The deposition, characterisation and biocompatibility of hydroxyapatite and silicon doped hydroxyapatite thin film coatings for orthopaedic applications

Silicon doped hydroxyapatite (SiHA) could be used as a thin film coating on load bearing bone implants to provide a bioactive layer enabling bone to form a direct bond with the implant/bone interface thus increasing implant lifetime by lowering the chances of aseptic loosening. This study has been undertaken to investigate silicon additions to RF magnetron sputtered hydroxyapatite (HA) thin films. Detailed characterisation was carried out on SiHA thin films to establish the structural, chemical, mechanical and compositional properties. Silicon content was altered by adjusting the power density applied to silicon targets in a co-deposition process resulting in SiHA films containing 0.0, 1.8, 4.2 and 13.4 wt.% silicon. All as-deposited thin films were found to be amorphous. After annealing at 600˚C in flowing argon for 2 h, it was found that films exhibited a single phase HA structure. The addition of silicon inhibited HA crystallite growth and acted to lower the stability of HA films in aqueous solutions. The 13.4 wt.% SiHA thin film did not recrystallise until a heat treatment at 800˚C. From the work presented here, it is proposed that, in post-plasma-deposited heat treated films, silicon substitutes as silicate species into the HA lattice. Asdeposited silicon containing thin films were found to be amorphous and have a polymeric silicate configuration, suggesting that, silicate groups may be randomly distributed throughout the amorphous film. After post-deposition annealing silicon containing films were in a monomeric state suggesting silicate groups had substituted for phosphate tetrahedra in the HA lattice. Furthermore, an HA-like phase was found to be present. Contrary to these findings, FTIR analysis did not manifest any silicate-based bands. This may, however, be due to the fact that technique used only samples a very small amount of material and, due to the low doping quantities of silicon in the HA films. Furthermore, Ca/P ratios consistently differed from the stoichiometric value of HA (1.67). This combined evidence raises the question of whether the post-deposition heat-treated films have a true HA-like structure. More work is required in order to truly understand the structures present in heat-treated SiHA thin films. HA thin film composition is commonly measured in terms of the Ca/P ratio. Energy dispersive X-ray analysis (EDX) and XPS were evaluated in terms of accuracy in conjunction with Rutherford backscattering spectroscopy (RBS) to measure the Ca/P ratio of HA thin films to establish the most appropriate technique for accurate compositional analysis. This was was found to the RBS, achieving an accuracy of within 2 %, with EDX averaging 8 % and XPS ranging from 25 - 42%. It was concluded that XPS gave such large differences in values because the top few atomic layers of thin films was of a different composition than the bulk of the coating. A Human osteoblast cell (HOB) model was used to establish the in vitro cellular response of SiHA thin films. Initially, HA and SiHA thin films annealed at 600˚C were compared. Cells attached and proliferated well on HA surfaces compared to SiHA surfaces, however, improved cell growth was seen with increasing silicon content. Dissolution studies showed that SiHA thin films were highly unstable in cell culture media and it is thought that the films dissolved, and where cell adhesion and growth did occur it was because cells adhered to the titanium substrates beneath the films. This was then compared with HA and SiHA thin films annealed at 700˚C. No significant difference was found between the two surfaces in terms of cell growth or protein expression indicating that silicon content and crystallinity play an important role in the cellular response of SiHA thin film

Pervasive remagnetization of detrital zircon host rocks in the Jack Hills, Western Australia and implications for records of the early geodynamo

It currently is unknown when Earth's dynamo magnetic field originated. Paleomagnetic studies indicate that a field with an intensity similar to that of the present day existed 3.5 billion years ago (Ga). Detrital zircon crystals found in the Jack Hills of Western Australia are some of the very few samples known to substantially predate this time. With crystallization ages ranging from 3.0–4.38 Ga, these zircons might preserve a record of the missing first billion years of Earth's magnetic field history. However, a key unknown is the age and origin of magnetization in the Jack Hills zircons. The identification of >3.9 Ga (i.e., Hadean) field records requires first establishing that the zircons have avoided remagnetization since being deposited in quartz-rich conglomerates at 2.65–3.05 Ga. To address this issue, we have conducted paleomagnetic conglomerate, baked contact, and fold tests in combination with U–Pb geochronology to establish the timing of the metamorphic and alteration events and the peak temperatures experienced by the zircon host rocks. These tests include the first conglomerate test directly on the Hadean-zircon bearing conglomerate at Erawandoo Hill. Although we observed little evidence for remagnetization by recent lightning strikes, we found that the Hadean zircon-bearing rocks and surrounding region have been pervasively remagnetized, with the final major overprinting likely due to thermal and/or aqueous effects from the emplacement of the Warakurna large igneous province at ∼1070 million years ago (Ma). Although localized regions of the Jack Hills might have escaped complete remagnetization, there currently is no robust evidence for pre-depositional (>3.0 Ga) magnetization in the Jack Hills detrital zircons

Production of High Silicon-Doped Hydroxyapatite Thin Film Coatings via Magnetron Sputtering: Deposition, Characterisation, and In Vitro Biocompatibility

In recent years, it has been found that small weight percent additions of silicon to HA can be used to enhance the initial response between bone tissue and HA. A large amount of research has been concerned with bulk materials, however, only recently has the attention moved to the use of these doped materials as coatings. This paper focusses on the development of a co-RF and pulsed DC magnetron sputtering methodology to produce a high percentage Si containing HA (SiHA) thin films (from1.8 to 13.4 wt. %; one of the highest recorded in the literature to date). As deposited thin films were found to be amorphous, but crystallised at different annealing temperatures employed, dependent on silicon content, which also lowered surface energy profiles destabilising the films. X-ray photoelectron spectroscopy (XPS) was used to explore the structure of silicon within the films which were found to be in a polymeric (SiO2; Q4) state. However, after annealing, the films transformed to a SiO44- Q0, state, indicating that silicon had substituted into the HA lattice at higher concentrations than previously reported. A loss of hydroxyl groups and the maintenance of a single-phase HA crystal structure further provided evidence for silicon substitution. Furthermore, a human osteoblast cell (HOB) model was used to explore the in vitro cellular response. The cells appeared to prefer the HA surfaces compared to SiHA surfaces, which was thought to be due to the higher solubility of SiHA surfaces inhibiting protein mediated cell attachment. The extent of this effect was found to be dependent on film crystallinity and silicon content

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multi-centre observational study

There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best-practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in 312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%)

Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome