91 Mrs Bad Bones: Impact of COVID-19 on Secondary Prevention of Fragility Fractures

Introduction

Management of osteoporosis is an important consideration for neck of femur fracture patients due to the morbidity and mortality it poses, and the significant financial burden to the NHS. Orthogeriatric teams input is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of healthcare teams and led to the redeployment of the orthogeriatricians to assist with the influx of medically unwell patients. This study explored the impact COVID-19 had on secondary fragility fracture prevention.

Method

A retrospective audit looking at the prescription of vitamin D/calcium supplements, bone-sparing medications, and DEXA scan requests in consecutive neck of femur fracture patients admitted to a trauma and orthopaedic unit pre- and post- UK lockdown in response to the pandemic. A re-audit was conducted following the implementation of our new mnemonic, “MRS BAD BONES”: Medication Review Rheumatology/Renal Advice Smoking Cessation Blood tests Alcohol limits DEXA scan Bone-sparing medications Orthogeriatric review Nutrition Exercise Supplements.

Results

Data for 50 patients was available in each phase. The orthogeriatric team reviewed 88% of patients pre-lockdown falling to 0% due to redeployment, before recovering to 38% in the post-intervention period. Upon lockdown there was a significant drop in the prescription of vitamin D/calcium supplements from 81.6% to 58.0% (p = 0.0156); of bone-sparing medications from 60.7% to 18.2% (p = 0.0037), and DEXA scan requests from 40.1% to 3.6% (p = 0.0027). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (p = 0.0034), bone-sparing medications to 72.4% (p = 0.0002) and DEXA scan requests to 60% (p < 0.0001).

Conclusion

COVID-19 had a major impact on the secondary prevention of fragility fractures in this population. The “MRS BAD BONES” mnemonic significantly improved the management and could be considered for use in a wider setting.

Evaluation of internet derived patient information for Acute Pancreatitis

INTRODUCTION

Possibly In the UK there are currently over 26,000 patients admitted to hospital for acute pancreatitis per annum and the incidence is rising. 55% of patients consult the internet for information regarding their medical condition. As the number of people using the internet has increased 57% since 2006, it is increasingly important for medical professionals to direct patients to accurate online sources of information. This paper aims to evaluate the quality of information available online for acute pancreatitis.

METHODS

The term 'acute pancreatitis' was searched using http://www.google.com, http://www.bing.com, and http://www.yahoo.com. The top 10 results of each of these websites were assessed using the University of Michigan consumer health website evaluation checklist.

RESULTS

Of the 30 websites found, 4 were excluded from the evaluation. Within the 26 evaluated websites there was high variability in website quality. However, the authors would have used 18 of the websites again for the purpose of finding out information on acute pancreatitis. 15 websites had a named author of which 11 displayed their credentials. 8 of the websites had been updated within the last year. 10 websites displayed a bias or conflict of interest. Generally, the layout and design of websites was good, however 7 of the websites contained distracting graphics and 9 of the websites had no search facility.

DISCUSSION

Doctors should give patients the information they want and need. With a high percentage of patients using the internet, medical professionals should recommend good quality websites to their patients. Engaging in this process could improve the consenting process as patients would be better informed. Good quality websites allows patients to explore conditions by themselves, with a re-consultation facilitating further discussion. Failure to engage in internet-based information risks patients making misinformed decisions due to bias and conflict of interest.

Trait phenomenological control predicts experience of mirror synaesthesia and the rubber hand illusion

In hypnotic responding, expectancies arising from imaginative suggestion drive striking experiential changes (e.g., hallucinations) - which are experienced as involuntary - according to a normally distributed and stable trait ability (hypnotisability). Such experiences can be triggered by implicit suggestion and occur outside the hypnotic context. In large sample studies (of 156, 404 and 353 participants), we report substantial relationships between hypnotisability and experimental measures of experiential change in mirror-sensory synaesthesia and the rubber hand illusion comparable to relationships between hypnotisability and individual hypnosis scale items. The control of phenomenology to meet expectancies arising from perceived task requirements can account for experiential change in psychological experiments.

Clinical presentation, cardiovascular findings, etiology, and outcome of myocarditis in dogs: 64 cases with presumptive antemortem diagnosis (26 confirmed postmortem) and 137 cases with postmortem diagnosis only (2004-2017)

INTRODUCTION

This study describes presentation, cardiovascular abnormalities, etiology, and outcome of canine myocarditis in geographic areas not endemic for Trypanosoma or Leishmania.

ANIMALS

Sixty-four (presumed antemortem diagnosis) and 137 (postmortem diagnosis only) client-owned dogs at two tertiary care facilities were included.

