Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery

BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure,placement site,and duration of use.There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery.AIM To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery.METHODS Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken.Intraoperative tourniquet duration,tourniquet pressure and site,and postoperative pain scores using Visual Analogue Score were collected in immediate recovery,at six hours and at 24 h post-op.Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure,duration,site,and pain scores using Pearson correlation coefficient.RESULTS All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh.There was no correlation between the site of the tourniquet and pain scores in recovery,at six hours and after 24 h.There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op(r=0.14,P=0.04)but not at six or 24 h post-operatively.CONCLUSION This study shows that there was no statistically significant correlation between tourniquet pressure,site and postop pain in patients undergoing foot and ankle surgery.The choice of using a tourniquet is based on the surgeon's preference,with the goal of minimizing the duration of its application at the operative site.

Management of a patient with an unusual trajectory of a temporary trans-venous pacing lead

Perforation of the right ventricle during placement of pacing wires is a welldocumented complication and can be potentially fatal.Use of temporary pacemaker,helical screw leads and steroids use prior to implant are recognised as risk factors for development of post-permanent pacemaker effusion.We reported an unusual case of pacing wire perforating interventricular septum into the left ventricle that occurred during the implant procedure performed in another institution.After the preoperative work-up and transfer to our tertiary cardiothoracic centre,the patient underwent successful surgical management.In conclusion,early recognition and timely diagnosis using advanced multimodality imaging can guide surgical intervention and prevent unfavourable consequences of device-related complications.

Perceived barriers and facilitators of day-case surgery for major foot and ankle procedures?A cross-sectional survey of United Kingdom surgeons

BACKGROUND Advances in minimally invasive surgery and improved post-operative pain management make it possible to consider performing even major foot/ankle operations as day-case.This could have significant benefits for patients and the health service.However there are theoretical concerns about post-operative complications and patient satisfaction due to pain.AIM To scope the current practice of foot and ankle surgeons on day-case surgery for major foot and ankle procedures in the United Kingdom(UK).METHODS An online survey(19 questions)was sent to UK foot and ankle surgeons via the British Orthopaedic Foot&Ankle Society membership list in August 2021.Major foot and ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge,with day surgery as the intended treatment pathway.RESULTS 132 people responded to the survey invitation with 80%working in Acute NHS Trusts.Currently 45%of respondents perform less than 100 day-case surgeries per year for these procedures.78%felt that there was scope to perform more procedures as day-case at their centre.Post-operative pain(34%)and patient satisfaction(10%)was not highly measured within their centres.Lack of adequate physiotherapy input pre/post-operatively(23%)and lack of out of hours support(21%)were the top perceived barriers to performing more major foot and ankle procedures as day-case.CONCLUSION There is consensus among UK surgeons to do more major foot/ankle procedures as day-case.Out of hours support and physiotherapy input pre/post-op were perceived as the main barriers.Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed.There is a need for nationally agreed protocols to optimise the delivery of and measurement of outcomes in this type of surgery.At a local level,the provision of physiotherapy and out of hours support should be explored at sites where this is a perceived barrier.

Risk factors for hepatocellular carcinoma associated with hepatitis C genotype 3 infection:A systematic review

BACKGROUND Hepatitis C virus(HCV)is a blood-borne virus which globally affects around 79 million people and is associated with high morbidity and mortality.Chronic infection leads to cirrhosis in a large proportion of patients and often causes hepatocellular carcinoma(HCC)in people with cirrhosis.Of the 6 HCV genotypes(G1-G6),genotype-3 accounts for 17.9%of infections.HCV genotype-3 responds least well to directly-acting antivirals and patients with genotype-3 infection are at increased risk of HCC even if they do not have cirrhosis.AIM To systematically review and critically appraise all risk factors for HCC secondary to HCV-G3 in all settings.Consequently,we studied possible risk factors for HCC due to HCV-G3 in the literature from 1946 to 2023.METHODS This systematic review aimed to synthesise existing and published studies of risk factors for HCC secondary to HCV genotype-3 and evaluate their strengths and limitations.We searched Web of Science,Medline,EMBASE,and CENTRAL for publications reporting risk factors for HCC due to HCV genotype-3 in all settings,1946-2023.RESULTS Four thousand one hundred and forty-four records were identified from the four databases with 260 records removed as duplicates.Three thousand eight hundred and eighty-four records were screened with 3514 excluded.Three hundred and seventy-one full-texts were assessed for eligibility with seven studies included for analysis.Of the seven studies,three studies were retrospective case-control trials,two retrospective cohort studies,one a prospective cohort study and one a cross-sectional study design.All were based in hospital settings with four in Pakistan,two in South Korea and one in the United States.The total number of participants were 9621 of which 167 developed HCC(1.7%).All seven studies found cirrhosis to be a risk factor for HCC secondary to HCV genotype-3 followed by higher age(five-studies),with two studies each showing male sex,high alpha feto-protein,directly-acting antivirals treatment and achievement of sustained virologic response as risk factors for developing HCC.CONCLUSION Although,studies have shown that HCV genotype-3 infection is an independent risk factor for end-stage liver disease,HCC,and liver-related death,there is a lack of evidence for specific risk factors for HCC secondary to HCV genotype-3.Only cirrhosis and age have demonstrated an association;however,the number of studies is very small,and more research is required to investigate risk factors for HCC secondary to HCV genotype-3.

