the Genoa University Medical School, Italy, and received the full specialty degrees in allergy and in respiratory medicine in 1994 and 2002. Under the chairmanship of Professor Giorgio Walter Canonica, he contributed to investigations in the mechanisms of allergic inflammation, the treatment of respiratory allergy and developed sublingual immunotherapy. Currently he is Associate Professor of Respiratory Medicine, for which also chairs the Specialty School at the University of Genoa. Dr Passalacqua has coauthored more than 300 publications in peer reviewed journals. He serves on the board of experts of Allergic Rhinitis and its Impact on Asthma (ARIA), and is co-Chairman of the immunotherapy committee of the World Allergy Organization. Robert BushRobert BushDr Robert Bush received his MD degree from West Virginia University, USA. After completing his residency in internal medicine and fellowship in allergy and immunology at the University of Wisconsin – Madison, USA, he joined the faculty. He is currently Professor (Emeritus) of Medicine and was the former Chief of Allergy at the William S Middleton VA Hospital, Madison, Wisconsin, USA. His research interests include sublingual immunotherapy, allergen characterization, fungal allergy, food allergy, and occupational asthma.

Pituitary stalk thickening: the role of an innovative MRI imaging analysis which may assist in determining clinical management.

Disease processes that affect the pituitary stalk are broad; the diagnosis and management of these lesions remains unclear. The aim was to assess the clinical, biochemical and histopathological characteristics of pituitary stalk lesions and their association with specific MRI features in order to provide diagnostic and prognostic guidance. Retrospective observational study of 36 patients (mean age 37years, range: 4-83) with pituitary stalk thickening evaluated at a university hospital in Oxford, UK, 2007-2015. We reviewed morphology, signal intensity, enhancement and texture appearance at MRI (evaluated with the ImageJ programme), along with clinical, biochemical, histopathological and long-term follow-up data. Diagnosis was considered certain for 22 patients: 46% neoplastic, 32% inflammatory and 22% congenital lesions. In the remaining 14 patients, a diagnosis of a non-neoplastic disorder was assumed on the basis of long-term follow-up (mean 41.3months, range: 12-84). Diabetes insipidus and headache were common features in 47 and 42% at presentation, with secondary hypogonadism the most frequent anterior pituitary defect. Neoplasia was suggested on size criteria or progression with 30% sensitivity. However, textural analysis of MRI scans revealed a significant correlation between the tumour pathology and pituitary stalk heterogeneity in pre- and post-gadolinium T1-weighted images (sensitivity: 88.9%, specificity: 91.7%). New techniques of MRI imaging analysis may identify clinically significant neoplastic lesions, thus directing future therapy. We propose possible textural heterogeneity criteria of the pituitary stalk on pre- and post-gadolinium T1 images with the aim of differentiating between neoplastic and non-neoplastic lesions with a high degree of accuracy.

Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression

Subacromial impingement is common and frequently treated with arthroscopic subacromial decompression (ASD); however, its efficacy has recently been questioned. Poor surgical outcomes have been associated with anxiety and depression within other orthopedic subspecialties but not within this group of patients. We hypothesized that anxiety and depression are associated with worse outcomes after ASD. A retrospective review of prospectively collected data was carried out of patients undergoing ASD. Inclusion criteria were short-term relief with injection therapy and presence of Hawkins sign. Rotator cuff tears were excluded. Patients completed the Oxford Shoulder Score (OSS), Hospital Anxiety and Depression Scale (HADS), and visual analog scale for pain before and after surgery in outpatient clinic follow-up at 6 weeks and by postal questionnaire at 6 months. The 86 patients who participated in the study were analyzed in 2 groups defined by HADS scores, group A being depressed and group B nondepressed. Both groups had less pain and improved OSS at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation (P < .01) between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation (P < .01) between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction (P < .05). Patients with HADS score >11 before ASD have worse outcomes. This should be taken into account when counseling patients for surgery.