MATERIALS AND METHODS

Medical records of dogs with clinical or histopathological diagnosis of myocarditis were reviewed retrospectively.

RESULTS

Common examination findings in dogs with a presumed antemortem diagnosis included fever (21%) and heart murmur (19%). Median cardiac troponin I was 12.2 ng/mL (range: 0.2-808.0 ng/mL), and troponin exceeded 1.0 ng/mL in 26 of 29 (90%) dogs. Ventricular ectopy was the most common arrhythmia (54%), whereas decreased left ventricular systolic function was the most common echocardiographic abnormality (56%). An infectious etiology was diagnosed in 35 of 64 (55%) dogs. Confirmed infectious etiologies included bacterial sepsis (n = 9) or extension of endocarditis (3), toxoplasmosis or neosporosis (3), parvovirus (2), and one case each of bartonellosis, trypanosomiasis, leptospirosis, and dirofilariasis. Median survival time was 4 days (range: 0-828 days) for all dogs vs. 82 days for dogs who survived at least 2 weeks after diagnosis. Presence of pericardial effusion or azotemia was a significant predictor of non-survival. The most common inflammatory infiltrate on histopathology was neutrophilic (47%), and 20 of 137 (14.5%) dogs had concurrent bacterial endocarditis on postmortem.

CONCLUSIONS

Bacterial infection was the most common confirmed etiology of myocarditis in this study. Prognosis for canine myocarditis is guarded and similar to that reported for infective endocarditis. Criteria for the antemortem diagnosis of canine myocarditis are suggested.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

X-ray diffraction at the National Ignition Facility

We report details of an experimental platform implemented at the National Ignition Facility to obtain in situ powder diffraction data from solids dynamically compressed to extreme pressures. Thin samples are sandwiched between tamper layers and ramp compressed using a gradual increase in the drive-laser irradiance. Pressure history in the sample is determined using high-precision velocimetry measurements. Up to two independently timed pulses of x rays are produced at or near the time of peak pressure by laser illumination of thin metal foils. The quasi-monochromatic x-ray pulses have a mean wavelength selectable between 0.6 Å and 1.9 Å depending on the foil material. The diffracted signal is recorded on image plates with a typical 2θ x-ray scattering angle uncertainty of about 0.2° and resolution of about 1°. Analytic expressions are reported for systematic corrections to 2θ due to finite pinhole size and sample offset. A new variant of a nonlinear background subtraction algorithm is described, which has been used to observe diffraction lines at signal-to-background ratios as low as a few percent. Variations in system response over the detector area are compensated in order to obtain accurate line intensities; this system response calculation includes a new analytic approximation for image-plate sensitivity as a function of photon energy and incident angle. This experimental platform has been used up to 2 TPa (20 Mbar) to determine the crystal structure, measure the density, and evaluate the strain-induced texturing of a variety of compressed samples spanning periods 2-7 on the periodic table.

Prevalence and Epidemiological Pattern of Abdominal Aortic Aneurysms in Africa: A Systematic Review

Introduction

The incidence of abdominal aortic aneurysms (AAAs) in high-income countries has been declining in the last three decades. However, in most low-income and middle-income countries especially in Africa, little is known about its burden. The absence of screening services for AAA in African countries makes it difficult to detect and promptly manage AAA before rupture, which has significant implications for mortality. This study sought to systematically assess the prevalence of AAA amongst patients visiting hospitals in Africa and evaluate its epidemiological pattern.

Materials and Methods

A systematic review was performed on the EMBASE, GLOBAL HEALTH, MEDLINE, and PUBMED databases. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement standards and protocol registered with PROSPERO (CRD42020162214). A data extraction tool was used to get relevant information from these studies. Quality assessment and risk of bias were performed using the Newcastle Ottawa Scale for cross-sectional studies. Results were summarised in tables, figures, and a forest plot. A narrative synthesis approach of the articles was taken.

Results

Two hundred and sixty-one studies were identified and after the exclusion of 246, a final 15 were deemed suitable for analysis. A total of 4012 participants were screened for AAA and of these, 129 cases were identified. The prevalence of AAA in these studies ranged from 0.7 to 6.4%. Male participants accounted for 115 (89.1%) of the cases. There was a wide age range (31-72 years) reflective of both its possible infective and degenerative aetiology. AAA was reported to be associated with hypertension, smoking, advanced age, coronary artery disease, and HIV infection. There was no association between AAA and diabetes. Over 50% of cases were identified incidentally. About one-third (23-54%) of the participants presented aortic rupture with a mortality rate ranging between 65 and 72%.