Cardiovascular magnetic resonance imaging assessment of outcomes in acute myocardial infarction

Cardiovascular magnetic resonance(CMR) imaging uniquely characterizes myocardial and microvascular injury in acute myocardial infarction(AMI), providing powerful surrogate markers of outcomes. The last 10 years have seen an exponential increase in AMI studies utilizing CMR based endpoints. This article provides a contemporary, comprehensive review of the powerful role of CMR imaging in the assessment of outcomes in AMI. The theory, assessment techniques, chronology, importance in predicting left ventricular function and remodelling, and prognostic value of each CMR surrogate marker is described in detail. Major studies illustrating the importance of the markers are summarized, providing an up to date review of the literature base in CMR imaging in AMI.

Management of acute spinal cord injury:A summary of the evidence pertaining to the acute management,operative and non-operative management

Acute traumatic spinal cord injury is often a lifechanging and devastating event with considerable mortality and morbidity.Over half a million people suffer from traumatic spinal cord injury annually with the majority resulting from road traffic accidents or falls.The Individual,societal and economic costs are enormous.Initial recognition and treatment of acute traumatic spinal cord injury are crucial to limit secondary injury to the spinal cord and to provide patients with the best chance of some functional recovery.This article is an overview of the management of the acute traumatic spinal cord injury patient presenting to the emergency department.We review the initial assessment,criteria for imaging and clearing the spine,and evaluate the literature to determine the optimum timing of surgery and the role of non-surgical treatment in patients presenting with acute spinal cord injury.

Delayed presentation of a loose body in undisplaced paediatric talar neck fracture

Fractures of the talus are rare in children.A high index of suspicion is needed to avoid missing such an injury,which is not an uncommon occurrence especially with undisplaced fractures.We present an unusual case of an undisplaced talar neck fracture in a five-year-old child leading to a delayed presentation of a symptomatic osteochondral loose body in the ankle joint.To our knowledge there are no reports in the literature of osteochondral loose bodies occurring in conjunction with an associated undisplaced talar neck fracture in either children or adults.The loose body was removed using anterior ankle arthroscopy.The child had an uneventful post operative recovery and regained full range of movement and function of his ankle joint and was discharged at one year follow-up.We aim to highlight the need to have a low threshold to further evaluate symptomatic children after fracture healing of an undisplaced talar neck fracture for a possible associated loose bodyin the ankle joint.

Age at diagnosis of type 2 diabetes and cardiovascular risk factor profile:A pooled analysis

BACKGROUND The diagnosis of type 2 diabetes(T2D)in younger adults,an increasingly common public health issue,is associated with a higher risk of cardiovascular complications and mortality,which may be due to a more adverse cardiovascular risk profile in individuals diagnosed at a younger age.AIM To investigate the association between age at diagnosis and the cardiovascular risk profile in adults with T2D.METHODS A pooled dataset was used,comprised of data from five previous studies of adults with T2D,including 1409 participants of whom 196 were diagnosed with T2D under the age of 40 years.Anthropometric and blood biomarker measurements included body weight,body mass index(BMI),waist circumference,body fat percentage,glycaemic control(HbA1c),lipid profile and blood pressure.Univariable and multivariable linear regression models,adjusted for diabetes duration,sex,ethnicity and smoking status,were used to investigate the association between age at diagnosis and each cardiovascular risk factor.RESULTS A higher proportion of participants diagnosed with T2D under the age of 40 were female,current smokers and treated with glucose-lowering medications,compared to participants diagnosed later in life.Participants diagnosed with T2D under the age of 40 also had higher body weight,BMI,waist circumference and body fat percentage,in addition to a more adverse lipid profile,compared to participants diagnosed at an older age.Modelling results showed that each one year reduction in age at diagnosis was significantly associated with 0.67 kg higher body weight[95%confidence interval(CI):0.52-0.82 kg],0.18 kg/m^(2) higher BMI(95%CI:0.10-0.25)and 0.32 cm higher waist circumference(95%CI:0.14-0.49),after adjustment for duration of diabetes and other confounders.Younger age at diagnosis was also significantly associated with higher HbA1c,total cholesterol,low-density lipoprotein cholesterol and triglycerides.CONCLUSION The diagnosis of T2D earlier in life is associated with a worse cardiovascular risk factor profile,compared to those diagnosed later in life.