Sudden onset of Cotard&amp;#8217;s syndrome as a clinical sign of brain tumor

We report the clinical case where the sudden onset of a Cotard syndrome in a 69 year old lady lead to the discovery of a multifocal glioblastoma in the right temporo-parietal lobe. Cotard’s syndrome is a rare psychiatric disorder in which the afflicted patient believes he or she is dead. These nihilistic thoughts are the expression of a rare syndrome first described by Jules Cotard in late XIX century. The Cotard’s syndrome has been studied and it seems that its psychopathology can be ascribed to the temporoparietal cortex. Although the Cotard’s syndrome is not part of the DSM-V it is common in psychiatric literature and is included in ICD-10-CM within code F22. It has been described associated with organic lesions and atrophy of the non-dominant temporo-parietal cortex, in pathologies like bipolar disorder, schizophrenia1, subdural hemorrhage2, multiple sclerosis, brain atrophy3 and cerebral infarction4 among others5-7. We observed the case of a female patient, 69 years old, with no relevant past medical history, that was admitted to the John Radcliffe Hospital in Oxford (UK) with an episode of numbness in the left hand and an episode of dizziness whilst at home, duration of symptoms was of 15 minutes and then resolved entirely. She had no history of head trauma. Neurological exam was unremarkable and the stroke team felt a CT scan was not required, however she failed occupational therapy assessment and was not sent home. During the night she developed the delusion of being dead. When being interviewed, in the next day early in the afternoon, she stated: – “I think I’m dead (...) it started during the night, like it was some kind of a dream, but this remain until now” (...) – “Do you rationally think you are dead?” – “I do. It may not make much sense since I realize I have blood pressure when they measure it but I rationally think I am dead.”

Insight Into Quality of Prescription Writing - An Instituitional Study.

Prescription writing is an important task performed by a doctor during patient management. Prescription refers to written instructions given to a patient regarding medications. Lack of attention during prescription writing can lead to prescription errors which in turn can adversely affect patients' well-being. Thus, prescriptions are an important target area for improvement. The purpose of the present study was to analyze the quality of prescriptions dispensed by the students of The Oxford Dental College and Hospital, Bangalore and to compare the prescription writing patterns amongst undergraduates, interns and postgraduates of this institution. A cross-sectional study was conducted on 500 randomly selected prescriptions dispensed by the students of The Oxford Dental College and Hospital, Bangalore, India. All the prescriptions were analyzed for the presence of (a) Patient's information: Out-Patient file number, name, age, gender, address and contact number (b) Doctors information: Full name, department name, qualification, contact details, date of prescription, superscription, and signature (c) Drug information: Name, strength, dosage form, dosage instructions, duration and total quantity. Each prescription was further categorized into groups A, B, C or D, depending on the scores obtained. Prescription quality was then compared between the undergraduates, interns and postgraduates. Analysis of prescriptions performed using Chi-square test showed that groups A, B, C and D had 12 (2%), 155 (31%), 333 (67%) and 0 (0%) students respectively. Association between the groups and qualifications showed statistically significant results (p<0.05). Undergraduate prescriptions were better written in comparison to interns and postgraduates. Findings of the current study demonstrate the need for further improvement in the quality of prescription writing by students of The Oxford Dental College and Hospital, Bangalore, India.

Impact of endometriosis on quality of life, anxiety, and depression: an Austrian perspective.

Several studies on the quality of life in patients with endometriosis have been performed with conflicting results. This cross-section survey examines the influence of endometriosis on the psychological well-being and the quality of life and the incidence of anxiety and depression among these patients, recruited from a tertiary care center in Austria. Three standardized questionnaires of 62 patients with endometriosis were evaluated: status of health questionnaire (SF-36), hospital anxiety and depression scale (HADS-D), and endometriosis health profile (EHP-30). Quality of life status (EHP-30) was compared with published samples of the Oxford hospital and the Charite Berlin. Chi-square tests, independent sample t-tests, and one-way independent ANCOVA's were used to compare SF- 36 and HADS- D scores to 61 healthy controls. Pearson product-moment-correlation coefficients were used to investigate correlations between symptoms of depression and anxiety in the patient sample. Moderate to severe anxiety symptoms were found in 29 %; depressive symptoms were present in 14.5 % of the patients. Both symptoms occurred in 12.9 %. We found significant better values in all subscales of the EHP compared to the Oxford and Berlin samples. The control sample showed significant better subjective general health (p < 0.001), vitality (p < 0.001), mental health (p < 0.001), and better emotional role functioning (p < 0.001). Participants age significantly influenced mental health and emotional role functioning. The impact of endometriosis on life quality in our study was considerably less than in other studies but equivalent to other chronic medical conditions. It could be shown that endometriosis is influenced by biopsychosocial variables. However, the elevated presence of anxiety and depressive symptoms indicates the need of psychosomatic treatment of affective disorders to prevent manifestation.

Clinical Features and Diagnostic Usefulness of Antibodies to Clustered Acetylcholine Receptors in the Diagnosis of Seronegative Myasthenia Gravis.

