bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk-stratified multi-round PSA screening for prostate cancer integrating the screening reference level and subgroup-specific progression indicators
Authors: Liu Xiaomin , Zhang Yu , Duan Hongyuan , Yang Lei , Sheng Chao , Fan Zeyu , Liu Ya , Gao Ying , Wang Xing , Zhang Qing , Lyu Zhangyan , Song Fangfang , Song Fengju , Huang Yubei
Published: July 2023

Background

Although prostate-specific antigen (PSA) is widely used in prostate cancer (PCa) screening, nearly half of PCa cases are missed and less than one-third of cases are non-lethal. Adopting diagnostic criteria in population-based screening and ignoring PSA progression are presumed leading causes.

Methods

A total of 31,942 participants with multi-round PSA tests from the PLCO trial were included. Time-dependent receiver-operating-characteristic curves and area under curves (tdAUCs) were performed to determine the screening reference level and the optimal subgroup-specific progression indicator. Effects of risk-stratified multi-round PSA screening were evaluated with multivariable Cox regression and measured with hazard ratio [HR (95%CIs)].

Results

After a median follow-up of 11.6 years, a total of 3484 PCa cases and 216 PCa deaths were documented. The tdAUC of 10-year incidence PCa with PSA was 0.816, and the cut-off value was 1.61 ng/ml. Compared to subgroup with stable negative PSA in both first-round (FR) and last-round (LR) tests [FR(−)/LR(−)], HRs (95%CI) of PCa incidence were 1.66 (1.20–2.29), 8.29 (7.25–9.48), and 14.52 (12.95–16.28) for subgroups with loss of positive PSA[FR(+)/LR(−)], gain of positive PSA[FR(−)/LR(+)], and stable positive PSA[FR(+)/LR(+)]; while HRs(95%CI) of PCa mortality were 1.47 (0.52–4.15), 5.71 (3.68–8.86), and 5.01 (3.41–7.37). After excluding regressive PSA [(namely FR(+)/LR(−)], absolute velocity was the shared optimal progression indicator for subgroups with FR(−)/LR(−), FR(−)/LR(+), and FR(+)/LR(+), with tdAUCs of 0.665, 0.681 and 0.741, and cut-off values of 0.07, 0.21, and 0.33 ng/ml/year. After reclassifying participants into groups with positive and negative progression based on subgroup-specific progression indicators, incidence HR (95%CI) were 2.41 (1.87–3.10), 2.91 (2.43–3.48), and 3.16 (2.88–3.46) for positive progression compared to negative progression within subgroups of FR(−)/LR(−), FR(−)/LR(+), and FR(+)/LR(+), while mortality HR (95%CI) were 2.22 (0.91–5.38), 2.37 (1.28–4.38), and 2.98 (1.94–4.59). To improve screening performances by excluding regressive PSA and low-risk positive progression in FR(−)/LR(−), optimized screening strategy not only significantly reduce 32.4% of missed PCa (54.0% [1881/3484] vs. 21.6% [754/3484], P < 0.001), but also detected additional 8.0% of high-grade PCa (Gleason score 7–10: 36.0% [665/1849] vs. 28.0% [206/736], P < 0.001) than traditional screening strategy.

Conclusions

Risk-stratified multi-round PSA screening strategy integrating the screening reference level and the optimal subgroup-specific progression indicator of PSA could be recommended as a fundamental strategy to reduce missed diagnosis and improve the detection of high-grade PCa cases.
Occurrence and outcome of COVID-19 in AIRD patients on concomitant treatment with Tofacitinib- results from KRA COVID COHORT (KRACC) subset
Authors: Chebbi Pramod , Shobha Vineeta , Rao Vijay K , Haridas Vikram , Janardana Ramya , Pinto Benzeeta , Kumar Sharath , Patil Abhishek , Tekkatte Roopa , Salanke Manasa , Mahendranath K M
Published: July 2023

Introduction

We assessed the risk factors and outcome of COVID-19 in patients with autoimmune rheumatic diseases(AIRD) who contracted infection while on background treatment with tofacitinib.

Methods

This is a non-interventional, cross-sectional, questionnaire based telephonic study which included consecutive AIRD patients on tofacitinib co-treatment. Data related to the AIRD subset, disease modifying anti rheumatic drugs(DMARDs) including glucocorticoids and comorbidities, was collected from 7 rheumatology centers across Karnataka during the second wave of COVID-19 pandemic. The information about COVID-19 occurrence and COVID-19 vaccination was recorded.

Results

During the study period (Jun-July 2021), 335 AIRD patients (80.6% female) on treatment with tofacitinib were included. The mean duration of tofacitinib use was 3.4+/-3.1months. Thirty-six(10.75%) patients developed COVID-19. Diabetes mellitus (p = 0.04 (OR 2.60 (1.13–5.99)) was identified as a risk factor for COVID-19 in our cohort. Almost half of our cohort was COVID-19 vaccinated with at least one dose, with resultant decline in incidence of COVID-19(OR 0.15 (0.06–0.39) among the vaccinated. Recovery amongst COVID-19 infection group was 91.2%.