Duration of treatment with 5-aminosalicylic acid compounds

The development of 5-aminosalicylic acid (5-ASA) therapy as a life long treatment for ulcerative colitis is reviewed from its origins in the 1940s to the present day. The drug was designed to treat rheumatoid arthritis,but was found helpful in the management of nine patients with ulcerative colitis. This discovery preceded the emergence of the clinical trial as a tool for assessing a new drug's efficacy; as a result it lacked scientific rigour and was selective in its presentation of results. Nevertheless it identified the future cornerstone of therapy in ulcerative colitis. In 1962,the first double blind controlled trial of sulphasalazine was conducted on 40 patients. Outcome measures were subjective and included symptoms and an assessment of the rectal mucosa. In 1973,the first two papers on the role of sulphasalazine in maintenance of remission were published. Both used placebo controls and had a stratified design. Outcomes were measured using "an intention to treat" approach. The British study of 64 patients used both subjective and objective criteria to assess outcomes. Patients on placebo had a relapse rate four times patients on active treatment and this founded the basis for a life long approach to therapy with 5-ASA compounds in ulcerative colitis. However,in 1985,a small "on demand" study of 32 patients suggested this approach might be as effective as continuous treatment. Some support for this view came from an Italian study which showed no benefit to continued treatment for those in remission for two years or more. The central problem these studies identify is that of adherence to treatment in the long-term. Few studies have considered patients' attitudes to continuous therapy and it is an area that needs further investigation.

Outcomes of Pringle maneuver in patients undergoing hepatic resection for colorectal liver metastases

To the Editor:The Pringle maneuver(PM)was initially described more than a century ago to control bleeding associated with hepatic trauma and it remains the most common method to block hepatic inflow and minimize blood loss during hepatic resections[1].

Vitreous haemorrhage as the first presentation of undiagnosed Waldenstrom macroglobulinemia

Dear Editor, Waldenstrom macroglobulinemia(WM) is a rare type of non-Hodgkin’s lymphoma, commonly associated with hyperviscosity syndrome. Unlike non-Hodgkin’s lymphoma, its ocular manifestations are less well described in the literature. Here we present the first case of undiagnosed WM presenting with dense vitreous haemorrhage. The study was conducted in accordance with the principles of the Declaration of Helsinki. The informed consent was obtained from the subject.

Utilising the impact of COVID-19 on trauma throughput to adapt elective care models for more efficient trauma care

BACKGROUND Coronavirus disease 2019(COVID-19)has necessitated adaptations in local trauma services,with implementation of novel methods of practice,strategic adaptations,and shifting of resource management.Many of these may serve the driver for landmark changes to future healthcare provision.AIM To analyse the impact of COVID-19 on service provision by comparing throughput and productivity metrics with preceding years to identify differences in practice that were successful,cost-effective,and sustainable.METHODS We quantified orthopaedic trauma care provision at a single University Teaching Hospital over a three consecutive year period,from 1st January 2018 to 31st December 2020.Each year was split into four phases based on the 2020 national COVID-19 pandemic periods.We quantitatively analysed change in rates of inpatient trauma operative case load,sub-specialty variation,theatre throughput,and changes in management strategy.Qualitative analysis was based on multidisciplinary team interviews to highlight changes to care pathways.RESULTS Of 1704 cases were admitted in 2020,11.9%and 12.4%fewer than 2019 and 2018,respectively.During phase 1,hip fractures encompassed the majority(48.8%)of trauma throughput,with all other subspecialties seeing a reduction.Mean length of stay was shorter during phase 1(5.7 d);however,the time in theatre was longer(144.3 min).Both,Charlson(0.90)and Elixhauser(1.55)Comorbidity Indices indicated the most co-morbid admissions during 2020 phase 1.CONCLUSION COVID-19 has resulted in a paradigm shift in how care is accessed and delivered,with many evolving changes and adaptations likely to leave an impression upon healthcare provision in the future.