Conclusions

AAA prevalence in Africa is probably higher than the current thinking as there is no baseline data to compare with. Aetiologically, AAA was shown to be associated with hypertension, smoking, coronary artery disease, and possibly infectious pathologies like HIV. Large epidemiological studies would help better characterise AAA in this setting. Lastly, efforts targeting the reduction of the risk factors for AAA would go a long way in reducing the burden of AAA.

Use of rivaroxaban for treatment of cranial vena cava syndrome secondary to transvenous pacemaker lead thrombosis in a dog

A six-year-old Brussels griffon was presented for cervical swelling three months after implantation of a transvenous pacemaker. Transthoracic echocardiography demonstrated a thrombus associated with the pacemaker lead, partially obstructing right atrial inflow. The laboratory findings were consistent with protein-losing nephropathy. Initial medical therapy consisted of rivaroxaban (0.68 mg/kg orally every 24 hours), clopidogrel (2.5 mg/kg orally every 24 hours), and enalapril (0.5 mg/kg orally every 12 hours). Resolution of cervical and thoracic edema was noted within two weeks of initiating therapy. Recheck echocardiography two months and one year later revealed decreasing thrombus size despite worsening proteinuria. To the authors' knowledge, this is the first documented use of rivaroxaban for successful medical treatment of cranial vena cava syndrome caused by intracardiac pacemaker lead thrombosis in a hypercoagulable patient.

Acute pseudogout – Measure serum magnesium

We report a 49-year-old woman with an acute swollen left knee due to acute pseudogout with chondrocalcinosis as a presenting feature of Gitelman syndrome due a novel homozygous mutation of the SLC12A3 gene. This report highlights the under-recognized importance of excluding metabolic disease, including Gitelman syndrome, in younger patients whose sole presenting feature may be chondrocalcinosis with or without pseudogout, as this may impact on management and risk of further episodes. We also suggest that chondrocalcinosis and hypomagnesaemia with or without hypokalaemia are diagnostic of Gitelman syndrome.

Multisensory enhancement of attention depends on whether you are already paying attention

Multisensory stimuli are argued to capture attention more effectively than unisensory stimuli due to their ability to elicit a super-additive neuronal response. However, behavioural evidence for enhanced multisensory attentional capture is mixed. Furthermore, the notion of multisensory enhancement of attention conflicts with findings suggesting that multisensory integration may itself be dependent upon top-down attention. The present research resolves this discrepancy by examining how both endogenous attentional settings and the availability of attentional capacity modulate capture by multisensory stimuli. Across a series of four studies, two measures of attentional capture were used which vary in their reliance on endogenous attention: facilitation and distraction. Perceptual load was additionally manipulated to determine whether multisensory stimuli are still able to capture attention when attention is occupied by a demanding primary task. Multisensory stimuli presented as search targets were consistently detected faster than unisensory stimuli regardless of perceptual load, although they are nevertheless subject to load modulation. In contrast, task irrelevant multisensory stimuli did not cause greater distraction than unisensory stimuli, suggesting that the enhanced attentional status of multisensory stimuli may be mediated by the availability of endogenous attention. Implications for multisensory alerts in practical settings such as driving and aviation are discussed, namely that these may be advantageous during demanding tasks, but may be less suitable to signaling unexpected events.

Availability of less invasive prenatal, perinatal and paediatric autopsy will improve uptake rates: a mixed-methods study with bereaved parents

Objective

To investigate whether less invasive methods of autopsy would be acceptable to bereaved parents and likely to increase uptake.

Design

Mixed methods study.

Setting

Bereaved parents recruited prospectively across seven hospitals in England and retrospectively through four parent support organisations.

Sample

Eight hundred and fifty‐nine surveys and 20 interviews with bereaved parents.

Methods

Cross‐sectional survey and qualitative semi‐structured telephone interviews.

Main outcome measures

Likely uptake, preferences, factors impacting decision‐making, views on different autopsy methods.

Results

Overall, 90.5% of participants indicated that they would consent to some form of less invasive autopsy [either minimally invasive autopsy (MIA), non‐invasive autopsy (NIA) or both]; 53.8% would consent to standard autopsy, 74.3% to MIA and 77.3% to NIA. Regarding parental preferences, 45.5% preferred MIA, 30.8% preferred NIA and 14.3% preferred standard autopsy. Participants who indicated they would decline standard autopsy but would consent to a less invasive option were significantly more likely to have a lower educational level (odds ratio 0.49; 95% CI 0.35–0.70; P = 0.000062). Qualitative findings suggest that parents value NIA because of the lack of any incision and MIA is considered a good compromise as it enables tissue sampling while easing the parental burden associated with consenting to standard autopsy.

