What are the common factors that lead to the failure to achieve minimal clinically important difference after shoulder surgery? A scoping review

INTRODUCTION

The goal of this research is to identify the factors that negatively impact the achievement of the minimum clinically significant change (MCID) for the American Shoulder and Elbow Surgeons (ASES) score within the realm of various orthopedic shoulder procedures.

METHODS

We conducted a comprehensive review of studies published from 2002 to 2023, utilizing OvidMedline and PubMed databases. Our search criteria included terms such as "minimal clinically important difference" or "MCID" along with associated MeSH terms, in addition to "American shoulder and elbow surgeon" or "ASES." We selectively included primary investigations that assessed factors linked to the failure to achieve MCID for the ASES score subsequent to orthopedic shoulder procedures, while excluding papers addressing anatomical, surgical, or injury-related aspects.

RESULTS

Our analysis identified 149 full-text articles, leading to the inclusion of 12 studies for detailed analysis. The selected studies investigated outcomes following various orthopedic shoulder procedures, encompassing biceps tenodesis, total shoulder arthroplasty, and rotator cuff repair. Notably, factors, such as gender, body mass index, diabetes, smoking habits, opioid usage, depression, anxiety, workers' compensation, occupational satisfaction, and the preoperative ASES score, were all associated with the inability to attain MCID.

CONCLUSION

In summary, numerous factors exert a negative influence on the attainment of MCID following shoulder procedures, and these factors appear to be irrespective of the specific surgical technique employed. Patients presenting with these factors may perceive their surgical outcomes as less successful when compared to those without these factors. Identifying these factors can enable healthcare providers to provide more effective counseling to patients regarding their expected outcomes and rehabilitation course. Furthermore, these findings can aid in the development of a screening tool to better identify these risk factors and optimize them before surgery.

Exploratory Study of the Brain Response in Facial Synkinesis after Bell Palsy with Systematic Review and Meta-analysis of the Literature

BACKGROUND

Facial synkinesis, characterized by unintentional facial movements paired with intentional movements, is a debilitating sequela of Bell palsy.

PURPOSE

Our aim was to determine whether persistent peripheral nerve changes arising from Bell palsy result in persistent altered brain function in motor pathways in synkinesis.

DATA SOURCES

A literature search using terms related to facial paralysis, Bell palsy, synkinesis, and fMRI through May 2021 was conducted in MEDLINE and EMBASE. Additionally, an fMRI study examined lip and eyeblink movements in 2 groups: individuals who fully recovered following Bell palsy and individuals who developed synkinesis.

STUDY SELECTION

Task-based data of the whole brain that required lip movements in healthy controls were extracted from 7 publications. Three studies contributed similar whole-brain analyses in acute Bell palsy.

DATA ANALYSIS

The meta-analysis of fMRI in healthy control and Bell palsy groups determined common clusters of activation within each group using activation likelihood estimates. A separate fMRI study used multivariate general linear modeling to identify changes associated with synkinesis in smiling and blinking tasks.

DATA SYNTHESIS

A region of the precentral gyrus contralateral to the paretic side of the face was hypoactive in synkinesis during lip movements compared with controls. This region was centered in a cluster of activation identified in the meta-analysis of the healthy controls but absent from individuals with Bell palsy.

LIMITATIONS

The meta-analysis relied on a small set of studies. The small sample of subjects with synkinesis limited the power of the fMRI analysis.

CONCLUSIONS

Premotor pathways show persistent functional changes in synkinesis first identifiable in acute Bell palsy.

Discerning a smile - The intricacies of analysis of post-neck dissection asymmetry

INTRODUCTION

Iatrogenic facial nerve palsy is distressing to the patient and clinician. The deformity is aesthetically displeasing, and can be functionality problematic for oral competence, dental lip trauma and speech. Furthermore such injuries have litigation implications. Marginal mandibular nerve (MMN) palsy causes an obvious asymmetrical smile. MMN is at particular risk during procedures such as rhytidoplasties, mandibular fracture, tumour resection and neck dissections. Cited causes for the high incidence are large anatomical variations, unreliable landmarks, an exposed neural course and tumour grade or nodal involvement dictating requisite nerve sacrifice. An alternative cause for post-operative asymmetry is damage to the cervical branch of the facial nerve or platysmal dysfunction due to its division. The later tends to have a transient course and recovers. Distinction between MMN palsy and palsy of the cervical branch of the facial nerve or platysma division should therefore be made. In 1979 Ellenbogen differentiated between MMN palsy and "Pseudo-paralysis of the mandibular branch of the facial nerve". Despite this, there is paucity in the literature & confusion amongst clinicians in distinguishing between these palsies, and there is little regarding these post-operative sequelae and neck dissections.