A Mobile App to Replace the Goniometer? A Pilot Study Focusing on the Measurement of Knee Range of Movement

Background: The universal goniometer is commonly used to measure knee range of movement in clinical practice. However, research has demonstrated that the universal goniometer lacks reliability failing to meet the standard of clinically acceptable error (5°). Objective: This study tested the concurrent validity and intra-rater reliability of a photographic based “app” developed for feedback in sport, the Hudl Ubersense App, as an alternative instrument for measuring knee range of movement. Methods: Measurements of knee range of movement were made concurrently with the electrogoniometer (the gold standard) and the Hudl Ubersense App across a pre-determined randomised set of 20 functional knee angles between 35° and 130°. This was then repeated. The pre-agreed standard of concurrent validity was that 95% of Hudl Ubersense App measurements would be within 5° of the electrogoniometer and differences were displayed in Bland-Altman plots. Results: Thirty nine (97%) of the forty app readings differed from the corresponding electrogoniometer readings by less than 5°. The mean differences between the electrogoniometer and Hudl Ubersense App measurements over each trial were 1.75° and 0.80° respectively, indicating a high level of concurrent validity. There was less than 1.0° mean difference between the first and second set of results indicating a high level of intra-rater reliability. Conclusions: The results suggest that the Hudl Ubersense App has high levels of concurrent validity (using the electrogoniometer as the gold standard) and intra-rater reliability, scoring better than previous research on the current clinical measuring device, the universal goniometer. The Hudl Ubersense App has clinical advantages over the electrogoniometer, so further research is recommended to determine its inter-rater reliability, acceptability, and appropriate clinical practice procedures.

Is there a role for fish oil in inflammatory bowel disease?

A number of animal and human studies suggest omega3-fatty acids are anti-inflammatory. As a result they may have a therapeutic role in inflammatory bowel disease(IBD). The aim of this review is to briefly assess the literature about the utility of poly-unsaturated fatty acids(PUFAs) in the management of IBD. Taken together, almost all studies suggest some beneficial effects of n-3 PUFAs in IBD but the mechanism remains controversial. In addition, clinical benefit seems to be largely confined to ulcerative colitis. However all studies have concluded that these compounds have no potential for a steroid/aminosalicylic acid sparing effect or to maintain remission. Now the question arises as to whether this treatment is of real value to IBD patients?Clearly they have some therapeutic potential but further work is needed.

When is a bone scan study appropriate in asymptomatic men diagnosed with prostate cancer？

Aims： To determine when a bone scan investigation is appropriate in asymptomatic men diagnosed with prostate cancer. Methods： Between November 2005 and July 2006, 317 men with prostate cancer underwent a bone scan study; 176 men fulfilled the inclusion criteria. Prostate-specific antigen （PSA） cut-offs as well as univariate and multivariate logistic regression analyses using digital rectal examination finding, biopsy Gleason scores and age were performed to determine when a bone scan study is likely to be of value. Results： Only 1/61 men （1.6%） with a serum PSA 〈 20 ng/mL had a positive bone scan. However, 2/38 men （4.7%） with a serum PSA 20.1-40.0 ng/mL, 3/20 men （15%） with a serum PSA 40.1-60.0 ng/mL, 7/19 men （36.8%） with a serum PSA 60.1-100.0 ng/mL and 19/38 men （50%） with a serum PSA 〉 100.0 ng/mL had positive bone scans. Univariate and multivariate logistic regression analyses were uninformative in these groups. Conclusion： Based on our findings, a bone scan is of limited value in asymptomatic prostate cancer patients presenting PSA 〈 20 ng/mL. Therefore, this investigation can be eliminated unless a curative treatment is contemplated. Furthermore, digital rectal examination finding, biopsy Gleason score and age are unhelpful in predicting those who might harbor bone metastasis.

