A cohort study of tibialis anterior tendon shortening in combination with calf muscle lengthening in spastic equinus in cerebral palsy

The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (±5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15°, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p=0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP.

Nurse-led varicose vein assessment and implementation of guidelines for treatment

Objective: Report of a nurse-led clinic to assess varicose veins and, based on locally developed guidelines, only offer treatment to those with skin changes and ulcers in order to reduce the number of patients listed for surgery.

Methods: Over 12 months, 152 patients were seen and 145 diagnosed as having varicose veins.

Results: Surgery was considered necessary for 38% of those with varicose veins. The remaining 62% were not listed for treatment. When compared with the previous 12 months, 53% fewer patients were listed for surgery and the number on the waiting list had fallen by 62%.

Conclusions: This new service was considered to have achieved its aim of reducing the size of the waiting list.

A systematic review and meta-analysis of the association between eating disorders and bone density

This meta-analysis investigates the effect of an eating disorder on bone mineral density in two eating disorder subtypes. Following conflicting findings in previous literature, this study finds that not only anorexia nervosa, but also bulimia nervosa has a detrimental effect on BMD. Key predictors of this relationship are discussed. This systematic review and meta-analysis investigates bone mineral density (BMD) in individuals with anorexia nervosa (AN) and bulimia nervosa (BN) in comparison to healthy controls (HCs). AN has been associated with low BMD and a risk of fractures and mixed results have been obtained for the relationship between BN and BMD. Deciphering the effect these two ED subtypes on BMD will determine the effect of low body weight (a characteristic of AN) versus the effects of periods of restrictive eating and malnutrition which are common to both AN and BN. We conducted a systematic search through the electronic databases MedLine, EMBASE and PsychInfo and the Cochrane Library to investigate and quantify this relationship. We screened 544 articles and included 27 studies in a random-effect meta-analysis and calculated the standardised mean difference (SMD) in BMD between women with a current diagnosis of AN (n = 785) vs HCs (n = 979) and a current diagnosis of BN (n = 187) vs HCs (n = 350). The outcome measures investigated were spinal, hip, femoral neck and whole body BMD measured by DXA or DPA scanning. A meta-regression investigated the effect of factors including age, duration since diagnosis, duration of amenorrhea and BMI on BMD. The mean BMI of participants was 16.65 kg/m(2) (AN), 21.16 kg/m(2) (BN) and 22.06 kg/m(2) (HC). Spine BMD was lowest in AN subjects (SMD, -3.681; 95 % CI, -4.738, -2.625; p < 0.0001), but also lower in BN subjects compared with HCs (SMD, -0.472; 95 % CI, -0.688, -0.255; p < 0.0001). Hip, whole body and femoral neck BMD were reduced to a statistically significant level in AN but not BN groups. The meta-regression was limited by the number of included studies and did not find any significant predictors. This meta-analysis confirms the association between low BMD and AN and presents a strong argument for assessing BMD not only in patients with AN, but also in patients with BN.

Salpingostomy in the treatment of hydrosalpinx: a systematic review and meta-analysis

STUDY QUESTION

What is the chance of natural conception when salpingostomy is used to treat hydrosalpinx?.

SUMMARY ANSWER

The natural clinical pregnancy rate following salpingostomy is 27%, in the hands of experienced surgeons who publish their results.

WHAT IS KNOWN ALREADY

Tubal surgery is not commonly offered for women with hydrosalpinges since the advent of assisted conception treatment. This is the first systematic review to investigate natural conception rates following salpingostomy in the treatment of hydrosalpinx.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis of 22 observational studies encompasses 2810 patients undergoing salpingostomy and attempting natural conception.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Literature searches were conducted to retrieve observational studies which reported salpingostomy for hydrosalpinx. Databases searched included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL, with no language restriction. Only studies that focused on salpingostomy (rather than other tubal conserving surgeries) for the treatment of hydrosalpinx were included. A total of 22 studies matched the inclusion criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

The pooled natural clinical pregnancy rate from the 22 observational studies (including 2810 patients) was 27% (95% confidence interval (CI): 25-29%) after salpingostomy was performed for hydrosalpinx. The cumulative clinical pregnancy rates were 8.7% (95% CI: 6.6-11.5%) at 6 months, 13.3% (95% CI: 10.6-16.7%) at 9 months, 20.0% (95% CI: 17.5-22.8%) at 12 months, 21.2% (95% CI: 18.6-24.1%) at 18 months and 25.5% (95% CI: 22.2-29.4%) at 24 months after salpingostomy. The pooled live birth rate (10 studies, 1469 patients) was 25% (95% CI: 22-28%) after salpingostomy was performed for hydrosalpinx. The pooled ectopic pregnancy rate (19 studies, 2662 patients) was 10% (95% CI: 9-11%). The pooled miscarriage rate (seven studies, 924 patients) was 7% (95% CI: 6-9%). The included studies scored well on the Newcastle Ottawa quality assessment scale.

LIMITATIONS, REASONS FOR CAUTION

Strict inclusion criteria were used in the conduct of the systematic review. However, the studies included are clinically heterogeneous in many aspects including patient characteristics, surgical technique and duration of follow-up after salpingostomy.

WIDER IMPLICATIONS OF THE FINDINGS

The findings of this systematic review suggest that salpingostomy is an alternative treatment strategy to tubal clipping or salpingectomy in patients presenting to fertility services with hydrosalpinx. Further prospective, large and high quality studies are needed to identify the subpopulation that would most benefit from tube conserving surgery.