METHOD

This article reflects on the surgical anatomy of the MMN and cervical nerve in relation to danger zones during lymphadenectomy. The authors review the anatomy of the smile. Finally, case studies are utilised to evaluate the differences between MMN palsy and its pseudo-palsy to allow clinical differentiation.

CONCLUSION

Here we present a simple method for clinical differentiation between these two prognostically different injuries, allowing appropriate reassurance, ongoing therapy & management.

128 Comparison of multiple maturation times on juvenile invitro embryo transfer (JIVET)-derived oocytes and embryo development in the goat

Juvenile invitro embryo transfer (JIVET) is an assisted reproductive technology (ART) with the potential to produce numerous offspring from a single young female goat at 4 to 8 weeks of age. It has been reported in small ruminants that there can be a marked variable response to the administration of exogenous hormones for superovulation, the subsequent number of oocytes generated, and subsequent embryo developmental potential. The industry standard (as well as the recommendation of commercial media suppliers) invitro maturation time is 21 to 24h for conventionally derived oocytes. This study investigated multiple maturation times for JIVET-derived oocytes: 16, 22, and 28h. Oocytes were collected from four JIVET animals at 6 to 8 weeks of age. The hormonal superovulation regimen used on the juvenile animals consisted of 4×40-mg FSH injections at ∼12h apart and a 400IU of PMSG injection given with the first FSH injection. Surgical recovery of the oocytes via a midline laparotomy was performed the day following the last FSH injection. All of the oocytes were collected via aspirating follicles that were 4mm and larger. Oocytes with compact cumulus cells subsequently underwent IVM, IVF, and invitro culture (IVC) utilising IVF Bioscience media and methods. A single straw of identical cryopreserved/thawed semen from the same buck was utilised for each of the IVF procedures. The results were (37/88) 42%, (37/85) 44%, and (39/91) 43% cleaved and (23/88) 26%, (24/85) 28%, and (28/91) 31% blastocyst rate based on respective maturation times for JIVET-derived ova. Development rate during the cleavage stage and blastocyst stage was analysed using a repeated-measures logistic regression model utilising generalized estimating equations (GEE), with maturation time as fixed effect and a compound symmetry within subject (juvenile goat) covariance structure. The main effect of maturation time on the odds of development during the cleavage stage (P=0.8727) and blastocyst stage (P=0.3857) was not significant. These results indicate that the time in maturation media does not have as profound an effect on development to blastocysts as a factor in the variability reported by other laboratories. The development rate of embryos from one juvenile goat produced very high blastocyst rates of (5/12) 42%, (11/12) 92%, and (11/15) 73%, respectively. Additional logistic regression analysis showed that the odds of development in this juvenile donor was significantly different compared with the other donors (pooled) during the cleavage stage at 16h (P=0.0083) and 28h (P=0.0021) maturation times. Likewise, the odds of development in this donor was significantly different than that of the other donors (pooled) during the blastocyst stage at 22h (P=0.0002) and 28h (P=0.0003) maturation times. This further indicates the wide variation of oocyte quality from JIVET-derived oocytes and indicates potential for higher development rates at 22 and 28h in this specific goat.

Alternatives to antibiotics in a One Health context and the role genomics can play in reducing antimicrobial use

BACKGROUND

This review follows on from the International Conference on One Health Antimicrobial Resistance (ICOHAR 2019), where strategies to improve the fundamental understanding and management of antimicrobial resistance at the interface between humans, animals and the environment were discussed.

OBJECTIVE

This review identifies alternatives to antimicrobials in a One Health context, noting how advances in genomic technologies are assisting their development and enabling more targeted use of antimicrobials.

SOURCES

Key articles on the use of microbiota modulation, livestock breeding and gene editing, vaccination, antivirulence strategies and bacteriophage therapy are discussed.

CONTENT

Antimicrobials are central for disease control, but reducing their use is paramount as a result of the rise of transmissible antimicrobial resistance. This review discusses antimicrobial alternatives in the context of improved understanding of fundamental host-pathogen and microbiota interactions using genomic tools.

IMPLICATIONS

Host and microbial genomics and other novel technologies play an important role in devising disease control strategies for healthier animals and humans that in turn reduce our reliance on antimicrobials.