Conclusions

The subset of AIRD patients who were on treatment with tofacitinib were found to have a higher rate of COVID-19 infection as compared to our KRACC cohort. Pre-existing comorbidity of diabetes mellitus was the significant risk factor in our cohort. This subset of the KRACC cohort shows RA patients had a lesser infection and PsA patients had a higher infection.
Evaluation of obstetric outcomes in Brazilian pregnant women with Takayasu arteritis
Authors: Ávila Marcela Ignacchiti Lacerda , Marques Marcela Gaiotti , da Rocha Maria Eduarda Araújo Machado , dos Santos Flávia Cunha , Ochtrop Manuella Lima Gomes , de Jesús Nilson Ramires , de Jesús Guilherme Ribeiro Ramires , Elias Camila Souto Oliveira
Published: July 2023

Objective

Takayasu arteritis (TAK) is a rare chronic granulomatous vasculitis that affects large vessels and usually begins in women of childbearing age, so it is not uncommon for pregnancies to occur in these patients. However, there is limited information about these pregnancies, with reports of adverse maternal and obstetric outcomes. The objective of this study is to evaluate adverse maternal, fetal and neonatal events in pregnant patients with TA.

Methods

This is a cross-sectional study with retrospective data collection. We reviewed 22 pregnancies in 18 patients with TAK, according to the American College of Rheumatology criteria, that were followed up in a high-risk prenatal clinic specialized in systemic autoimmune diseases and thrombophilia (PrAT) at Hospital Universitário Pedro Ernesto, from 1998 to 2021.

Results

In twenty-two pregnancies, the mean age of patients was 28.09 years and the mean duration disease was 10.9 years. Of the 18 patients with TAK studied, only one had the diagnosis during pregnancy and had active disease. All other patients had a previous diagnosis of TAK and only 3 had disease activity during pregnancy. Twelve patients (66.6%) had previous systemic arterial hypertension and eleven (61.1%) had renal involvement. Among maternal complications, eight patients (36.3%) developed preeclampsia and six (27.2%) had uncontrolled blood pressure without proteinuria, while 10 (45%) had puerperal complications. Four (18.1%) births were premature, all due to severe preeclampsia and eight newborns (34.7%) were small for gestational age. When all maternal and fetal/neonatal outcomes included in this study were considered, only 6 (27.2%) pregnancies were uneventful.

Conclusion

Although there were no maternal deaths or pregnancy losses in this study, the number of adverse events was considerably high. Hypertensive disorders and small for gestational age newborns were more common than general population, while the number of patients with active disease was low. These findings suggest that pregnancies in patients with TAK still have several complications and a high-risk prenatal care and delivery are necessary for these patients.
A Buyer Power Theory of Exclusive Dealing and Exclusionary Bundling
Authors: Chambolle Claire , Molina Hugo
Published: July 2023

We develop a unified theory of exclusive dealing and exclusionary bundling. In a framework with two competing manufacturers that supply their product(s) through a monopolist retailer, we show that buyer power restores the profitability of such practices involving inefficient exclusion. The mechanism underlying this exclusion is that the compensation required by the retailer to renounce selling the rival product erodes with its buyer power. We further show that our theory holds when buyer power differs across manufacturers or when the retailer can strategically narrow (or expand) its product assortment. (JEL D42, D43, K21, L42, L60, L81)
Competition for Attention and News Quality
Authors: Chen Heng , Suen Wing
Published: July 2023

Over the past decades the number of news outlets has increased dramatically, but the quality of news products has declined. We propose a model to reconcile these facts where consumers’ attention allocation decisions not only depend on but also affect news outlets’ quality choices. When competition is intensified by new entries, the informativeness of the news industry rises. Thus, attention is diverted from existing outlets, reducing their incentives to improve news quality, which begets a downward spiral. Furthermore, when attention becomes cheaper, a larger number of news outlets can be accommodated in equilibrium, but news quality still falls. (JEL D83, L15, L82)
Bid Caps in Noisy Contests
Authors: Fu Qiang , Wu Zenan , Zhu Yuxuan
Published: July 2023

This paper studies optimal bid caps in a multiplayer noisy contest in which a higher bid does not guarantee a sure win. The bid cap can be either rigid or flexible. The former imposes outright bidding restrictions on players’ bids, while the latter taxes bids. A designer structures the bid cap to maximize a weighted sum between aggregate bid and tax revenue. Our analysis characterizes the optimum. A rigid bid is always outperformed by flexible ones, and a laissez-faire policy—i.e., no cap—is optimal when the designer maximizes the aggregate bid. The results also generate novel practical implications. (JEL C72, D44, D82)
Characteristics of Site from Scientific Analysis of Iron By-product Excavated from Osong in Cheongju, Korea
Authors: Jung Da Yeon , Cho Nam Chul
Published: July 2023

