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Arthroscopic bone block stabilisation procedures for glenoid bone loss in anterior glenohumeral instability: A systematic review of clinical and radiological outcomes.
No full textINTRODUCTION
Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation.
METHODS
This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20 July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool.
RESULTS
Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5-37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0 - 18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92-100% in 8 out of 10 studies at mean follow up range 6-78.7 months but two reported lower rates ranging from 58.3 - 84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10-16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation.
CONCLUSION
Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods.
LEVEL OF EVIDENCE
IV; systematic review
Clinical considerations in providing intravenous sedation with midazolam for obese patients in dentistry.
No full textThe widespread prevalence of obesity continues to rise. Obesity and dental disease share common risk factors and so the demand for dental care for obese patients is escalating. For some of these patients, there is a corresponding need to be able to provide intravenous sedation safely when it is necessary and appropriate to do so. However, obesity often presents with multiple comorbidities and airway complexities, leading to more challenging management and potentially increased risk. The risk assessment process as well as patient monitoring and management strategies will be explored in this article. By reviewing the literature from dentistry and other medical specialties, we also aim to establish the potential benefit in administering supplemental oxygen and the use of capnography in monitoring this cohort of patients
Longitudinal study of medical downgrades in the Royal Air Force.
No full textINTRODUCTION
As the focus of the Royal Air Force (RAF) shifts from sustained to contingency operations and the number of personnel is reduced, the burden of retained, medically downgraded personnel may affect operational readiness. The main aims were: to define the prevalence of morbidity leading to permanent medical downgrading; to determine at risk populations and identify areas for improvement.
METHOD
Database of personnel referred to the RAF Medical Board was analysed from January 2012 to October 2013 and January 2017 to December 2019. Patients were excluded if they did not require a formal medical board; incomplete and duplicate entries were also excluded. The primary reason for medical downgrade was categorised with an ICD-10 code. Further subanalysis compared musculoskeletal disease with age, individual trade groups and anatomic region.
RESULTS
2% of RAF service personnel were permanently downgraded annually. Musculoskeletal disease was the leading cause for permanent downgrade across both periods: 58% and 49%. Female personnel were at a greater risk of musculoskeletal downgrade compared with males. Spinal and knee pathology were the leading cause for downgrading among 'high risk' personnel. Personnel downgraded due to musculoskeletal pathology were often retained in a limited role with 10% and 5% retained as medically fully deployable. 14% and 12% of personnel downgraded due to musculoskeletal pathology were medically discharged.
CONCLUSION
Musculoskeletal disease was the leading cause for permanent medical downgrades in the RAF. A greater proportion of downgraded personnel with musculoskeletal conditions were retained in service with medical limitations rather than medically discharged
The Role of Metabolism in Migraine Pathophysiology and Susceptibility.
No full textMigraine is a highly prevalent and disabling primary headache disorder, however its pathophysiology remains unclear, hindering successful treatment. A number of key secondary headache disorders have headaches that mimic migraine. Evidence has suggested a role of mitochondrial dysfunction and an imbalance between energetic supply and demand that may contribute towards migraine susceptibility. Targeting these deficits with nutraceutical supplementation may provide an additional adjunctive therapy. Neuroimaging techniques have demonstrated a metabolic phenotype in migraine similar to mitochondrial cytopathies, featuring reduced free energy availability and increased metabolic rate. This is reciprocated in vivo when modelling a fundamental mechanism of migraine aura, cortical spreading depression. Trials assessing nutraceuticals successful in the treatment of mitochondrial cytopathies including magnesium, coenzyme q10 and riboflavin have also been conducted in migraine. Although promising results have emerged from nutraceutical trials in patients with levels of minerals or vitamins below a critical threshold, they are confounded by lacking control groups or cohorts that are not large enough to be representative. Energetic imbalance in migraine may be relevant in driving the tissue towards maximum metabolic capacity, leaving the brain lacking in free energy. Personalised medicine considering an individual's deficiencies may provide an approach to ameliorate migraine
Relative Adipose Tissue Failure in Alström Syndrome Drives Obesity-Induced Insulin Resistance.
No full textObesity is a major risk factor for insulin resistance (IR) and its attendant complications. The pathogenic mechanisms linking them remain poorly understood, partly due to a lack of intermediary monogenic human phenotypes. Here, we report on a monogenic form of IR-prone obesity, Alström syndrome (ALMS). Twenty-three subjects with monogenic or polygenic obesity underwent hyperinsulinemic-euglycemic clamping with concomitant adipose tissue (AT) microdialysis and an in-depth analysis of subcutaneous AT histology. We have shown a relative AT failure in a monogenic obese cohort, a finding supported by observations in a novel conditional mouse model ( ) and ALMS1-silenced human primary adipocytes, whereas selective reactivation of ALMS1 gene in AT of an ALMS conditional knockdown mouse model ( ) restores systemic insulin sensitivity and glucose tolerance. Hence, we show for the first time the relative AT failure in human obese cohorts to be a major determinant of accelerated IR without evidence of lipodystrophy. These new insights into adipocyte-driven IR may assist development of AT-targeted therapeutic strategies for diabetes
Patient perceptions of outcome measures in chronic inflammatory demyelinating polyneuropathy: a study of the I-RODS scale.
