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Nagra NS, van der Veken L, Stanzl E, Champagne D, Devereson A, Macak M. The company landscape for artificial intelligence in large-molecule drug discovery. Nat Rev Drug Discov 2023; 22:949-950. [PMID: 37644185 DOI: 10.1038/d41573-023-00139-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
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Sánchez-Campamà J, Nagra NS, Pineda-Moncusí M, Prats-Uribe A, Prieto-Alhambra D. The association between smoking and the development of rheumatoid arthritis: a population-based case-control study. Reumatol Clin (Engl Ed) 2021; 17:566-569. [PMID: 34823822 DOI: 10.1016/j.reumae.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/06/2020] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Smoking is one of the few modifiable risk factors associated with the development of rheumatoid arthritis (RA). Most published data are over 10 years old, and none included Mediterranean populations. We therefore took advantage of primary care routinely collected data to study the association between smoking and the development of RA in the general population of Catalonia, Spain. METHODS We conducted a case-control study including all patients with a new diagnosis of RA registered in the SIDIAP database between 01/01/2008 and 31/12/2018; and matched them to up to 1:5 controls by age, gender and general practitioner. Smoking was classified by primary care staff into never, ex- or current smoking. Odds Ratios and 95% confidence intervals for the association between current and ex-smoking (compared to never smoking) and RA were estimated using conditional logistic regression adjusted for potential confounders. RESULTS A total of 13,920 RA cases and 69,535 controls were included. Compared with never smokers, current and ex-smokers were at increased risk of RA, with adjusted OR of 1.28 [95% CI 1.20-1.37] and OR 1.19 [1.12-1.26] respectively. CONCLUSION Our findings confirm an association between smoking and the risk of developing RA. The effect seems to prevail in the long-term and even in ex-smokers for 2 or more years after smoking cessation. More research is needed on the effects of smoking discontinuation on RA prevention and related outcomes.
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Affiliation(s)
| | - Navraj S Nagra
- Centre for Statistics in Medicine, Botnar Research Centre, NDORMS, University of Oxford, UK
| | - Marta Pineda-Moncusí
- IMIM (Hospital del Mar Research Institute), Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Barcelona, Spain
| | - Albert Prats-Uribe
- Centre for Statistics in Medicine, Botnar Research Centre, NDORMS, University of Oxford, UK.
| | - Daniel Prieto-Alhambra
- Centre for Statistics in Medicine, Botnar Research Centre, NDORMS, University of Oxford, UK; GREMPAL Research Group, Idiap Jordi Gol, Universitat Autonoma de Barcelona and CIBERFES, Barcelona, Spain
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Nagra NS, Tsangaris E, Means J, Hassett MJ, Dominici LS, Bellon JR, Broyles J, Kaplan RS, Feeley TW, Pusic AL. Correction to: Time-Driven Activity-Based Costing in Breast Cancer Care Delivery. Ann Surg Oncol 2021; 28:899. [PMID: 34546481 DOI: 10.1245/s10434-021-10795-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Navraj S Nagra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA.
| | - Elena Tsangaris
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jessica Means
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Justin Broyles
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert S Kaplan
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Thomas W Feeley
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Andrea L Pusic
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Findings from the patch augmented rotator cuff surgery (PARCS) feasibility study. Pilot Feasibility Stud 2021; 7:163. [PMID: 34416915 PMCID: PMC8377837 DOI: 10.1186/s40814-021-00899-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery. The use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh) have been used to produce patches. However, clinical evidence on their use is limited. The patch augmented rotator cuff surgery (PARCS) feasibility study aimed to determine the design of a definitive randomised controlled trial (RCT) assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. Methods A mixed methods feasibility study of conducing a subsequent RCT. The project involved six stages: a systematic review of clinical evidence; a survey of the British Elbow and Shoulder Society’s (BESS) surgical membership; a survey of surgeon trialists; focus groups and interviews with stakeholders; a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. Results The BESS surgeons’ survey identified a variety of patches in use (105 (21%) responses received). Twenty-four surgeons (77%) completed the trialist survey relating to trial design. Four focus groups were conducted involving 24 stakeholders. Twenty-nine (67% of invited) individuals took part in the Delphi. Differing views were held on a number of aspects including the appropriate patient population for trial participation. Agreement on the key research questions and the outline of two potential RCTs were achieved through the Delphi study and the consensus meeting. Conclusions Randomised comparisons of on-lay patch use for completed rotator cuff repairs, and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. The main limitation was that the findings were influenced by the participants, who might not necessarily reflect all stakeholders.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Nagra NS, Tsangaris E, Means J, Hassett MJ, Dominici LS, Bellon JR, Broyles J, Kaplan RS, Feeley TW, Pusic AL. ASO Visual Abstract: Time-Driven Activity-Based Costing (TDABC) in Breast Cancer Care Delivery. Ann Surg Oncol 2021. [PMID: 34378094 DOI: 10.1245/s10434-021-10537-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Navraj S Nagra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA.