The characteristics of the sites were identified through scientific analysis of by-products excavated from Osong site in Cheongju, and regional characteristics were investigated by comparing the by-products of Jincheon Songdu-ri, Jincheon Gusan-ri, and Cheongwon Yeonje-ri site at the same time. In the total Fe and deoxidation agent by smelting, direct smelting total Fe is 33.16-59.01 wt%, and deoxidation agent is 20.58-51.54 wt%, and Osong sites correspond to this. The compound analysis result indicated that fayalite and wüstite, oliven are the main compounds in slag. Furthermore, the microstructure analysis result confirmed the presence of fayalite and wüstite in the slag. In particular, two of the four samples have high CaO content, and Kirschsteinite was detected as a result of XRD analysis, and Kirschsteinite was also confirmed in Raman micro-spectroscopy analysis. This is a major feature of the slag of Osong sites in Cheongju used in this analysis, and it is estimated that the ingredients contained in the original ore have been eluted. In the case of locally close Jincheon Songdu-ri, Jincheon Gusan-ri, and Cheongwon Yeonje-ri, the overall amount of total Fe and deoxidation agent were similar, and as a result of comparing rare earth elements, it is estimated that there is no significant difference in raw materials. Through these results, the Osong sites in Cheongju produced iron by direct smelting using raw ore containing Kirschsteinite with high CaO content, and similar iron-making process characteristics were confirmed in all four sites.
Cytogenetic profile of Acute Myeloid Leukemia and Acute Lymphoblastic Leukemia in Northern Pakistan
Authors: Maria Khan  , Chaudhry Altaf Hussain  , Hamid Saeed Malik  , Mohammad Abdul Naeem
Published: July 2023

Objective: To determine the frequencies of different cytogenetic abnormalities in patients of Acute Myeloid Leukemia and Acute Lymphoblastic Leukemia in Northern Pakistan.

Methods: It was descriptive cross-sectional study conducted in Hematology Department of a Tertiary care referral institute from June 2015 to July 2017. All newly diagnosed cases of Acute Leukemia were analyzed. Cytogenetic analysis was performed on bone marrow aspirate samples using Giemsa-trypsin banding technique. Karyotypes were identified and interpreted according to ISCN criteria.

Results: A total of 355 newly diagnosed patients of Acute Leukemia were analyzed. Out of these, 180 patients had AML and 175 had ALL. In Acute Myeloid Leukemia chromosomal abnormalities were detected in 28.2 % cases. Of these the common ones included t(8;21),t(15;17),+8, Inversion 16 and Monosomy 7. Other abnormalities included Complex karyotype, Down’s syndrome related AML, Hyperdiploidy, del 16q,-8,+Y and t(3p;17q)del 10. In Acute Lymphoblastic Leukemia chromosomal abnormalities were detected in 40% cases. Common ones included Hyperdiploidy, Tetraploidy and t(9;22). Other abnormalities included t(1;19) and t(2;8)t(8;14).

Conclusion: Cytogenetically favorable abnormalities are commonest occurring chromosomal defects in both Acute Myeloid Leukemia and Acute Lymphoblastic Leukemia in Northern Pakistan, i.e., t(8;21) in AML and Hyperdiploidy in ALL.

doi: https://doi.org/10.12669/pjms.39.5.6405

How to cite this: Khan M, Altaf C, Malik HS, Naeem MA. Cytogenetic profile of Acute Myeloid Leukemia and Acute Lymphoblastic Leukemia in Northern Pakistan. Pak J Med Sci. 2023;39(5):---------. doi: https://doi.org/10.12669/pjms.39.5.6405

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
System-Synergetic Approach to the Formation of a Mechanism for Assessing the State of Economic Security of the Economic System
Authors: Kulabuhova M.
Published: July 2023

The article is devoted to the issues of applying the conclusions of the system-synergetic methodology in the formation of a mechanism for assessing the state of economic security of economic systems. The evolution of methodological approaches to describing the stability and variability of economic systems, their crisis development is considered. Such approaches are characterized from the standpoint of assessing the state of economic security of the ES. The analysis of scientific works of a number of domestic and foreign authors was carried out, based on the results of which conclusions were drawn, projected to resolve problems associated with the formation of adequate logic of the development of ES and effective procedures for assessing economic security. The role of system-synergetic methodology in solving problems of economic security assessment is shown.
COMUNICAÇÃO EDUCATIVA NAS VIVÊNCIAS DE POLÍTICAS PÚBLICAS CONFORME AS ABORDAGENS COGNITIVAS, AS TEORIAS DECOLONIAIS E A EDUCAÇÃO COMO PRÁTICA DE LIBERDADE EM PAULO FREIRE
Authors: Martins Jonathan Alves , Knox Winifred
Published: July 2023

O artigo apresenta resultados do trabalho de conclusão do curso de Bacharelado em Gestão de Políticas Públicas (GPP) realizado na Universidade Federal do Rio Grande do Norte (UFRN), que consistiu em um estudo propositivo e reflexivo acerca da experiência com a curricularização da extensão universitária desenvolvidas no componente curricular “Vivências em Gestão de Políticas Públicas”. Estabelecemos um diálogo teórico e metodológico entre as Abordagens Cognitivas de Políticas Públicas, especialmente a teoria francesa dos referenciais (MULLER, SUREL, 2002; LASCOUMES; LE GALÈS, 2012; MULLER, 2018), a teoria decolonial da Sociologia das Ausências e Emergências (SANTOS, 2002, RESENDE, 2019) e a concepção de educação para a liberdade enquanto prática dialógica (FREIRE, 1979, 1983a, 1983b, 1992,1993). Verificamos a pertinência da elaboração desta proposta de ensino que considera a extensão como uma ação de comunicação, logo uma prática pautada pelo diálogo. A defesa de uma prática de ensino comunicativa considera a importância da não imposição de saberes, como também da ideia de educação enquanto prática para a liberdade e para a transformação das realidades sociais por meio da conscientização oriunda da leitura de mundo das pessoas envolvidas.
Cannabidiol and naturalistic fallacy: it's natural so it's safe?
Authors: Lowe Robyn
Published: July 2023