Ophthalmic photographer virtual clinics in medical retina

AIM: To determine whether ophthalmic photographers(OPs) can conduct virtual clinics(VCs) in medical retina appropriately and whether this increases clinic capacity.METHODS: Three OPs underwent a training programme to learn how to assess and manage macular edema secondary to diabetes or retinal vein occlusion. The 300 consecutive patients over a 7-month observation period in 2018 were assessed in VCs by both OPs and medical retina consultants. The degree of agreement in treatment decisions between doctors and photographers, as well as adverse events, was recorded. The change in number of patients seen in VCs over two years was also measured.RESULTS: There was 100% agreement in management decisions between doctors and photographers during the 300-patient observation period. No adverse events were recorded. In 2017, 572 patients were seen in VCs by doctors. After OP clinics were introduced in 2018, this number increased by 24% to 709 patients seen by both photographers and doctors. There was a significant increase in mean number of patients seen per month between 2017(47.7±11.7) and 2018(59.1±14.4;P=0.045, 95%CI-22.5 to-0.296).CONCLUSION: OPs can manage certain medical retina patients in VCs appropriately and can increase clinic capacity significantly for particular conditions.

Should pyridoxine be given to breastfed infants whose mothers are on isoniazid?

A mother was recently started on isoniazid and rifampicin for latent tuberculosis infection.She was breastfeeding her 1-monthold infant.There was no indication to treat the child with antituberculous therapy.As isoniazid can be present in breast milk,question was raised whether the baby should receive pyridoxine supplementation to prevent peripheral neuropathy or seizures.There were variable views in the management approach due to uncertainties of evidence in this topic.

Communication after cancellations in orthopaedics: The patient perspective

AIM: To examine patients' perceptions on communication surrounding the cancellation of orthopaedic operations and to identify areas for improvement in communication.METHODS: A prospective survey was undertaken at a university teaching hospital within the department of Trauma and Orthopaedics. Patients admitted to an acute orthopaedic unit, whose operations were cancelled, were surveyed to assess patient satisfaction and preferences for notification of cancellation of their operations. Patients with an abbreviated mental test score of < 9, patients unable to complete the survey independently, those under 16 years of age, and any patient notified of the cancellation by any of the authors were excluded from this study. Patients were surveyed themorning after their operation had been cancelled thus ensuring that every opportunity was given for the medical staff to discuss the cancellation with the patient. The survey included questions on whether or not patients were notified of the cancellation of their surgery, the qualifications of the person discussing the cancellation, and patient preferences on the process. Satisfaction was assessed via 5-point Likert scale questions.RESULTS: Sixty-five consecutive patients had their operations cancelled on 75 occasions. Fifty-four point seven percent of the patients who had cancellations were notified by a nurse and 32% by a doctor. No formal communication occurred for 13.3% cancellations and no explanation was provided for a further 16%. Patients reported that they were dissatisfied with the explanation provided for 36 of the 75(48%) cancellations. Of those patients who were dissatisfied, 25(69.4%) were notified by a nurse. Twenty-three of the 24(96%) patients notified by a doctor were satisfied with the explanation and that communication. Of those patients who were notified by a nurse 83% patients reported that they would have preferred it if a doctor had discussed the cancellation with them. There was a significant difference in satisfaction between those counselled by a nurse and those notified by a doctor(P < 0.0001).CONCLUSION: Communication surrounding cancellations does not meet patient expectations. Patients prefer to be notified by a doctor, illustrating the importance of communication in the doctor-patient relationship.

Nephrectomy Avoided in a Patient with Lipid Poor Angiomylipoma with Radiological Features Suspicious for Renal Cell Carcinoma: A Case Report

Angiomyolipoma (AML) is a benign neoplasm that is easily mistaken for renal cell carcinoma (RCC) upon radiological investigation. The management of the two pathologies is significantly different, and so accurate diagnosis is vital. We report a case in which ultrasound guided biopsy saved the patient from an unnecessary nephrectomy when an AML had radiological appearances consistent with RCC. This case report also discusses the literature surrounding radiological features and novel imaging techniques of minimal-fat AML and RCC.

致命性肺栓塞的6岁儿童

Pulmonary thromboembolism is rarely recognized in young children, even in hospital settings. All current management decisions for children with deep vein thrombosis (DVT) are directly extrapolated from treatment recommendations for adults with no further validation. We report the case of a 6-y-old child presenting with deep vein thrombosis of the leg veins and fatal pulmonary embolism. The fatal outcome in our case highlights the need for more epidemiological studies in children, not only to predict the recurrence of pulmonary emboli but also to prepare standard treatment guidelines for the management of DVT and pulmonary emboli in children. We speculate that there may be a role for temporary inferior vena cava filters in young children with extensive DVT of the legs. Conclusions: This case highlights the need for more epidemiological studies to predict the recurrence of pulmonary emboli and effective guidelines for the management of paediatric DVT and pulmonary emboli in children.