154 A method of oviductal semen deposition for use in the goat

The objective of this study was to investigate a method of oviducal semen deposition as a strategy for producing offspring from poor-quality cryopreserved goat sperm. Invitro fertilisation (IVF) and AI are common assisted reproductive technologies used in small ruminants, but they have varied results in the goat. The use of poor-quality cryopreserved-thawed sperm (<50% live/dead ratio at post-thaw) can decrease the rate of success. These procedures were performed in the month of November in Central Massachusetts in the United States (42° N). Seven 10-year-old dairy goats (Saanen, Toggenburg, and Alpine breeds) were synchronised and superovulated using a progesterone implant on Day 0, a prostaglandin injection at Day 7, two daily injections of 36mg of FSH ~12h apart on Days 12-15, and progesterone implant removal on Day 14 followed by an injection of 50µg of gonadotrophin-releasing hormone. Sperm deposition was performed on Day 17 (72 h after implant removal). The animals were anaesthetised using a standardised protocol, intubated, and maintained using isoflurane, and sterile prep was performed before a midline laparotomy procedure. Straws from a single ejaculate from a transgenic founder that was cryopreserved using a commercial two-step glycerol-egg yolk-based extender were used. A straw from this collection was post-thawed 30 days after collection and, using a commercial live/dead stain, 67% live sperm was determined. The optimal type of sperm prep and sperm concentration is unknown and may be dependent on sperm quality. Therefore, different gradient preps using Vitrolife SpermGrad at three volumes (1.5 (used on two animals), 1.0, and 0.5mL) as well as two volumes of IVF Bioscience Bovine BO-SemenPrep (4.0mL (used on two animals) and 2.0mL) were used. All five pellets were diluted in 1.0mL of IVF Bioscience Bovine BO-IVF media. Sperm concentrations ranging from 75×106 to 27×106 spermmL−1 were deposited into one oviduct; then, a 10:1 dilution was performed and 7.5×106 to 2.7×10 spermmL−1 were deposited into the contralateral oviduct. The depositions were performed just proximal to the uterotubal junction in a volume of 0.1mL of diluent via a tuberculin syringe attached to a 20-gauge needle. Two days following the procedure, oviducts were flushed postmortem from three of the seven randomly selected goats. All three had fertilised embryos, and nineteen 8-cell embryos were retrieved. Three of these embryos were surgically transferred to the distal uterine horn of a suitable recipient. The recipient became pregnant and produced a single offspring. The remaining four of seven goats were killed 41 days post-surgery. Two of the four goats were pregnant, with one carrying one fetus and the other carrying five fetuses. Further studies are needed to optimise this method, but these initial results indicate that oviducal semen deposition directly into the oviduct proximal to the uterotubal junction may be a suitable alternative for producing offspring from suboptimal cryopreserved-thawed goat sperm.

194 Superovulation response does not affect embryo development of pronuclear microinjected embryos in the goat

Superovulation of donor animals is essential in the production of transgenic founder goats generated through microinjection. There can be a marked variable response to the exogenous hormones used for superovulation. The objective of this study was to examine how the superovulatory response of individual goats affected the ability of the fertilized, microinjected embryos to develop into offspring. The donors were superovulated using a progesterone implant on Day 0, a prostaglandin injection at Day 7, 2 injections ~12h apart of 32 to 36mg of FSH on Day 12 to 15, progesterone implant removal on Day 14, bred by intact bucks several times starting on Day 15 to 16, an injection of 50μg of gonadotropin-releasing hormone, and surgical collection of 1- to 2-cell embryos from retrograde flushing of the oviduct on Day 17 (~24-48 h, 1-2 days after breeding). Surgical collection allows for an accurate ovulation point (OP) count before the oviduct being retrograde flushed and ova collected and counted. Data from donor animals were grouped by superovulatory response based on OP counts of 1-10, 11-20, 21-30, or >30. The number of donors that contributed per group were 130, 280, 175, and 52, respectively. The recovery rate was 76, 72, 68, and 62%, respectively. After collection, ova were viewed under a dissecting microscope and assessed for fertilization by identifying pronuclei, and 1 pronucleus was microinjected. The fertilization rate was 47, 52, 51, and 56%, respectively. The survivability rate after microinjection was 80, 76, 75, and 76%, respectively. Surviving embryos were transferred (3-5) into recipient goats following a 2- to 6-h in vitro culture (as 1- to 2-cell embryos), allowing for a suitable period to assess viability post-injection. Further in vitro development rates were not assessed because of the short timeframe the embryos stayed in culture. The conception rates were 71, 56, 65, and 53%, respectively, and abortion rates were 23, 10, 14, and 9%, respectively. As some recipients received embryos from multiple donors, this data could not be included in the analysis as identifying which offspring were from the corresponding embryo group could not be confirmed. Data were analysed using SAS software (version 9.4, SAS Institute Inc., Cary, NC, USA). The Wald chi square test under linear regression was used to analyse the number of offspring produced per embryo transferred. No significant differences were found between groups (all P-values were>0.05). This analysis indicated that the range of superovulation response does not affect the developmental competence of the pronuclear microinjected embryo or the ability to produce viable offspring. Table 1.Comparison of the donor ovulation counts, number of embryos transferred, offspring produced and overall efficiency