The projected market value of the UK CBD industry looks to hit £1 billion by 2025. The statistics for its safety in animals are not easily obtainable. Many owners could be, and are suspected to be, using CBD products without a veterinary prescription. Many are using CBD as a ‘natural’ alternative, it is important to question and explore this relatively new trend to assess if natural really does mean safe and benign, and importantly if there is enough evidence base to warrant its use in veterinary medicine.
UK Drivetrain for S America Buses
Authors: Wade Andrew
Published: July 2023

Vehicles will have world's most power/torque dense electric motor
Inspiring Engineers of the Future
Authors: Excell Jon
Published: July 2023

Museum offers hands-on experience
Action Stations
Authors: Nathan Stuart
Published: July 2023

Stuart Nathan looks at the engineering challenges involved in the final part of Crossrail: fitting out the interiors of the Elizabeth Line stations
X-RAY BEAM GEOMETRY AS APPLIED TO CIRCULAR EXTERNAL FIXATOR IMAGING
Authors: Harris Peter C , Lacey Stephen , Steward Adam , Sertori Mikayla , Homan James
Published: July 2023

Introduction

The various problems that are managed with circular external fixation (e.g. deformity, complex fractures) also typically require serial plain x-ray imaging.

One of the challenges here is that the relatively radio-opaque components of the circular external fixator (e.g. the rings) can obscure the view of the area of interest (e.g. osteotomy site, fracture site).

In this presentation we describe how the geometry of the x-ray beam affects the produced image and how we can use knowledge of this to our advantage.

Whilst this can be applied to any long bone, we have focused on the tibia, given that it's the most common long bone that is treated by circular external fixation.

Materials & Methods

In the first part of the presentation we describe the known attributes (geometry) of the x-ray beam and postulate what effect it would have when we x-ray a long bone that is surrounded by a circular external fixator.

In the second part we demonstrate this in practice using a tibia and a 3 ring circular external fixator. Differing x-ray beam orientations are used to demonstrate both how the geometry of the beam affects the produced image and how we can use this to our advantage to better visualise part of the bone.

Results

The practical part of the study confirmed the theoretical part.

Conclusions

Knowledge of the beam geometry can be used to minimise the obscuring nature of the circular fixator. This technique is simple and can be easily taught to the radiographer. It is a useful adjunct for the limb reconstruction surgeon.
OSSEOINTEGRATION OUTCOMES FOLLOWING AMPUTEE LENGTHENING
Authors: Hoellwarth Jason , Oomatia Atiya , Chavan Anuj , Al Muderis Munjed
Published: July 2023

Introduction

Percutaneous EndoProsthetic Osseointegration for Limbs (PEPOL) facilitates improved quality of life (QOL) and objective mobility for most amputees discontent with their traditional socket prosthesis (TSP) experience. Some amputees desiring PEPOL have residual bone much shorter than the currently marketed press-fit implant lengths of 14–16 cm, potentially a risk for failure to integrate. We report on the techniques used, complications experienced, the management of those complications, and the overall mobility outcomes of seven patients who had femur distraction osteogenesis (DO) with a Freedom nail followed by PEPOL.

Materials & Methods

Retrospective evaluation of a prospectively maintained database identified nine patients (5 females) who had transfemoral DO in preparation for PEPOL with two years of follow-up after PEPOL. Six patients had traumatic causes of amputation, one had perinatal complications, one was performed to manage necrotizing fasciitis and one was performed as a result of osteosarcoma.

Results

The average age at which DO commenced was 39.4±15.9 years, and seven patients had their amputation more than ten years prior (average 25.5±18.8 years). The residual femurs on average started at 102.2±39.7 mm and were lengthened 58.1±20.7 mm, 98±45% of goal (99±161% of the original bone length). Five patients (56%) had a complication requiring additional surgery: four events of inadequate regenerate were managed with continued lengthening to desired goal followed by autograft placement harvested from contralateral femur reaming; one patient had the cerclage wires break which required operative replacement. All patients had osseointegration performed, at 355±123 days after the initial lengthening nail surgery. One patient had K-level >2 before DO, at a mean of 3.4±0.6 (2.6–4.4) years following osseointegration six patients had K-level >2. The 6 Minute Walk Test remained unchanged (267±56 vs 308 ± 117 meters). Patient self-rating of prosthesis function, problems, and amputee situation did not significantly change from before DO to after osseointegration. Six patients required additional surgery following osseointegration: six to remove fixation plates placed to maintain distraction osteogenesis length at osseointegration; two required irritation and debridement for infection.