| | - Elena Tsangaris
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jessica Means
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Justin Broyles
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert S Kaplan
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Thomas W Feeley
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Andrea L Pusic
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Nagra NS, Tsangaris E, Means J, Hassett MJ, Dominici LS, Bellon JR, Broyles J, Kaplan RS, Feeley TW, Pusic AL. Time-Driven Activity-Based Costing in Breast Cancer Care Delivery. Ann Surg Oncol 2021; 29:510-521. [PMID: 34374913 DOI: 10.1245/s10434-021-10465-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Accurate measurement of healthcare costs is required to assess and improve the value of oncology care. OBJECTIVES We aimed to determine the cost of breast cancer care provision across collaborating health care organizations. METHODS We used time-driven activity-based costing (TDABC) to calculate the complete cost of breast cancer care-initial treatment planning, chemotherapy, radiation therapy, surgical resection and reconstruction, and ancillary services (e.g., psychosocial oncology, physical therapy)-across multiple hospital sites. Data were collected between December 2019 and February 2020. TDABC steps involved (1) developing process maps for care delivery pathways; (2) determine capacity cost rates for staff, medical equipment, and hospital space; (3) measure the time required for each process step, both manually through clinic observation and using data from the Real-Time Location System (RTLS); and (4) calculate the total cost of care delivery. RESULTS Surgical care costs ranged from $1431 for a lumpectomy to $12,129 for a mastectomy with prepectoral implant reconstruction. Radiation therapy was costed at $1224 for initial simulation and patient education, and $200 for each additional treatment. Base costs for chemotherapy delivery were $382 per visit, with additional costs driven by chemotherapy agent(s) administered. Personnel expenses were the greatest contributor to the cost of surgical care, except in mastectomy with implant reconstruction, where device costs equated to up to 60% of the cost of surgery. CONCLUSION The cost of complete breast cancer care depended on (1) treatment protocols; (2) patient choice of reconstruction; and (3) the need for ancillary services (e.g., physical therapy). Understanding the actual costs and cost drivers of breast cancer care delivery may better inform resource utilization to lower the cost and improve the quality of care.
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Affiliation(s)
- Navraj S Nagra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA.
| | - Elena Tsangaris
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jessica Means
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Justin Broyles
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert S Kaplan
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Thomas W Feeley
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Andrea L Pusic
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study. Health Technol Assess 2021; 25:1-138. [PMID: 33646096 PMCID: PMC7958078 DOI: 10.3310/hta25130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh). OBJECTIVES The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. DESIGN A mixed-methods feasibility study of a randomised controlled trial. DATA SOURCES MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018. METHODS The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6. RESULTS The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended. LIMITATIONS The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups. CONCLUSION The need for further clinical studies was clear, particularly given the range and number of different patches available. FUTURE WORK Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study. STUDY REGISTRATION The systematic review is registered as PROSPERO CRD42017057908. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Patient representative, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Baldwin M, Nagra NS, Greenall G, Carr AJ, Beard D, Rees JL, Rangan A, Merritt N, Dritsaki M, Hopewell S, Cook JA. Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis. BMJ Open 2020; 10:e039552. [PMID: 33293307 PMCID: PMC7722806 DOI: 10.1136/bmjopen-2020-039552] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 09/03/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs). DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020. ELIGIBILITY CRITERIA All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions. DATA EXTRACTION AND SYNTHESIS Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane). RESULTS We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%). CONCLUSIONS While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations. PROSPERO REGISTRATION NUMBER CRD42017057908.
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Affiliation(s)
- Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - N S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - J L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
- Department of Orthopaedics, James Cook University Hospital, Middlesbrough, Middlesbrough, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Melina Dritsaki
- Centre for Statistics in Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Sally Hopewell
- Centre for Statistics in Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Jonathan Alistair Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
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Sánchez-Campamà J, Nagra NS, Pineda-Moncusí M, Prats-Uribe A, Prieto-Alhambra D. The Association Between Smoking and the Development of Rheumatoid Arthritis: A Population-Based Case-Control Study. Reumatol Clin (Engl Ed) 2020; 17:S1699-258X(20)30203-5. [PMID: 33060030 DOI: 10.1016/j.reuma.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/02/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Smoking is one of the few modifiable risk factors associated with the development of rheumatoid arthritis (RA). Most published data are over 10 years old, and none included Mediterranean populations. We therefore took advantage of primary care routinely collected data to study the association between smoking and the development of RA in the general population of Catalonia, Spain. METHODS We conducted a case-control study including all patients with a new diagnosis of RA registered in the SIDIAP database between 01/01/2008 and 31/12/2018; and matched them to up to 1:5 controls by age, gender and general practitioner. Smoking was classified by primary care staff into never, ex- or current smoking. Odds Ratios and 95% confidence intervals for the association between current and ex-smoking (compared to never smoking) and RA were estimated using conditional logistic regression adjusted for potential confounders. RESULTS A total of 13,920 RA cases and 69,535 controls were included. Compared with never smokers, current and ex-smokers were at increased risk of RA, with adjusted OR of 1.28 [95% CI 1.20-1.37] and OR 1.19 [1.12-1.26] respectively. CONCLUSION Our findings confirm an association between smoking and the risk of developing RA. The effect seems to prevail in the long-term and even in ex-smokers for 2 or more years after smoking cessation. More research is needed on the effects of smoking discontinuation on RA prevention and related outcomes.