Conclusion

Less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience. Further health economic, validation and implementation studies are now required to assess the viability of offering these in routine widespread clinical care.

Tweetable abstract

Mixed methods UK study finds less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience.

Mixed methods UK study finds less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience.

The association of parental and offspring educational attainment with systolic blood pressure, fasting blood glucose and waist circumference in Latino adults

Objective

The objective of the study is to evaluate the association of intergenerational educational attainment with cardiovascular disease (CVD) risk factors among US Latinos.

Methods

We used cross‐sectional data from the Niños Lifestyle and Diabetes Study, an offspring cohort of middle‐aged Mexican‐Americans whose parents participated in the Sacramento Latino Study on Aging. We collected educational attainment, demographic and health behaviours and measured systolic blood pressure (SBP), fasting glucose and waist circumference. We evaluated the association of parental, offspring and a combined parent–offspring education variable with each CVD risk factor using multivariable regression.

Results

Higher parental education was associated only with smaller offspring waist circumference. In contrast, higher offspring education was associated with lower SBP, fasting glucose and smaller waist circumference. Adjustment for parental health behaviours modestly attenuated these offspring associations, whereas adjustment for offspring health behaviours and income attenuated the associations of offspring education with offspring SBP and fasting glucose but not smaller waist circumference, even among offspring with low parental education.

Conclusions

Higher offspring education is associated with lower levels of CVD risk factors in adulthood, despite intergenerational exposure to low parental education.

Tobacco exposure and sleep disturbance in 498 208 UK Biobank participants

Background

The prevalence of sleep disturbance is high and increasing. The study investigated whether active, former and passive smoking were associated with sleep disturbance.

Methods

This cross-sectional study used data from the UK Biobank: a cohort study of 502 655 participants, of whom 498 208 provided self-reported data on smoking and sleep characteristics. Multivariable multinomial and logistic regression models were used to examine the associations between smoking and sleep disturbance.

Results

Long-sleep duration (>9 h) was more common among current smokers [odds ratio (OR): 1.47; 95% confidence interval (CI): 1.17-1.85; probability value (P) = 0.001] than never smokers, especially heavy (>20/day) smokers (OR: 2.85; 95% CI: 1.66-4.89; P < 0.001). Former heavy (>20/day) smokers were also more likely to report short (<6 h) sleep duration (OR: 1.41; 95% CI: 1.25-1.60; P < 0.001), long-sleep duration (OR: 1.99; 95% CI: 1.47-2.71; P < 0.001) and sleeplessness (OR: 1.47; 95% CI: 1.38-1.57; P < 0.001) than never smokers. Among never smokers, those who lived with more than one smoker had higher odds of long-sleep duration than those not cohabitating with a smoker (OR: 2.71; 95% CI: 1.26-5.82; P = 0.011).

Conclusions

Active and passive exposure to high levels of tobacco smoke are associated with sleep disturbance. Existing global tobacco control interventions need to be enforced.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results

PURPOSE

The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR.

METHODS

This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain.

RESULTS

Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm³, p = 0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019).

CONCLUSION

Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions.

CLINICAL TRIAL NUMBER

NCT02542085.

Cannabis use and risk of schizophrenia: a Mendelian randomization study

Cannabis use is observationally associated with an increased risk of schizophrenia, but whether the relationship is causal is not known. Using a genetic approach, we took 10 independent genetic variants previously identified to associate with cannabis use in 32 330 individuals to determine the nature of the association between cannabis use and risk of schizophrenia. Genetic variants were employed as instruments to recapitulate a randomized controlled trial involving two groups (cannabis users vs nonusers) to estimate the causal effect of cannabis use on risk of schizophrenia in 34 241 cases and 45 604 controls from predominantly European descent. Genetically-derived estimates were compared with a meta-analysis of observational studies reporting ever use of cannabis and risk of schizophrenia or related disorders. Based on the genetic approach, use of cannabis was associated with increased risk of schizophrenia (odds ratio (OR) of schizophrenia for users vs nonusers of cannabis: 1.37; 95% confidence interval (CI), 1.09-1.67; P-value=0.007). The corresponding estimate from observational analysis was 1.43 (95% CI, 1.19-1.67; P-value for heterogeneity =0.76). The genetic markers did not show evidence of pleiotropic effects and accounting for tobacco exposure did not alter the association (OR of schizophrenia for users vs nonusers of cannabis, adjusted for ever vs never smoker: 1.41; 95% CI, 1.09-1.83). This adds to the substantial evidence base that has previously identified cannabis use to associate with increased risk of schizophrenia, by suggesting that the relationship is causal. Such robust evidence may inform public health messages about cannabis use, especially regarding its potential mental health consequences.