Conclusions

Extremely short residual femurs which make TSP use troublesome can be lengthening with externally controlled telescoping nails, and successfully achieve osseointegration. However, it is imperative to counsel patients that additional surgery to address inadequate regenerate or to remove painful hardware used to maintain fixation may be necessary. This may improve the amputee's expectations before beginning on a potentially arduous process.
MEDIUM-TERM OUTCOMES OF TRANSFEMORAL OSSEOINTEGRATION IN ASSOCIATION WITH TOTAL HIP ARTHROPLASTY
Authors: Hoellwarth Jason , Oomatia Atiya , Al Muderis Munjed
Published: July 2023

Introduction

Transfemoral osseointegration (TFOI) for amputees has substantial literature proving superior quality of life and mobility versus a socketed prosthesis. Some amputees have hip arthritis that would be relieved by a total hip replacement (THR). No other group has reported performing a THR in association with TFOI (THR+TFOI). We report the outcomes of eight patients who had THR+TFOI, followed for an average 5.2 years.

Materials & Methods

Our osseointegration registry was retrospectively reviewed to identify all patients who had TFOI and also had THR, performed at least two years prior. Six patients had TFOI then THR, one simultaneous, one THR then TFOI. All constructs were in continuity from hip to prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in subjective hip pain, K-level, daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but one patient did not have complete mobility and quality of life survey data at both time periods.

Results

Four (50%) were male, average age 52.7±14.8 years. Three patients (38%) had amputation for trauma, three for osteosarcoma, one each (13%) infected total knee and persistent infection after deformity surgery. One patient died one year after THR+TOFA from subsequently diagnosed pancreatic cancer. One patient had superficial debridement for infection with implant retention after five years. No implants were removed, no fractures occurred. All patients reported severe hip pain preoperatively versus full relief of hip pain afterwards. K-level improved from 0/8=0% K>2 (six were wheelchair-bound) to 5/8=63% (p=.026). At least 8 hours of prosthesis wear was reported by 2/7=29% before TOFA vs 5/7=71% after (p=.286). The QTFA improved in all categories, but not significantly: Global (40.0±21.6 vs 60.0±10.9, p=.136), Problem (50.2±33.2 vs 15.4±8.4, p=.079), and Mobility (35.9±26.8 vs 58.3±30.7, p=.150). The SF36 also improved minimally and not significantly: Mental (53.6±12.0 vs 54.7±4.6, p=.849) and Physical (32.5±10.9 vs 36.3±11.2, p=.634).

Conclusions

THR+TFOI is a successful reconstruction option for amputees who desire relief from severe pain related to hip joint degeneration, and also the opportunity for improved mobility and quality of life that TFOI typically confers. In our cohort, the procedure proved safe: no associated deaths, no removals, one soft tissue debridement. Mobility improved markedly. Quality of life improved, but not to significant thresholds as measured by the surveys. THR+TFOI appears safe and reasonable to offer to transfemoral amputees with painful hip joint degeneration.
IS METALLOSIS AN ISSUE IN INTERNAL LENGTHENING?
Authors: Wade Anna , Devane Yvonne , Nowlan Niamh , Donnelly Thomas , Green Connor
Published: July 2023

Introduction

There is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation.

Materials & Methods

All patients in who a retained Precice nail at the time of the field safety notice were identified. Patients and families were contacted to explain the issued safety notice from the company and explain that we would be scheduling them for nail removal. This was part of our standard care but we prioritised this group on our waiting list. Consent was obtained for nail removal but also for histological assessment of canal scrapings, blood ion level analysis and independent assessment of the retrieved nail by our academic collaborators at University College Dublin. Ion levels were then repeated at an interval post removal with consent.

Results

We identified 7 Precice nails in 5 patients still implanted. All patients had consolidated after lengthening and were ready for nail removal. Elevated Titanium blood ion levels were identified at the time of retrieval. Histological abnormalities consistent with metalosis were identified. In all cases the nail was grossly intact and examination of the motor showed no evidence of wear or failure. Follow up ion levels obtained post retrieval showed persistent elevation.

Conclusions

Our retrieval audit shows persistent elevation of Titanium ion levels and abnormal histology despite apparent nail integrity. These findings require further evaluation in a larger retrieval series to determine if there is a high incidence of this phenomenon and if ion levels have a clinical effect.
TELEMEDICINE IN LIMB RECONSTRUCTION: REDUCING LENGTH OF STAY WITH REMOTE SUPPORT
Authors: Timms Anna , Sironi Alessandro , Wright Jonathan , Goodier David , Martin Luke , Calder Peter
Published: July 2023

Introduction

Adjusting an external fixator can be a daunting process for patients. Despite comprehensive training, patients often request supervision for the initial adjustments which may result in a prolonged hospital stay. Following the introduction of telemedicine during the pandemic we believed that this could be utilised to support patients with their fixator adjustments. A quality improvement project was implemented to assess and evaluate a change in practice from existing Face to Face support to a telemedicine format. The aim of the project was to reduce median length of stay (LOS).