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Affiliation(s)
| | - Navraj S Nagra
- Centre for Statistics in Medicine, Botnar Research Centre, NDORMS, University of Oxford, UK
| | - Marta Pineda-Moncusí
- IMIM (Hospital del Mar Research Institute), Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Barcelona, Spain
| | - Albert Prats-Uribe
- Centre for Statistics in Medicine, Botnar Research Centre, NDORMS, University of Oxford, UK.
| | - Daniel Prieto-Alhambra
- Centre for Statistics in Medicine, Botnar Research Centre, NDORMS, University of Oxford, UK; GREMPAL Research Group, Idiap Jordi Gol, Universitat Autonoma de Barcelona and CIBERFES, Barcelona, Spain
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Abstract
A symptomatic bone stress reaction is an early pathological feature, which can lead to stress fractures. It typically affects bones of the lower limbs in response to unaccustomed disproportional compressive loading. Professional sportspeople are susceptible to both bone stress reaction and stress fractures, where training regimes and competition predispose to overuse injuries. We discuss a unique case of a professional cricketer developing pain in the throwing arm due to bone stress reaction in the distal humerus, as confirmed on MRI. Modification of the patient's training regime, presented in this case, facilitated complete recovery within 6 weeks. The positive response to modified training suggests a biomechanical origin of the pain. This case illustrates that tensile stress associated with throwing activities can result in a symptomatic bone stress reaction of the humerus in elite cricketers.
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Affiliation(s)
- Matthew Beech
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Oxford University Hospitals, Oxford, UK
| | | | - Stefan Kluzek
- The Botnar Research Centre (NDORMS), Oxford University Hospitals, Oxford, UK
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11
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Greenall G, Carr A, Beard D, Rees J, Rangan A, Merritt N, Dritsaki M, Nagra NS, Baldwin M, Hopewell S, Cook JA. Systematic review of the surgical management of rotator cuff repair with an augmentative patch: a feasibility study protocol. Syst Rev 2018; 7:187. [PMID: 30424809 PMCID: PMC6234662 DOI: 10.1186/s13643-018-0851-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 10/22/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Shoulder pain is a common problem in the general population and is responsible for prolonged periods of disability, loss of productivity, absence from work and inability to carry out household activities. Rotator cuff problems account for up to 70% of shoulder pain problems and are the third most prevalent musculoskeletal disorder after those occurring in the lower back and neck. Rotator cuff surgery has high failure rates (25-50% within 12 months), and as a result, there is a pressing need to improve the outcome of rotator cuff surgery. Patch augmented surgery for rotator cuff repairs has recently been developed and is increasingly being used within the UK National Health Service. Patch augmented surgery could lead to a dramatic improvement in patient and surgical outcomes, but its clinical and cost effectiveness needs rigorous evaluation. The existing evidence on the use of patches may be at risk of bias as currently only a small number of single-centre comparative studies appear to have been carried out. Additionally, it is unclear for which patches a clinical study (comparative and non-comparative) has been conducted. This paper outlines the protocol for a systematic review intended to summarise the best available clinical evidence and will indicate what further research is required. METHODS Electronic databases (Medline, Embase and Cochrane) will be systematically searched between April 2006 and the present day for relevant publications using a specified search strategy, which can be adapted for the use in multiple electronic databases, and inclusion criteria. Screening of both titles and abstracts will be done by two independent reviewers with any discrepancies resolved by a third independent reviewer. Data extraction will include information regarding the type of participants, type of intervention and outcomes including but not limited to shoulder-specific function and pain scores, patch-related adverse events and type of study. The results will be summarised in a narrative review where qualitative analysis is not possible. DISCUSSION This review aims to collate the current evidence base regarding the use of patches to augment rotator cuff repair. The results of this review will help to develop, using consensus methods, the design of a definitive randomised trial assessing the clinical and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and is feasible. SYSTEMATIC REVIEW REGISTRATION CRD42017057908.