Cell-based assays (CBAs) were shown to improve detection of acetylcholine receptor (AChR) antibodies in patients with myasthenia gravis (MG). Herein, we asked whether these assays were able to help determine the diagnosis in patients studied in routine clinical practice. To determine the diagnostic usefulness of CBAs in the diagnosis of MG and to compare the clinical features of patients with antibodies only to clustered AChRs with those of patients with seronegative MG (SNMG). All patients with clinical suspicion of MG who were seen within the Division of Clinical Neurology at the John Radcliffe Hospital in Oxford, England, between November 1, 2009, and November 30, 2013. Their serum antibodies and clinical features were studied. Radioimmunoprecipitation assay (RIPA) and CBA were used to test for standard AChR antibodies and antibodies to clustered AChRs in 138 patients. All available samples from patients with SNMG were retrospectively tested for lipoprotein receptor-related protein 4 (LRP4) antibodies. Demographic, clinical, neurophysiological, and laboratory data. In total, 138 patients were tested for antibodies to clustered AChRs, and 42 had a final diagnosis of MG. The clustered AChR CBA detected antibodies in 38.1% (16 of 42) of RIPA-negative patients with MG with 100% specificity. All patients with SNMG who were tested for LRP4 antibodies (21 of 26) were negative by CBA. Compared with patients with SNMG, patients with antibodies only to clustered AChRs had frequent prepubertal onset (62.5% [median age, 6 years; age range, 1-52 years] vs 11.5% [median age, 38 years; age range, 2-72 years], P ≤ .05), high prevalence of ocular MG (62.5% vs 42.3%), milder disease severity with less bulbar involvement (25.0% vs 46.2%), and absence of respiratory symptoms (0% vs 23.1%). Response to treatment and prognosis was good, with a reduced need for thymectomy (6.3% vs 19.2%) and a high proportion of patients going into remission (50.0% vs 8.3%, P ≤ .05). These observations also apply to the classic AChR MG phenotype seen in large series. Cell-based assay is a useful procedure in the routine diagnosis of RIPA-negative MG, particularly in children. Patients with antibodies only to clustered AChRs appear to be younger and have milder disease than other patients with MG. These observations will have implications in planning treatment.

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Paul T. HeathPaul T. HeathPaul T. Heath is a Professor and Honorary Consultant in Paediatric Infectious Diseases at St George's, University of London, UK, and St George's Vaccine Institute in London, UK. His training in paediatrics and infectious diseases was at the Royal Children's Hospital, Melbourne, Australia, the John Radcliffe Hospital, Oxford, UK, and St George's Hospital, London, UK. His particular research interests are in: the epidemiology of vaccine preventable diseases, clinical vaccine trials (particularly in at-risk groups), and in perinatal infections. He has published over 150 original or review papers in these areas. He sits on national committees concerned with neonatal infections, meningitis, group B streptococcus prevention, and on immunisation policies in children. He is a Fellow of the Royal Australasian College of Physicians, a Fellow of the Royal College of Paediatrics and Child Health, a member of the research committee of the European Society of Paediatric Infectious Diseases and a member of the Science Board of the international Brighton Collaboration on vaccine safety. Dennis L. StevensDennis L. StevensDr Stevens received his PhD in Microbiology from Montana State University, USA, and his MD from the University of Utah College of Medicine, USA. Following a residency in internal medicine at the University of Utah, Dr Stevens completed an infectious disease fellowship at Brooke Army Medical Center in San Antonio, Texas, USA. Since 1979 he has been Chief of Infectious Diseases at the Veterans Affairs Medical Center in Boise, Idaho, USA. Dr Stevens is Professor of Medicine at the University of Washington School of Medicine, USA, and his major clinical interests have been in Staphylococcal and Streptococcal toxic shock syndromes and in skin and soft tissue infections, including necrotizing fasciitis and gas gangrene. His research interests are centered around gram positive bacteria and the role of extracellular toxins in the pathogenesis of severe soft tissue infection caused by Streptococcus pyogenes, Clostridium perfringens, and methicillin-resistant Staphylococcus aureus. His current research efforts investigate the mechanisms of toxin induced shock and organ dysfunction, including cardiomyopathy, the effects of toxins on endothelial cells, granulocytes, and platelets, and the importance of the mechanisms of action of antibiotics in treating gram positive infections. Dr Stevens has published over 170 original research papers, 89 book chapters, 143 abstracts and three books: Streptococcal Infections: Clinical Aspects, Microbiology and Molecular Pathogenesis (co-authored with Dr Edward Kaplan), An Atlas of Infectious Diseases: Skin and Soft Tissue, Bone and Joint Infections and Netter's Textbook of Infectious Diseases (co- authored with Dr Elaine Jong). Dr Stevens is a member of the American Society of Microbiology, a Fellow in the American College of Physicians, a Fellow in the Infectious Disease Society of America and a member of the Association of American Physicians. In 2000, Dr Stevens received the Infectious Disease Society of America's Society Citation Award and in 2001 The William Altemier Award from the Surgical Infectious Disease Society. Dr Stevens has served as a consultant for the CDC Working Group on Invasive Group A streptococcal infections and for the WHO and NIH on similar matters. Dr Stevens is currently Chairman of the Infectious Disease Society of America Guidelines Committee on Skin and Soft Tissue Infections.