Materials & Methods

The telemedicine platform was introduced in our unit from April 2021 with the change in practice. Using the life QI platform, run charts were used to record the numbers of patients whose LOS was 4 days or less. Median LOS was assessed prior to and following introduction of the telemedicine platform. Service user experience with telemedicine as well as overall training and education by the CNS team was sought through on-line questionnaires.

Results

Baseline data collected from April 2019 to April 2021 showed that our median LOS for patients undergoing external fixation was 6 days with 36% of patients being discharged at day 4 or earlier. After implementation of telemedicine, median LOS reduced to 4 days with 50% of patients leaving hospital in 4 days or less. Service user responses demonstrated that 100% felt that sufficient information was provided by the CNS team, a mean score of 8.4/10 was reported when asked how confident they were when adjusting the fixator. When asked how the service could be improved access to a recorded video was suggested.

Conclusions

Initial fixator adjustment support via telemedicine is not appropriate for all of our patient group due to a lack of access or co-morbidities/ social issues that necessitate a prolonged hospital stay. However, this project has demonstrated that it has had positive long-term benefits within our service through reducing our median length of stay by 2 days without compromising patient satisfaction with their care.
MID- TO LONG-TERM OUTCOME OF OPEN TIBIAL FRACTURES DEFINITIVELY MANAGED WITH A CIRCULAR FRAME
Authors: Shields David , Eng Khemerin , Clark Tom , Madhavani Kiran , Coundurache Codrin , Fong Angus , Mills Edward , Dennison Mick , Royston Simon , McGregor-Riley Jonathan
Published: July 2023

Introduction

Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures

Materials & Methods

A prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions

Results

247 open tibial fractures with a soft tissue manipulation in order to achieve skin cover, of which 203 had a minimum follow up of 2 years. Mean age was 43.2 years old, with 72% males, 34% smokers and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Nine (4.4%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-five (37%) of patients had a secondary intervention of which; 8 comprised debridement of deep infection, 1 amputation for deep infection and the remainder adjustments of frames.

Conclusions

Orthoplastic care including circular frame fixation for GA 3B fractures of the tibia results in a low rate of deep infection, around a quarter of contemporary literature for internal fixation.
ROLE OF 18F-FDG PET-CT IN PREOPERATIVE PLANNING OF SURGICAL DEBRIDEMENT IN CHRONIC OSTEOMYELITIS
Authors: Elsheikh Ahmed , Elazazy Mostafa , Elkaramany Mamdouh
Published: July 2023

Introduction

Osteomyelitis is a challenge in diagnosis and treatment. 18F-FDG PET-CT provides a non-invasive tool for diagnosing and localizing osteomyelitis with a sensitivity reaching 94% and specificity reaching 100%. We aimed to assess the agreement in identifying the geographic area of infected bone and planned resection on plain X-ray versus 18F-FDG PET-CT.

Materials & Methods

Clinical photos and X-rays of ten osteomyelitis patients were shown to ten consultant surgeons; they were asked to draw the area of infection and extent of planned surgical debridement; data will be compared to 18F-FDG PET-CT results.

Results

We tested the agreement between the surgeons in every parameter. Regarding height, there was poor agreement between surgeons. Regarding perimeter, the ten surgeons showed low-moderate agreement. The ten surgeons showed a low-moderate agreement for circularity. Results document the variability of assessment and judgement based on plain X-rays. In comparison to PET-CT, All parameters were significantly different in favour of 18F-FDG PET-CT over X-ray (P < 0.001).

Conclusions

18F FDG PET-CT provides a three-dimensional tool for localizing the exact location of the infected bone and differentiating it from the normal bone. Thus, it could be beneficial in precise pre-operative planning and surgical debridement of chronic osteomyelitis.
STRATEGIES AND OUTCOMES IN SURGICAL MANAGEMENT OF ATYPICAL FEMORAL FRACTURES: A REAL-WORLD STUDY
Authors: Chandra Arjun , Trompeter Alex
Published: July 2023

Atypical femoral fracture non-union (AFFNU) is both, rare (3–5 per 1000 proximal femur fractures) and difficult to treat. Lack of standardised guidelines leads to a variability in fixation constructs, use of bone grafting and restricted weight bearing protocols, which are not evidence based. We hypothesised that there is no change in union rates without the use of bone grafting and immediate weight bearing post-operatively does not lead to increased complications.

Materials & Methods

A retrospective review of all consecutively treated AFFNU cases between March 2015 to December 2019 was carried out. 9 patients with a mean age of 63.87 years and M:F ratio of 7:2 met the inclusion criteria. Primary outcome variable was radiographic union at 12 months after revision surgery. All surgeries were carried out by a single surgeon. Fixation construct, neck-shaft angle, use of bone graft and immediate postoperative weight bearing protocols were recorded.

Results

Radiographic union was achieved in 7 of 9 patients (78%) after first revision surgery. 1 patient achieved union after 2nd revision surgery and 1 patient died in the early post-operative period due to pulmonary embolism. No bone grafting was used in any of the patients and weight-bearing as tolerated was allowed from the first post-operative day. The mean neck-shaft angle after non-union surgery was 136 degrees.