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Affiliation(s)
- Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S. Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan A. Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Clavé A, Gauthier E, Nagra NS, Fazilleau F, Le Sant A, Dubrana F. Single-stage bilateral medial Oxford Unicompartmental Knee Arthroplasty: A case-control study of perioperative blood loss, complications and functional results. Orthop Traumatol Surg Res 2018; 104:943-947. [PMID: 29729936 DOI: 10.1016/j.otsr.2018.03.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/22/2018] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The benefits and risks of a single-stage medial UKA remains a subject of debate because of the theoretically higher risk of complications and specifically blood loss. The aim of this study was to evaluate the perioperative blood loss, risks and the functional results of single-stage bilateral medial Oxford Unicompartmental Knee Arthroplasty (OUKA) compared to a standard unilateral medial OUKA procedure (control group). HYPOTHESIS The blood loss observed during bilateral single-stage medial Oxford UKA is not different from that of the control group. METHODS In this case-control prospective study, fifty patients (100 knees) who underwent single-stage bilateral medial OUKA (study group) were compared to a hundred patients (100 knees) with unilateral medial OUKA (control group), performed by the same surgeon. The real blood loss (in mL of hematocrit at 100%), incidence of blood transfusions, and complication rates were compared. Clinical results were assessed at 6 month and at a two-year minimum follow-up (FU) using IKS, KOOS and OKS scores, in addition to a satisfaction questionnaire. RESULTS Groups were deemed comparable. Concerning blood loss, no significant difference was observed compared to the control group (465mL±225 vs. 396±190; p=0.07). No difference was found, either, between groups regarding the complication rates (p=0.36), nor the clinical results (p=0.61) and patient satisfaction (p=0.23) at last FU. CONCLUSION Single-stage bilateral procedure does not cause increased blood loss compared with controls. Moreover, clinical results were deemed good and excellent in spite of a slightly greater complication rate than those found in the literature but similar to controls. LEVEL OF EVIDENCE Case-control study, level III.
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Affiliation(s)
- Arnaud Clavé
- Faculté de médecine, université de Bretagne Occidentale, 29200 Brest, France; Service d'orthopédie, CHU de la Cavale-Blanche, 29200 Brest, France; Oxford Orthopaedic Engineering Centre, NDORMS, University of Oxford, Oxford, UK.
| | - Emeline Gauthier
- Faculté de médecine, université de Bretagne Occidentale, 29200 Brest, France; Service d'orthopédie, CHU de la Cavale-Blanche, 29200 Brest, France
| | - Navraj S Nagra
- Oxford University Clinical Academic Graduate School (OUCAGS), Medical Sciences Division, John Radcliffe Hospital, Oxford, UK
| | - François Fazilleau
- Faculté de médecine, université de Bretagne Occidentale, 29200 Brest, France; Service d'orthopédie, CHU de la Cavale-Blanche, 29200 Brest, France
| | - Anthony Le Sant
- Faculté de médecine, université de Bretagne Occidentale, 29200 Brest, France; Service d'orthopédie, hôpital de Morlaix, 29600 Morlaix, France
| | - Frédéric Dubrana
- Faculté de médecine, université de Bretagne Occidentale, 29200 Brest, France; Service d'orthopédie, CHU de la Cavale-Blanche, 29200 Brest, France
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Stace ET, Nagra NS, Tiberwel S, Khan W, Carr AJ. The Use of Electrospun Scaffolds in Musculoskeletal Tissue Engineering: A Focus on Tendon and the Rotator Cuff. Curr Stem Cell Res Ther 2018; 13:619-631. [DOI: 10.2174/1574888x13666180129105707] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 05/15/2017] [Accepted: 01/10/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Edward T. Stace
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Headington, Oxford, United Kingdom
| | - Navraj S. Nagra
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Headington, Oxford, United Kingdom
| | - Saket Tiberwel
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Wasim Khan
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andrew J. Carr
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Headington, Oxford, United Kingdom
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14
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Clavé A, Maurer DG, Nagra NS, Fazilleau F, Lefèvre C, Stindel E. Reproducibility of length measurements of the lower limb by using EOS™. Musculoskelet Surg 2017; 102:165-171. [PMID: 29094321 DOI: 10.1007/s12306-017-0518-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 10/25/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lower-limb discrepancy following total hip arthroplasty is the third-most common reason for patient dissatisfaction in orthopaedic surgery. Therefore, accurate planning and evaluation methods are mandatory. The main aim of this study was to evaluate the reliability of the EOS™ system by establishing and comparing the reproducibility of lower-limb automatic and manual 3D measurements. We hypothesized that the reproducibility of the lower-limb measurements is similar regardless of the method used and with an agreement higher than 0.95 for the length parameters. MATERIALS AND METHODS This study utilized an EOS radiological database of 112 patients. Two independent observers performed two rounds of lower-limb measurements twice, either in manual 3D or automatic 3D mode. The intra- and inter-observer reproducibility was evaluated by the calculation of the intra-class coefficient for each measurement method. The methods were then compared. RESULTS The intra- and inter-observer reproducibility for length measurements found with the manual and automatic 3D methods was always > 0.98. There was no significant difference in the reproducibility between the two measurement modes, with the exception of the offset, hip-knee-shaft, and neck-shaft angles. CONCLUSION Our results indicate a very good reproducibility of EOS™ length measurement, regardless of the method used. Automated 3D mode is preferred for the collection of angular and offset measurements. Furthermore, manual mode measurements are not affected by surgical history. Level of evidence IV.