94 Impact of number of embryos transferred on the number of offspring produced in a commercial transgenic founder production operation

The production of transgenic founder dairy goats (cross-bred Saanens, Alpines, Toggenburgs, and Nubians) involves the collection, microinjection, and transfer of numerous embryos into suitable recipient goats to ultimately produce a transgenic founder(s). The objective of this study was to determine the most efficient number of microinjection embryos to transfer to suitable recipients for transgenic founder generation. This is critically important in a commercial production program, as it impacts the goal for the number of embryos collected from donors, number of recipients utilised, and, hence, the overall number of surgical procedures being performed. The entire embryo collection, transfer, and founder-generation process is continuously being evaluated for ways to become more efficient in producing transgenic animals. During LFB USA’s commercial founder-production campaigns over the years (1997-2017), pronuclear microinjection was performed and 3, 4, or 5 embryos were transferred to female goat recipients. The recipients were synchronized using a progesterone implant on Day 0, a prostaglandin injection at Day 7, an injection of 300-500IU of pregnant mare serum gonadotropin on Day 13, progesterone implant removal on Day 14, and surgical transfer of pronuclear microinjected 1- or 2-cell embryos into the oviduct on Day 17. The individual totals and calculation for offspring per embryos transferred was compared for 3, 4, and 5 embryos transferred per recipient and was determined to be (1659/8637) 0.19, (912/4548) 0.20, and (112/675) 0.17, respectively. These embryo efficacy ratios were not significantly different (P>0.05) using the Wald Chi-squared test under logistic regression, and suggests that the number of offspring born is not impacted by number of embryos transferred. Seasonality was also evaluated in this production environment located in North America, with in-season being considered September to December and out-of-season being January to July. Nulliparous recipients during in-season (September to December) embryo transfer operations produced a significant difference, with totals and calculation for (offspring per embryo transferred) of (470/2346) 0.20, (260/1088) 0.24, and (23/190) 0.12 for 3, 4, and 5 embryo transfers, respectively (Table 1). This data indicates that when using nulliparous recipients during the in-season, transferring 4 embryos is optimal for offspring produced. Table 1.Comparison of the individual totals and the calculation of (offspring/embryo) by parity and season

Open reduction internal fixation vs non-operative management in proximal humerus fractures: a prospective, randomized controlled trial protocol

BACKGROUND

Proximal humerus fractures are the third most common fracture in the elderly population and are expected to increase due to the aging population. Surgical fixation with locking plate technology has increased over the last decade despite a lack of proven superiority in the literature. Three previous randomized controlled trials have not shown a difference in patient-centered outcomes when comparing non-operative treatment with open reduction and internal fixation. Low patient enrollment and other methodological concerns however limit the generalizability of these conclusions and as a result, management of these fractures remains a controversy. By comparing the functional outcomes of locked plate surgical fixation versus non-operative treatment of displaced three and four-part proximal humerus fractures in the elderly population with a large scale, prospective, multi-centered randomized controlled trial, the optimal management strategy for this common injury may be determined.

METHODS

We will conduct a prospective, single blind randomized controlled parallel arm trial to compare non-operative management of proximal humerus fractures with open reduction and internal fixation using locked plating technology. One-hundred and sixty patients > age 60 with acute 3- or 4- part proximal humerus fractures will be randomized to either open reduction and internal fixation with locked plating technology or non-operative management treatment arms. The primary outcome measure is the Constant Score at 24 months post-operative. Secondary outcome measures include the American Shoulder and Elbow Surgeon's Score (ASES), EuroQol EQ-5D-5 L Health Questionnaire Score, short form PROMIS upper extremity score and IPAQ for the elderly score. Further outcome measures include assessment of the initial classification, displacement and angulation and the quality of surgical reduction via a standard computed tomography (CT) scan; rates of non-union, malunion, arthrosis, osteopenia or other complications including infection, nerve injury, intra-articular screw penetration, reoperation rates and hospital re-admission rates.

DISCUSSION

The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02362100 . Registered 5 Feb 2015.