Conclusions

In this case series, the union rate was comparable to those reported in literature previously and achieved without any form of bone grafting. To our knowledge, this is the only case series where no bone grafting was used in the management of AFFNU. Limited by a small sample size and retrospective study design, still, this study brings into question the efficacy of practice of bone grafting and restricted weight-bearing in the management of AFFNU. Bone grafting is associated with the risk of infection at donor site, postoperative pain, and morbidity, while early weight bearing is critical in elderly patients. There is no evidence supporting restricted weight-bearing and it should not be adopted as the default practice as it may even be detrimental to patients
SHOULD WOUND SWABS BE SENT ON ALL PIN SITE INFECTIONS?
Authors: Bridgeman Philippa , Heeley Emily
Published: July 2023

Introduction

Introduction: Pin site infection is a common complication during treatment with a circular frame external fixator and increases time and support patients require from the limb reconstruction team. Wound swabs were not routinely sent by the clinical nurse specialists prior to this study, with most pin site infections treated as Staphylococcus aureus with flucloxacillin (clindamycin in penicillin allergy). The aim of this study was to ascertain whether routine sending of wound swabs in pin site infection would change antibiotic treatment.

Materials & Methods

Materials and Method: Patients presenting at clinic or physiotherapy with clinical signs of pin site infection were assessed using the Maz Oxford Nuffield (MON) Pin Site Infection Grading System© (OUH, 2021). Antibiotics were commenced as per unit guidelines and swabs sent for microscopy, culture and sensitivity.

Results

Results: There were forty patients treated with pin site infections. Swab results showed S. aureus in 60% (N=24), other organisms in 15% (N=6) and no growth or mixed skin organisms in 10% (N=10). Flucloxacillin was prescribed to 77.5% (n=31) of patients with the remaining 22.5% (n=9) of patients receiving clindamycin (due to allergy) or rifampicin and ciprofloxacin (due to a previous MRSA diagnosis). Antibiotic management was subsequently changed in only 5% (n=2) of patients due to one patient with a new MRSA diagnosis and one patient growing Enterobacter in three pin sites tested.

Conclusions

Conclusion: This study has shown that routine swab testing of pin sites does not usually change antibiotic management but should still be used in multiple, severe or unresolving pin site infections.
WHICH FACTORS PREDICT A SUCCESSFUL OUTCOME FOLLOWING TOTAL HIP ARTHROPLASTY IN PATIENTS WITH EARLY RADIOLOGICAL OSTEOARTHRITIS?
Authors: Sharrock Martin , Board Tim
Published: July 2023

It is unclear whether patients with early radiographic osteoarthritis (OA) but severe hip symptoms benefit from total hip replacement (THR). We aimed to assess which factors were associated with successful THR in this patient group.

From a consecutive series of 1,935 patients undergoing THR we identified 70 (3.6%) patients with early OA (Kellgren and Lawrence (KL) grades 0-2). These were compared with 200 patients with advanced OA (KL grades 3–4). Outcomes were Oxford Hip Scores (OHS), EQ5D and EQ-VAS scores; compared pre-operatively with one year post-operatively. We investigated which clinical and radiographic (plain x-ray, CT, MRI) features predicted successful THR in the early OA group. Success was defined as reaching a postoperative OHS≥42.

The early OA group were significantly younger (61 vs 66 years; P=0.0035). There were no significant differences in body mass index, ASA grade or gender. After adjusting for confounders, the advanced OA group had a significantly greater percentage of possible change (PoPC) in OHS (75.8% versus 50.4%; P<0.0001) and improvement in EQ5D (0.151 versus 0.002; P<0.0001). There were no significant differences in complication, revision or readmission rates. In the early OA group, we identified 16/70 (22.9%) patients who had a ‘successful’ THR. Of those with early OA, 38 patients had pre-operative CT or MRI scans. Patients who had a ‘successful’ THR were significantly more likely to have subchondral cysts on CT/MRI (91.7% versus 57.7%; P=0.0362). The presence of cysts on CT/MRI was associated with a significantly greater PoPC in OHS (61.6% versus 38.2%; P=0.0353). The combination of cysts and joint space width (JSW) <1mm was associated with a PoPC of 68%. Plain radiographs were found to significantly underestimate the narrowest JSW compared to CT/MRI (2.4mm versus 1.0mm; P<0.0001).

We advise caution in performing THRs in patients with early OA (KL grades 0-2) on plain radiographs. We advocate pre-operative cross-sectional imaging (CT or MRI) in these patients. In the absence of cysts on cross-sectional imaging, a THR seems unlikely to provide a satisfactory outcome.
THE PERIARTICULAR MUSCLE ENVELOPE SHOWS ATROPHY AFTER ILIOPSOAS TENOTOMY
Authors: Declercq Jonas , Vandeputte Frans-Jozef , Corten Kristoff
Published: July 2023

Tenotomy of the iliopsoas tendon has been described as an effective procedure to treat refractive groin pain induced by iliopsoas tendinitis. However, the procedure forces the rectus femoris to act as the primary hip flexor and little is known about the long-term effects of this procedure on the peri-articular muscle envelope (PAME). Studies suggest that iliopsoas tenotomy results in atrophy of the iliopsoas and decreased hip flexion strength with poorer outcomes, increasing the susceptibility for secondary tendinopathy. The aim of this study is to describe changes in the PAME following psoas release.