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Affiliation(s)
- A Clavé
- Faculté de Médecine, Université de Bretagne Occidentale, 22 av Camille Desmoulins, 29200, Brest Cedex, France. .,Service de Chirurgie Orthopédique et Traumatologique de la Cavale Blanche, CHRU Brest, bd Tanguy Prigent, 29609, Brest Cedex, France. .,LaTIM, Unité INSERM, Hôpital Morvan, 2 Av Foch, 29609, Brest Cedex, France.
| | - D G Maurer
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - N S Nagra
- NDORMS, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Headington, Oxford, UK
| | - F Fazilleau
- Faculté de Médecine, Université de Bretagne Occidentale, 22 av Camille Desmoulins, 29200, Brest Cedex, France.,Service de Chirurgie Orthopédique et Traumatologique de la Cavale Blanche, CHRU Brest, bd Tanguy Prigent, 29609, Brest Cedex, France
| | - C Lefèvre
- Faculté de Médecine, Université de Bretagne Occidentale, 22 av Camille Desmoulins, 29200, Brest Cedex, France.,Service de Chirurgie Orthopédique et Traumatologique de la Cavale Blanche, CHRU Brest, bd Tanguy Prigent, 29609, Brest Cedex, France.,LaTIM, Unité INSERM, Hôpital Morvan, 2 Av Foch, 29609, Brest Cedex, France
| | - E Stindel
- Faculté de Médecine, Université de Bretagne Occidentale, 22 av Camille Desmoulins, 29200, Brest Cedex, France.,Service de Chirurgie Orthopédique et Traumatologique de la Cavale Blanche, CHRU Brest, bd Tanguy Prigent, 29609, Brest Cedex, France.,LaTIM, Unité INSERM, Hôpital Morvan, 2 Av Foch, 29609, Brest Cedex, France
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Abstract
INTRODUCTION Enhanced recovery programmes (ERPs) reduce patient morbidity and mortality, and provide significant cost savings by reducing length of stay. Currently, no uniform ERP guidelines exist for lower limb arthroplasty in the UK. The aim of this study was to identify variations in ERPs and determine adherence to local policy. METHODS Hospitals offering elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) (23 and 22 centres respectively) contributed details of their ERPs, and performed an audit (15 patients per centre) to assess compliance. RESULTS Contrasting content and detail of ERPs was noted across centres. Adherence to ERPs varied significantly (40-100% for TKA, 17-94% for THA). Analysis identified perioperative use of dexamethasone, tranexamic acid and early mobilisation for TKA, and procedures performed in teaching hospitals for THA as being associated with a reduced length of stay. CONCLUSIONS This study highlights variation in practice and poor compliance with local ERPs. Given the proven benefits of ERPs, evidence-based guidelines in the context of local skillsets should be established to optimise the patient care pathway.
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Affiliation(s)
- N S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - T W Hamilton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - L Strickland
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - D W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
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- *The British Orthopaedic Trainees Association, British Orthopaedic Association, London, UK
| | - H Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Parker S, Nagra NS, Kulkarni K, Pegrum J, Barry S, Hughes R, Ghani Y. Inadequate pelvic radiographs: implications of not getting it right the first time. Ann R Coll Surg Engl 2017; 99:534-539. [PMID: 28682132 DOI: 10.1308/rcsann.2017.0095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Pelvic radiography is a frequent investigation. European guidelines aim to ensure appropriate use and adequate quality. When initial images are inadequate, repeat radiographs are often required, which may have significant patient safety and economic implications. Objectives The study aimed to assess the adequacy of pelvic imaging across three orthopaedic centres, to identify causes for inadequate imaging and to establish the cost of inadequate imaging from financial and patient safety perspectives. Methods Pelvic radiographs were identified on Picture Archiving and Communication System software at three UK hospitals. Radiographs were assessed against European guidelines and indications for repeat imaging were analysed. Results A total of 1,531 sequential pelvic radiographs were reviewed. The mean age of patients was 60 years (range 5 months to 101 years). Of this total, 51.9% of images were suboptimal, with no significant difference across the three hospitals (P > 0.05). Hospital 3 repeated radiographs in 6.3% of cases, compare with 18.1% and 19.7% at hospitals 1 and 2, respectively (P > 0.05). Hospital 3 identified pathology missed on the initial radiograph in 1% of cases, compared with 5.4% and 5.5% at hospitals 1 and 2, respectively (P > 0.05). Out-of-hours imaging is associated with a higher rate of suboptimal quality (69.1%) compared with normal working hours (51.3%; P = 0.006). Adequacy rates vary with age (χ 2 = 43.62, P < 0.001). Risk of having a suboptimal radiograph increases above the age of 60-years (χ 2 = 4.45, P < 0.05). The annual cost of repeat radiographs was £56,200 per hospital. Discussion and conclusion High rates of pelvic radiograph inadequacy can lead to missed pathology and the requirement for repeat imaging, which has significant patient safety and financial implications. Risk factors for inadequate radiographs include older patients and those having out-of-hours imaging.