Deep vein thrombosis resolution, recurrence and post-thrombotic syndrome: a prospective observational study protocol

Background

Reasons for the variation in response of deep vein thrombosis (DVT) to anticoagulation treatment are not known. Some patients develop complications such as post-thrombotic syndrome or recurrent DVT but others make a full recovery. The aim of the study is to identify the level of variation in response to anticoagulation treatment and provide more precise and quantitative disease characterisation in response to treatment.

Methods

A prospective observational study using duplex ultrasound to examine changes in thrombus characterisation, evolution and resolution over a 2 year period in patients with a confirmed DVT. Logistic regression analysis will be used to seek associations between characteristics present at baseline and the outcomes of DVT resolution, recurrence and the development of post-thrombotic syndrome (PTS).

Discussion

This research into the response to treatment of lower limb DVT and predictive factors for DVT resolution, recurrence and PTS could inform a more tailored approach to anticoagulation therapy for the future management of DVT.

UKCRN ID: 16016. Registered on 20 January 2014.

Protocol for a randomised controlled trial for Reducing Arthritis Fatigue by clinical Teams (RAFT) using cognitive-behavioural approaches

INTRODUCTION

Rheumatoid arthritis (RA) fatigue is distressing, leading to unmanageable physical and cognitive exhaustion impacting on health, leisure and work. Group cognitive-behavioural (CB) therapy delivered by a clinical psychologist demonstrated large improvements in fatigue impact. However, few rheumatology teams include a clinical psychologist, therefore, this study aims to examine whether conventional rheumatology teams can reproduce similar results, potentially widening intervention availability.

METHODS AND ANALYSIS

This is a multicentre, randomised, controlled trial of a group CB intervention for RA fatigue self-management, delivered by local rheumatology clinical teams. 7 centres will each recruit 4 consecutive cohorts of 10-16 patients with RA (fatigue severity ≥ 6/10). After consenting, patients will have baseline assessments, then usual care (fatigue self-management booklet, discussed for 5-6 min), then be randomised into control (no action) or intervention arms. The intervention, Reducing Arthritis Fatigue by clinical Teams (RAFT) will be cofacilitated by two local rheumatology clinicians (eg, nurse/occupational therapist), who will have had brief training in CB approaches, a RAFT manual and materials, and delivered an observed practice course. Groups of 5-8 patients will attend 6 × 2 h sessions (weeks 1-6) and a 1 hr consolidation session (week 14) addressing different self-management topics and behaviours. The primary outcome is fatigue impact (26 weeks); secondary outcomes are fatigue severity, coping and multidimensional impact, quality of life, clinical and mood status (to week 104). Statistical and health economic analyses will follow a predetermined plan to establish whether the intervention is clinically and cost-effective. Effects of teaching CB skills to clinicians will be evaluated qualitatively.

ETHICS AND DISSEMINATION

Approval was given by an NHS Research Ethics Committee, and participants will provide written informed consent. The copyrighted RAFT package will be freely available. Findings will be submitted to the National Institute for Health and Care Excellence, Clinical Commissioning Groups and all UK rheumatology departments.

ISRCTN

52709998; Protocol v3 09.02.2015.

Obesity is associated with more activated neutrophils in African American male youth

BACKGROUND

There is emerging evidence suggesting the role of peripheral blood leukocytes in the pathogenesis of obesity and related diseases. However, few studies have taken a genome-wide approach to investigating gene expression profiles in peripheral leukocytes between obese and lean individuals with the consideration of obesity-related shifts in leukocyte types.

METHOD

We conducted this study in 95 African Americans (AAs) of both genders (age 14-20 years, 46 lean and 49 obese). Complete blood count with differential test (CBC) was performed in whole blood. Genome-wide gene expression analysis was obtained using the Illumina HumanHT-12 V4 Beadchip with RNA extracted from peripheral leukocytes. Out of the 95 participants, 64 had neutrophils stored. The validation study was based on real-time PCR with RNA extracted from purified neutrophils.

RESULTS

CBC test suggested that, in males, obesity was associated with increased neutrophil percentage (P=0.03). Genome-wide gene expression analysis showed that, in males, the majority of the most differentially expressed genes were related to neutrophil activation. Validation of the gene expression levels of ELANE (neutrophil elastase) and MPO (myeloperoxidase) in purified neutrophils demonstrated that the expression of these two genes--important biomarkers of neutrophils activation--were significantly elevated in obese males (P=0.01 and P=0.02, respectively).

CONCLUSION

The identification of increased neutrophil percentage and activation in obese AA males suggests that neutrophils have an essential role in the pathogenesis of obesity-related disease. Further functional and mechanistic studies on neutrophils may contribute to the development of novel intervention strategies reducing the burden associated with obesity-related health problems.