No full textBACKGROUND
Patients' perceptions of outcome measures used in chronic inflammatory demyelinating polyneuropathy (CIDP) are unknown.
METHODS
We performed a cross-sectional evaluation of patient perceptions of the Inflammatory Rasch-built Overall Disability Scale (I-RODS) from 41 subjects with CIDP through a structured questionnaire. We assessed perceived hesitation to provide a response, item importance and relevance, understanding of specific items and factors affecting responses.
RESULTS
Hesitation to provide a categorical answer was reported by 20% of subjects or more, for 5/24 (20.8%) items. Uncertainty was most frequent for "travel by public transport" (22.4%) and "catch an object (e.g. ball)" (24%). Six of 24 (25%) items were perceived as unimportant to their disease by at least a third of participants. Items most commonly perceived as unimportant were "travel by public transport" in 53.7%, "catch an object e.g. ball" in 61%, "dance" in 65.9%. Several items were frequently perceived as irrelevant. These included "move a chair" (39%), "do the dishes" (46.3%), "catch an object e.g. ball" (61%), "travel by public transport" (68.3%), and "stand for hours" (82.9%). The understanding of multiple items such as "read a book", "sit on a toilet" and "take a shower" was found highly variable. Fatigue was perceived more commonly than mood (53.7% vs.17.1%, p=0.001), and more commonly in younger subjects (p=0.037), as influencing responses to the I-RODS.
DISCUSSION
Patient-perceived uncertainty, unimportance, irrelevance and poor understanding of items as well as fatigue and mood, impact on the value of the I-RODS. Greater emphasis on individualized disability assessments require consideration in future
The clinical course of COVID-19 in pregnant versus non-pregnant women requiring hospitalisation: results from the multicentre UK CA-COVID-19 study.
No full textThe impact of COVID-19 infection on pregnant women remains relatively unknown but the physiological changes of pregnancy and hypercoagulability of COVID-19 may further increase thrombotic risk. In this retrospective multicentre observational study, we report clinical characteristics and outcomes in 36 pregnant women requiring hospitalisation for COVID-19 compared to a propensity matched cohort of non-pregnant women. Pregnant women had lower haemoglobin and higher lymphocyte counts but no differences in other haematological or biochemical parameters on admission compared to non-pregnant women. There was no significant difference in the duration of hospitalisation; median 2days (1-77) for pregnant women vs 8days (1-49) for non-pregnant. A higher proportion of non-pregnant women required mechanical ventilation [11/36 (31%) vs 3/36 (8%), p=0.03] and received thromboprophylaxis with low molecular weight heparin within 24hrs of admission [25/36 (69%) vs 15 /36(42%), p=0.03] compared to pregnant women. One pregnant woman required extracorporeal membrane oxygenation. Rate of thrombosis was similar in both groups (1 in each group). No women developed major bleeding or died. Data suggests that although non-pregnant women had severe clinical course, overall outcomes were not different between women with or without pregnancy. Use of thromboprophylaxis was inconsistent, demonstrating a need for establishing evidence-based guidance for COVID-19 during pregnancy
Type 2 Autoimmune Hepatitis and Nonadherence to Medication Correlate With Premature Birth and Risk of Postpartum Flare.
No full textAutoimmune hepatitis (AIH) is an immune-mediated chronic liver disease that affects all ages, including women of childbearing age. Optimal management during pregnancy is poorly defined. We aimed to explore the clinical and biochemical course of AIH in the antenatal and postpartum periods, and assess factors associated with premature birth and postpartum flares. Pregnant women with AIH reviewed in the autoimmune liver disease clinic at the Queen Elizabeth Hospital Birmingham between 2009 and 2020 were identified retrospectively, and clinical, biochemical, and immunological data 1 year before conception to 1 year postpartum were collected. Analysis was performed to identify trends in blood markers over the antenatal period, with an interrupted time series approach used to assess postpartum trends. Data were available for n = 27 pregnancies (n = 20 women), with median gestation of 38 weeks (30% premature) and most having type 1 AIH (78%) and delivering via caesarean section (63%). Levels of alanine transaminase, aspartate transaminase, and immunoglobulin G all declined significantly during gestation, followed by significant step-change increases after delivery. Postpartum flare developed in 58% of pregnancies. AIH type 2 was associated with a higher rate of premature births (67% vs. 19%, = 0.044), and a trend toward a higher rate of postpartum flare (100% vs. 48%, = 0.053). Although not significant, medication nonadherence was associated with almost double the risk of prematurity (40% vs. 24%, = 0.415) and postpartum flare (80% vs. 44%, = 0.109). Biochemical and immunological remission of AIH occurs during pregnancy, although subsequent postpartum flare is common. Type 2 AIH is associated with a higher risk of premature birth and postpartum flare, although further research is required to validate and explain this finding