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Affiliation(s)
- S Parker
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital , Reading , UK
| | - N S Nagra
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital , Oxford , UK
| | - K Kulkarni
- Department of Trauma and Orthopaedics, East and North Herts NHS Trust, Lister Hospital , Stevenage , UK
| | - J Pegrum
- Department of Orthopaedics, Nuffield Orthopaedic Centre, Headington , Oxford , UK
| | - S Barry
- Department of Radiology, John Radcliffe Hospital , Oxford , UK
| | - R Hughes
- Department of Radiology, Stoke Mandeville Hospital , Aylesbury , UK
| | - Y Ghani
- Department of Trauma and Orthopaedic Surgery, Stoke Mandeville Hospital , Aylesbury , UK
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17
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McClelland TJ, Penfold R, Kluzek S, Nagra NS. A large chronic pericardial effusion in an ultramarathon runner with anti-CCP positive rheumatoid arthritis. BMJ Case Rep 2017; 2017:bcr-2017-219350. [PMID: 28611162 DOI: 10.1136/bcr-2017-219350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pericardial effusions arise as an extra-articular manifestation of rheumatoid arthritis (RA). Pericardial effusions are often asymptomatic, particularly in the early phase, but patients are at risk of cardiac tamponade as the effusion progresses. We discuss the case of a 40-year-old male ultramarathon runner with RA who presented with mild pleuritic chest pain and exertional dyspnoea after a recent long-haul flight. Despite a relative tachycardia, his observations were otherwise unremarkable. His blood tests revealed a C-reactive protein (CRP) of 86 mg/L and an anti-cyclic citrullinated peptide (anti-CCP) titre of 360 units/mL. He was initially diagnosed with a pulmonary embolism; however, a large pericardial effusion was found incidentally on CT pulmonary angiogram with over 1500 mL subsequently drained. The patient's symptoms resolved and CRP normalised 2 weeks later. This unique case illustrates that physically fit patients may physiologically compensate for large pericardial effusions and that arthritic symptoms do not correlate with the severity of extra-articular features in RA.
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Affiliation(s)
| | - Rose Penfold
- Botnar Research Centre (NDORMS), University of Oxford, Oxford, UK
| | - Stefan Kluzek
- Botnar Research Centre (NDORMS), University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Botnar Research Centre (NDORMS), University of Oxford, Oxford, UK
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18
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Nagra NS, Cox MP, Nana GR, Isherwood J. Diagnosing a painful abdominal hernia. Emerg Med J 2017; 34:356. [PMID: 28539369 DOI: 10.1136/emermed-2016-205820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Navraj S Nagra
- Department of General Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK.,Medical Sciences Division, Oxford University Clinical Academic Graduate School (OUCAGS), John Radcliffe Hospital, Oxford, UK
| | - Maxime P Cox
- Oxford University Medical School, Medical Sciences Teaching Centre, Oxford, UK
| | - Gael R Nana
- Department of General Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Jenny Isherwood
- Department of General Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
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Nagra NS, Van Popta D, Whiteside S, Holt EM. Postoperative hemoglobin level in patients with femoral neck fracture. Acta Orthop Traumatol Turc 2017; 50:315-22. [PMID: 27130388 DOI: 10.3944/aott.2015.15.0320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the changes of hemoglobin levels in patients undergoing fixation for femoral neck fracture. METHODS Peroperative hemoglobin levels of patients who underwent either dynamic hip screw (DHS) fixation (n=74; mean age: 80 years) or hip hemiarthroplasty (n=104; mean age: 84 years) for femoral neck fracture was monitored. RESULTS There was a statistically and clinically significant mean drop of 31.1 g/L between the preoperative (D0) and postoperative Day 5 Hb levels (p<0.001), with significant reductions from D0 to Day 1 and Day 1 to Day 2 (p<0.001). At each postoperative measurement, DHS patients had lower hemoglobin values over hemiarthroplasty patients (p=0.046). CONCLUSION The decrease in hemoglobin in the first 24-hour postoperative period (D0 to Day 1) is an underestimation of the ultimate lowest value in hemoglobin found at Day 2. Relying on the Day 1 hemoglobin level could be detrimental to patient care. We propose a method of predicting patients likely to be transfused and recommend a protocol for patients undergoing femoral neck fracture surgery to standardize postoperative hemoglobin monitoring.
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Affiliation(s)
- Navraj S Nagra
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Department of Orthopaedic Surgery, Oxford, United Kingdom.