Principles of Operative Surgery: Viva Practice for the MRCS (3rd edn)

This is the latest addition to the Master Pass series of texts designed to support candidates preparing for examinations and the third edition offering viva practice for the intercollegiate MRCS. The authors are based in the departments of surgery at St George's Hospital in London and the John Radcliffe Hospital in Oxford. They have carefully assembled and updated the material to include topics collected from candidates who have sat the MRCS during the last 3 years with others from examiners who have set questions. Indeed, they point out in the preface that a number are questions that have actually been used, while others are included as teaching points. In addition, they recommend that the book be used with the assistance of a colleague playing the role of an examiner to improve its effectiveness. It opens with valuable tips for success in the viva, including a simple but practical framework for describing an operation from pre-operative preparation, in theatre and on to postoperative care. More than 60 surgical topics are covered in alphabetical order from, for example, acute limb ischaemia, appendicitis and ATLS through paediatric inguinal hernia, robot-assisted laparoscopic surgery and sutures and needles to vasectomy and wound healing. Each is completed in no more than four pages in a relatively simple, easy-to-read manner. Following this, there are short sections on controlled clinical trials, medical statistics and surgical audit with a helpful concluding list of guidance for further reading. Presented in an economical format in paperback, this book should fit into a white coat pocket (for the sadly diminishing number who wear them these days) with the consequent potential of being a helpful aide-memoire to reinforce live clinical scenarios on the ward, in the accident and emergency department and in the operating theatre. Although its stated aim is to assist MRCS candidates, it is also likely to prove helpful for those preparing for certifying examinations of the American Board of General Surgery, the fellowship of the Royal Australasian College of Surgeons and Canadian Board examinations. In addition, those approaching undergraduate surgical finals will also find it helpful as will those needing to update their general surgical knowledge in preparation for postgraduate examinations in dental and oral surgery.

Experience of managing open fractures of the lower limb at a major trauma centre.

In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.

‘Voice of the Visitors’: An Exploration of the Work of the Charity Organisation Society in Oxford, 1878–1880

The article explores the role of the Charity Organisation Society (COS) in conjunction with the local voluntary hospital (Radcliffe Infirmary) in Oxford, in attempts to filter the ‘deserving’ from the ‘undeserving’ poor in order to ensure the right people received ‘gratuitous medical relief’. This was during a time when there was increased pressure on the out-patients department due to an expanding population, and the government had curbed public spending to restrict out-relief, which included medical relief. Through examination of unique patient records made by the COS visitors from 1878 to 1880, a picture of the work of the Oxford COS is gained. Other documentary sources concerned with associated health and welfare projects have also been examined to measure the outcome of the project, identify key personnel and influences within the city.

Christopher Berkeley (“Kit”) Wynn Parry

Rheumatologist who specialised in hand injuries and performing arts medicine When as a young medical graduate Kit Wynn Parry found out that the Royal Air Force was looking for recruits...

The expression of cathepsin-D in odontogenic cysts and tumors: Immunohistochemistry study

Background: Cathepsin-D, a protease, which is an invasion promoter and plays a central role in solid tumors including oral cancer. Our aim of the study was to look for their expression pattern in epithelium and stroma of odontogenic cysts and tumors and correlate their aggressiveness to the staining intensity. Materials and Methods: To elucidate the expression patterns of this marker, we examined immunohistochemically on formalin-fixed, paraffin-embedded sections of 24 odontogenic cysts and 10 odonogenic tumors, which are received for histopathologic examination in the Department of Oral Pathology, The Oxford Dental College and Hospital, Bengaluru. Results: The epithelium of granular cell ameloblastoma (GCA) and odontogenic keratocyst (OKC) showed maximum staining with spillage of stained material in the connective tissue wall and at the separation of epithelium to capsule in OKC compared to other cysts and tumors. Conclusions: Cathepsin-D could be one of the enzymes important in separation of epithelium and connective tissue in OKC which helps in recurrence and intense expression in GCA with spillage into stroma, compared to other odontogenic tumors may explain its aggressive behavior, recurrence, and metastatic potential. To further validate our findings, it is suggested to use more sample size and monoclonal antibody for cathepsin-D.