All patients who presented for clinical examination at our hospital between 2016 and 2021 were retrospectively reviewed. Patients who presented after psoas tenotomy with groin pain and who were unable to actively lift the leg against gravity, were included. Pelvic MRI was taken. Qualitative muscle evaluation was done with the Quartile classification system. Quantitative muscle evaluation was done by establishing the cross-sectional area (CSA).

Two independent observers evaluated the ipsi- and contralateral PAME twice. The muscles were evaluated on the level: iliacus, psoas, gluteus minimus-medius-maximus, rectus femoris, tensor fasciae lata, piriformis, obturator externus and internus.

For the qualitative evaluation, the intra- and inter-observer reliability was calculated by using kappastatistics. A Bland-Altman analysis was used to evaluate the intra- and inter-observer reliability for the quantitative evaluation. The Wilcoxon test was used to evaluate the changes between the ipsi- and contra-lateral side.

17 patients were included in the study. Following psoas tenotomy, CSA reduced in the ipsilateral gluteus maximus, if compared with the contralateral side. Fatty degeneration occurred in the tensor fascia latae. Both CSA reduction and fatty degeneration was seen for psoas, iliacus, gluteus minimus, piriformis, obturator externus and internus. No CSA reduction and fatty degeneration was seen for gluteus medius and rectus femoris.

Conclusions/Discussion

Following psoas tenotomy, the PAME of the hip shows atrophy and fatty degeneration. These changes can lead to detrimental functional problems and may be associated with debilitating rectus femoris tendinopathy. In patients with psoas tendinopathy, some caution is advised when considering an iliopsoas tenotomy.
CARDIAC FUNCTION IS COMPROMISED IN PATIENTS WITH ELEVATED BLOOD COBALT LEVELS SECONDARY TO METAL-ON-METAL HIP IMPLANTS
Authors: Jenkinson Mark , Meek Dominic , MacMillan Sandy , Tate Rothwelle , Grant M Helen , Currie Susan
Published: July 2023

Elevated blood cobalt secondary to metal-on-metal (MoM) hip arthroplasties has been shown to be a risk factor for developing cardiovascular complications including cardiomyopathy. Published case reports document cardiomyopathy in patients with blood cobalt levels as low as 13µg/l (13ppb, 221nmol/l). Clinical studies have found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Global longitudinal strain (GLS) is an echocardiography measurement known to be more sensitive than ejection fraction at diagnosing early cardiomyopathies. The extent of cardiovascular injury, as measured by GLS, in patients with elevated blood cobalt levels has not previously been examined.

Sixteen patients with documented blood cobalt ion levels above 13µg/l were identified from a regional arthroplasty database. They were matched with eight patients awaiting hip arthroplasty with no history of cobalt implants. All patients underwent electrocardiogram and echocardiogram assessment for signs of cardiomyopathy including GLS.

Patients with MoM hip arthroplasties had a mean blood cobalt level of 29µg/l (495nmol/l) compared to 0.01µg/l (0.2nmol/l) in the control group. There was no difference or correlation in ejection fraction (EF), left ventricular (LV) end systolic dimension, LV end diastolic dimension, fractional shortening, ventricular wall thickness or E/e’ ratio. However, GLS was significantly reduced in patients with MoM hip arthroplasties compared to those without (−15.2% v −18%, (MoM v control) p= 0.0125). Pearson correlation demonstrated that GLS is significantly correlated with blood cobalt level (r= 0.8742, p=0.0009).

For the first time, this study has demonstrated reduced cardiac function in the presence of normal EF as assessed by GLS in patients with elevated cobalt above 13µg/l. As GLS is a more sensitive measure of systolic function than EF, routine echocardiogram assessment including GLS should be performed in all patients with MoM hip arthroplasties and elevated blood cobalt above 13µg/l. Further work is recommended to assess if these cardiac changes are present in patients with elevated blood cobalt levels below 13µg/l.
A COMPARISON OF INTERNAL FIXATION AND HEMIARTHROPLASTY IN THE MANAGEMENT OF UNDISPLACED OR MINIMALLY DISPLACED HIP FRACTURES IN PATIENTS OVER 60 YEARS OLD
Authors: Ahmed Maryam , Tirimanna Romesh , Ahmed Umar , Hussein Soltan , Syed Habib , Malik-Tabassum Khalid , Edmondson Mark
Published: July 2023

The incidence of hip fractures in the elderly is increasing. Minimally displaced and un-displaced hip fractures can be treated with either internal fixation or hemiarthroplasty. The aim was identifying the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method.

A retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study.

1273 patients were included of which 26.2% (n=334) had cannulated hip fixation (CHF), 19.4% (n=247) had a dynamic hip screw (DHS) and 54.7% (n=692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n=23) vs. 33.3% (n=3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively.

Fixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. When considering a fixation method in such patients, DHS is more robust than a screw construct, followed by hemiarthroplasty.