| | - Dmitri Van Popta
- University Hospital of South Manchester NHS Foundation Trust, Department of Orthopaedic Surgery, Wythenshawe, United Kingdom
| | - Sigrid Whiteside
- University Hospital of South Manchester NHS Foundation Trust, Department of Orthopaedic Surgery, Wythenshawe, United Kingdom
| | - Edward M Holt
- University Hospital of South Manchester NHS Foundation Trust, Department of Orthopaedic Surgery, Wythenshawe, United Kingdom
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Abstract
Objectives All-suture anchors are increasingly used in rotator cuff repair procedures. Potential benefits include decreased bone damage. However, there is limited published evidence for the relative strength of fixation for all-suture anchors compared with traditional anchors. Materials and Methods A total of four commercially available all-suture anchors, the ‘Y-Knot’ (ConMed), Q-FIX (Smith & Nephew), ICONIX (Stryker) and JuggerKnot (Zimmer Biomet) and a traditional anchor control TWINFIX Ultra PK Suture Anchor (Smith & Nephew) were tested in cadaveric human humeral head rotator cuff repair models (n = 24). This construct underwent cyclic loading applied by a mechanical testing rig (Zwick/Roell). Ultimate load to failure, gap formation at 50, 100, 150 and 200 cycles, and failure mechanism were recorded. Significance was set at p < 0.05. Results Overall, mean maximum tensile strength values were significantly higher for the traditional anchor (181.0 N, standard error (se) 17.6) compared with the all-suture anchors (mean 133.1 N se 16.7) (p = 0.04). The JuggerKnot anchor had greatest displacement at 50, 100 and 150 cycles, and at failure, reaching statistical significance over the control at 100 and 150 cycles (22.6 mm se 2.5 versus 12.5 mm se 0.3; and 29.6 mm se 4.8 versus 17.0 mm se 0.7). Every all-suture anchor tested showed substantial (> 5 mm) displacement between 50 and 100 cycles (6.2 to 14.3). All-suture anchors predominantly failed due to anchor pull-out (95% versus 25% of traditional anchors), whereas a higher proportion of traditional anchors failed secondary to suture breakage. Conclusion We demonstrate decreased failure load, increased total displacement, and variable failure mechanisms in all-suture anchors, compared with traditional anchors designed for rotator cuff repair. These findings will aid the surgeon’s choice of implant, in the context of the clinical scenario. Cite this article: N. S. Nagra, N. Zargar, R. D. J. Smith, A. J. Carr. Mechanical properties of all-suture anchors for rotator cuff repair. Bone Joint Res 2017;6:82–89. DOI: 10.1302/2046-3758.62.BJR-2016-0225.R1
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Affiliation(s)
- N S Nagra
- NDORMS, University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, UK and, Oxford University Clinical Academic Graduate School, Medical Sciences Divisional Office, Level 3, John Radcliffe Hospital, Oxford, UK
| | - N Zargar
- University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, UK
| | - R D J Smith
- University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, UK
| | - A J Carr
- University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, UK
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Nagra NS, Hamilton TW, Ganatra S, Murray DW, Pandit H. One-stage versus two-stage exchange arthroplasty for infected total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2016; 24:3106-3114. [PMID: 26392344 DOI: 10.1007/s00167-015-3780-8] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 09/08/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE Infection complicating total knee arthroplasty (TKA) has serious implications. Traditionally the debate on whether one- or two-stage exchange arthroplasty is the optimum management of infected TKA has favoured two-stage procedures; however, a paradigm shift in opinion is emerging. This study aimed to establish whether current evidence supports one-stage revision for managing infected TKA based on reinfection rates and functional outcomes post-surgery. METHODS MEDLINE/PubMed and CENTRAL databases were reviewed for studies that compared one- and two-stage exchange arthroplasty TKA in more than ten patients with a minimum 2-year follow-up. RESULTS From an initial sample of 796, five cohort studies with a total of 231 patients (46 single-stage/185 two-stage; median patient age 66 years, range 61-71 years) met inclusion criteria. Overall, there were no significant differences in risk of reinfection following one- or two-stage exchange arthroplasty (OR -0.06, 95 % confidence interval -0.13, 0.01). Subgroup analysis revealed that in studies published since 2000, one-stage procedures have a significantly lower reinfection rate. One study investigated functional outcomes and reported that one-stage surgery was associated with superior functional outcomes. Scarcity of data, inconsistent study designs, surgical technique and antibiotic regime disparities limit recommendations that can be made. CONCLUSION Recent studies suggest one-stage exchange arthroplasty may provide superior outcomes, including lower reinfection rates and superior function, in select patients. Clinically, for some patients, one-stage exchange arthroplasty may represent optimum treatment; however, patient selection criteria and key components of surgical and post-operative anti-microbial management remain to be defined. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Navraj S Nagra
- Medical Sciences Division, John Radcliffe Hospital, Oxford University Clinical Academic Graduate School, Oxford, OX3 9DU, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - Thomas W Hamilton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK.
| | - Sameer Ganatra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - Hemant Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
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Panteliadis P, Nagra NS, Edwards KL, Behrbalk E, Boszczyk B. Athletic Population with Spondylolysis: Review of Outcomes following Surgical Repair or Conservative Management. Global Spine J 2016; 6:615-25. [PMID: 27556003 PMCID: PMC4993622 DOI: 10.1055/s-0036-1586743] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/27/2016] [Indexed: 01/13/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The study aims to critically review the outcomes associated with the surgical repair or conservative management of spondylolysis in athletes. METHODS The English literature listed in MEDLINE/PubMed was reviewed to identify related articles using the term "spondylolysis AND athlete." The criteria for studies to be included were management of spondylolysis in athletes, English text, and no year, follow-up, or study design restrictions. The references of the retrieved articles were also evaluated. The primary outcome was time to return to sport. This search yielded 180 citations, and 25 publications were included in the review. RESULTS Treatment methods were dichotomized as operative and nonoperative. In the nonoperative group, 390 athletes were included. A combination of bracing with physical therapy and restriction of activities was used. Conservative measures allowed athletes to return to sport in 3.7 months (weighted mean). One hundred seventy-four patients were treated surgically. The most common technique was Buck's, using a compression screw (91/174). All authors reported satisfactory outcomes. Time to return to play was 7.9 months (weighted mean). There were insufficient studies with suitably homogenous subgroups to conduct a meta-analysis. CONCLUSION There is no gold standard approach for the management of spondylolysis in the athletic population. The existing literature suggests initial therapy should be a course of conservative management with thoracolumbosacral orthosis brace, physiotherapy, and activity modification. If conservative management fails, surgical intervention should be considered. Two-sided clinical studies are needed to determine an optimal pathway for the management of athletes with spondylolysis.