STUDY FUNDING/COMPETING INTERESTS

No external funding was either sought or obtained for this study. The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Magnitude of fragility fracture risk in the very old--are we meeting their needs? The Newcastle 85+ Study

Fractures due to osteoporosis are common in older people. This study assessed the management of osteoporosis in a group of 85-year-olds and found both assessment and current treatment to be suboptimal.

INTRODUCTION

Fragility fractures are a major cause of excess mortality, substantial morbidity, and health and social service expenditure in older people. However, much less is known about fracture risk and its management in the very old, despite this being the fastest growing age group of our population.

METHODS

Cross-sectional analysis of people who reached the age of 85 during the year of 2006 was carried out. Data were gathered by general practice record review (GPRR) and a multidimensional health assessment (MDHA).

RESULTS

Seven hundred thirty-nine individuals were recruited. Mean age was 85.55 years (SD 0.44), and 60.2% were female; 33.7% (n = 249) had experienced one or more fragility fractures (F 45.2% vs M 16.3% p < 0.001); in total, 332 fractures occurred in these 249 individuals. A formal documented diagnosis of osteoporosis occurred in 12.4%, and 38% of individuals had experienced a fall in the last 12 months. When the fracture risk assessment tool (FRAX) and National Osteoporosis Guideline Group (NOGG) guidelines were applied, osteoporosis treatment would be recommended in 35.0%, with a further 26.1% identified as needing bone mineral density (BMD) measurement and 38.9% not requiring treatment or BMD assessment. Women were more likely than men to need treatment (47.4 vs 16.3%, p < 0.001, odds ratio (OR) 4.62 (3.22-5.63)) and measurement of BMD (40.0 vs 5.1%, p < 0.001, OR 12.4 (7.13-21.6)). Of the 259 individuals identified as requiring treatment, only 74 (28.6%) were on adequate osteoporosis treatment.

CONCLUSION

The prevalence of high fracture risk in the very old is much higher than the documented diagnosis of osteoporosis or the use of adequate treatments.

Body mass index, perceived and actual physical competence: the relationship among young children

BACKGROUND

The purpose of this study was to examine the relationship between perceived physical competence (PPC), actual motor competence (MC) and body mass index (BMI) in young children.

METHODS

We assessed MC (Test of Gross Motor Development - 2nd Edition), PPC (Pictorial Scale of Perceived Competence and Social Acceptance) and BMI (CDC calculator) of 178 young children ages 4-7 years.

RESULTS

The linear regression model for the overall sample showed that BMI was a better predictor of PPC than MC. Also, obese children had lower PPC, but showed no differences in MC compared with leaner peers.

CONCLUSIONS

PPC of young obese children was lower than their leaner counterparts, yet their MC was similar. That outcome draws attention to the importance of promoting positive PPC in young children.

Paediatric x-ray radiation dose reduction and image quality analysis

Collaboration of multiple staff groups has resulted in significant reduction in the risk of radiation-induced cancer from radiographic x-ray exposure during childhood. In this study at an acute NHS hospital trust, a preliminary audit identified initial exposure factors. These were compared with European and UK guidance, leading to the introduction of new factors that were in compliance with European guidance on x-ray tube potentials. Image quality was assessed using standard anatomical criteria scoring, and visual grading characteristics analysis assessed the impact on image quality of changes in exposure factors. This analysis determined the acceptability of gradual radiation dose reduction below the European and UK guidance levels. Chest and pelvis exposures were optimised, achieving dose reduction for each age group, with 7%-55% decrease in critical organ dose. Clinicians confirmed diagnostic image quality throughout the iterative process. Analysis of images acquired with preliminary and final exposure factors indicated an average visual grading analysis result of 0.5, demonstrating equivalent image quality. The optimisation process and final radiation doses are reported for Carestream computed radiography to aid other hospitals in minimising radiation risks to children.

Spatial learning impairments in PLB1Triple knock-in Alzheimer mice are task-specific and age-dependent

We recently generated an advanced mouse model of Alzheimer's disease (AD) by targeted knock-in of single-copy mutated human amyloid precursor-protein (APP) and tau genes, crossed with a non-symptomatic presenilin (PS1A246E) over-expressing mouse line. These PLB1Triple mice presented with age-dependent and AD-relevant phenotypes. Homozygous PLB1Triple mice aged 4-12 months were assessed here in a battery of spatial learning tasks: Exp.1 radial-arm water maze (spatial reference and working memory) Exp.2 open-field water maze (spatial reference memory); Exp.3 home cage observation system with spatial learning (IntelliCage); Exp.4 spontaneous object recognition (SOR; novel object and spatial object shift). A separate test with high-expression transgenic APP mice matching the design of experiment 1 was also performed. Spatial deficits in PLB1Triple mice were confirmed at 12, but not 4 months in both water maze tasks. PSAPP mice, by contrast, presented with severe yet non-progressive spatial learning deficits already at 4 months. During tests of spatial learning in SOR and IntelliCage, PLB1Triple mice neither acquired the location of the water-rewarded corner, nor recognize novel or spatially shifted objects at 4 months, indicating these protocols to be more sensitive than the water maze. Collectively and in line with AD symptomatology, PLB1Triple mice present with a graded and progressive age-dependent loss of spatial memory that can be revealed by the use of a battery of tasks. With the emergence of subtle deficits progressively increasing in severity, PLB1Triple mice may offer a more patho-physiologically relevant model of dementia than aggressive expression models.