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Affiliation(s)
- Pavlos Panteliadis
- Spinal Department, Oxford University Hospitals, Headley Way, Oxford, United Kingdom,Address for correspondence Pavlos Panteliadis, MD Spinal Department, Oxford University HospitalsHeadley Way, Oxford OX3 9DUUnited Kingdom
| | - Navraj S. Nagra
- Orthopaedic Department, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, United Kingdom,Division of Medical Sciences, Oxford University Clinical Academic Graduate School, Headley Way, Oxford, United Kingdom
| | | | - Eyal Behrbalk
- The Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Bronek Boszczyk
- The Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, United Kingdom
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Abstract
Myeloid sarcoma is a rare tumour associated with acute myeloid leucaemia (AML). Infrequently, it can occur in myelodysplastic/myeloproliferative overlap syndrome conditions such as chronic monomyelocytic leucaemia (CMML), where it often heralds the transformation towards an AML. We discuss a rare presentation of myeloid sarcoma in the perianal region of a 51-year-old man, who was seen by various clinicians and treated for haemorrhoids and perianal abscess. There were no gross abnormalities in initial haematological investigations and the patient was systemically well. A histological biopsy demonstrated myeloid sarcoma and bone marrow aspirate, and trephine confirmed CMML transforming to AML. Treatment of myeloid sarcoma is dependent on whether there is associated AML in the bone marrow. Dual chemotherapy with cytarabine and daunorubicin remains the gold standard treatment in these patients. Sending histology samples of atypical lesions when performing incision and drainage procedures is extremely important, as it contributes to early detection of rare and malignant tissue diagnoses.
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Affiliation(s)
- Navraj S Nagra
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | - Emilio Lozano
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | | | - Pepe Mullerat
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
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Gilbert HTJ, Nagra NS, Freemont AJ, Millward-Sadler SJ, Hoyland JA. Integrin - dependent mechanotransduction in mechanically stimulated human annulus fibrosus cells: evidence for an alternative mechanotransduction pathway operating with degeneration. PLoS One 2013; 8:e72994. [PMID: 24039840 PMCID: PMC3764176 DOI: 10.1371/journal.pone.0072994] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 07/23/2013] [Indexed: 12/11/2022] Open
Abstract
Intervertebral disc (IVD) cells derived from degenerate tissue respond aberrantly to mechanical stimuli, potentially due to altered mechanotransduction pathways. Elucidation of the altered, or alternative, mechanotransduction pathways operating with degeneration could yield novel targets for the treatment of IVD disease. Our aim here was to investigate the involvement of RGD-recognising integrins and associated signalling molecules in the response to cyclic tensile strain (CTS) of human annulus fibrosus (AF) cells derived from non-degenerate and degenerate IVDs. AF cells from non-degenerate and degenerate human IVDs were cyclically strained with and without function blocking RGD – peptides with 10% strain, 1.0 Hz for 20 minutes using a Flexercell® strain device. QRT-PCR and Western blotting were performed to analyse gene expression of type I collagen and ADAMTS -4, and phosphorylation of focal adhesion kinase (FAK), respectively. The response to 1.0 Hz CTS differed between the two groups of AF cells, with decreased ADAMTS -4 gene expression and decreased type I collagen gene expression post load in AF cells derived from non-degenerate and degenerate IVDs, respectively. Pre-treatment of non-degenerate AF cells with RGD peptides prevented the CTS-induced decrease in ADAMTS -4 gene expression, but caused an increase in expression at 24 hours, a response not observed in degenerate AF cells where RGD pre-treatment failed to inhibit the mechano-response. In addition, FAK phosphorylation increased in CTS stimulated AF cells derived from non-degenerate, but not degenerate IVDs, with RGD pre-treatment inhibiting the CTS – dependent increase in phosphorylated FAK. Our findings suggest that RGD -integrins are involved in the 1.0 Hz CTS – induced mechano-response observed in AF cells derived from non-degenerate, but not degenerate IVDs. This data supports our previous work, suggesting an alternative mechanotransduction pathway may be operating in degenerate AF cells.
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Affiliation(s)
- Hamish T. J. Gilbert
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Navraj S. Nagra
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Anthony J. Freemont
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Sarah J. Millward-Sadler
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Judith A. Hoyland
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
- * E-mail:
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