Dystonia in children with acquired brain injury

AIM

To quantify the proportion of children who develop dystonia after acquired brain injury (ABI) admitted to a tertiary paediatric intensive care unit (PICU) and analyse the trajectory of dystonia over a 6 month period.

METHODS

Children's Health Ireland at Temple Street PICU electronic database was searched for key terms related to ABI from January 1, 2016 to March 14, 2021. Individuals meeting inclusion criteria were analysed, and clinical data pertinent to ABI, dystonia, treatment and outcomes were reviewed.

RESULTS

Six-hundred and forty-three PICU episodes (580 patients) met search criteria for ABI, with 379 included in the final analysis. Twelve patients developed dystonia following ABI, giving an incidence of 3.2%. The incidence was higher in the hypoxia/anoxia and TBI cohort at 8.3% and 6.2%, respectively. All patients developed dystonia within the first month following ABI (50% by a week). Patients who developed dystonia compared to non-dystonia cohort had a median lower GCS on admission (4.5 versus 7.0, p value 0.032), longer median length of PICU stay (14.0 versus 3.0 days, p value < 0.001) and were older (median age 9.08 versus 4.68 years, p value 0.06). Dystonia persisted in the majority at 6 months (10/11), requiring on-going medical therapies.

CONCLUSION

In our retrospective study, the estimated incidence of dystonia following ABI admitted to the PICU was 3.2%, highest in the hypoxia/anoxia (8.3%) and TBI (6.2%) cohorts. Dystonia emerged early and persisted at 6 months in the majority. This is the first review of dystonia, clinical trajectory and outcomes conducted post-PICU admission for ABI. Future prospective studies are required to determine the true prevalence and burden of disease in the PICU setting.

Requirements for Rehabilitation Services for Children after Severe Acquired Brain Injury

Aim Acquired brain injury (ABI) is a common cause of acquired disability in children. Rehabilitation services are known to be underdeveloped in Ireland. We aimed to estimate the incidence of severe ABI in young people in Ireland. Methods The National Quality Assurance and Information System (NQAIS) database was analysed to identify patients aged 1-16 years who had suffered a "probable severe acquired brain injury requiring rehabilitation" (PSABIR) from 2016 - 2019. PSABIR is defined as the co-occurrence of a medical condition likely to cause ABI with a length of hospital admission longer than 28 days. Results 187 young people in Ireland had PSABIRs from 2016-2019, accounting for 21.4% of all prolonged admissions (incidence 4.55 per 100,000 per year). Median length of stay was 46 days (IQR 35- 80 days). Two children (1%) were discharged directly to specialist rehabilitation; 132 (70.6%) were discharged directly home. Conclusion Severe ABI accounts for a significant proportion of prolonged paediatric admissions, with an average of 47 such events per year. Most young people spend the acute and subacute phases of recovery in a tertiary acute hospital, before being discharged directly home. Rehabilitation services need to be developed in all settings to address unmet need.

Evolving Practice in Management of Pelvic-Acetabular Trauma: COVID-19 Experience From a Tertiary Referral Centre in the UK

Introduction

The United Kingdom was one of the hardest-hit countries during the COVID-19 Pandemic. The UK government announced three national lockdowns to control the spread of the coronavirus and prevent the NHS from getting overburdened with COVID-19 related attendances. Two of the most significant peaks in terms of COVID-19 related hospitalizations and COVID-19 related deaths were in Summer 2020 (corresponding to lockdown 1, which was in effect from 26th March to 26th May 2020) and early 2021 (corresponding to lockdown 3, which was in effect 6th January to 8th March 2021).

During this time, a significant proportion of NHS resources was being diverted towards the treatment of COVID-19 patients. Measures were being taken to prevent unnecessary hospitalizations and reduce patient contact. These included but were not limited to measures to reduce attendances to Emergency departments, introducing telemedicine clinics, and pausing elective services. 

Our hospital is a Major Trauma Centre providing Tertiary Pelvic trauma service to the Greater Manchester area and the North West of England. We conducted this retrospective comparative study to compare the trends in presentation and Management of Pelvic trauma and identify trends in how these changed throughout the pandemic. We want to share these insights with our readers.

Methodology

We conducted a retrospective comparative study by comparing two cohorts of patients, patients presenting to the Pelvic Trauma service during Lockdown 1 and Lockdown 3 in the UK, named Group A and Group B, respectively. Data on patient demographics, injuries, and their management was identified from the Electronic Patient Record System. The data analysis was carried out with the aid of Stata/IC version 16.1. using descriptive Statistics.

Results

Group A contained 19 patients, with a mean age of 66.9 years. Group B contained 23 patients with a mean age of 67.4 years. There was no statistically significant difference in these patients' population demographics, injury patterns, and management (operative vs conservative). However, there was an absolute reduction in the complication rate from Group A to Group B of 17.2% (26.3% vs 9.1%). The higher complication rate during Lockdown 1 can be explained by conservatively managing Pelvic and Acetabular Fractures that would have been eligible for fixation, had COVID-19 not been a factor.

Conclusions

Within the limitations of our study, it appears that operatively managing a carefully selected cohort of acute Pelvic Trauma patients with proper precautions was safe and effective. It is unclear whether there was an added benefit to having a higher threshold to operate and adopting the watch-and-wait policy in Lockdown 1. We recommend continuing to follow the current evidence and fix these fractures early.

Two-Stage Revision Hip Arthroplasty with or without the Use of an Interim Spacer for Managing Late Prosthetic Infection: A Systematic Review of the Literature

The aim of the present paper was to identify, appraise, and synthesize the available evidence on two-stage revision hip arthroplasty with or without the use of an interim spacer for managing late prosthetic infection. The review methodology was designed by referencing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist and flow diagram, and a Population, Intervention, Comparator, Outcomes and Study (PICOS) design framework was used to search for studies to incorporate within the review. Two independent investigators were involved in searching for relevant articles that fulfilled the inclusion criteria for the study. Critical appraisal of the selected articles was carried out using the relevant Critical Appraisal Skills Programme checklists. From an initial pool of 125 articles, four studies satisfied the inclusion criteria and quality assessment and were included for final review. Two patient groups were identified from within the selected studies: spacer and non-spacer. Both groups were assessed in terms of functional outcome, infection cure rates, and technical difficulties encountered during treatment. Better functional outcome was reported in the spacer group, both in the interim period between the two stages and after completion of treatment. The use of spacers reduced operative difficulty during the second stage and accelerated patient discharge. Reinfection and infection persistence rates were higher in the non-spacer group. Within the spacer group, articulated spacers performed better in all parameters. The results of this review reinforce the available evidence supporting the use of interim hip spacers in revision hip arthroplasty for managing prosthetic infection and also indicate that articulated hip spacers could be an attractive option going forward.

Older age and comorbidity are independent mortality predictors in a large cohort of 1305 COVID-19 patients in Michigan, United States

INTRODUCTION

Higher comorbidity and older age have been reported as correlates of poor outcomes in COVID-19 patients worldwide; however, US data are scarce. We evaluated mortality predictors of COVID-19 in a large cohort of hospitalized patients in the United States.

DESIGN

Retrospective, multicenter cohort of inpatients diagnosed with COVID-19 by RT-PCR from 1 March to 17 April 2020 was performed, and outcome data evaluated from 1 March to 17 April 2020. Measures included demographics, comorbidities, clinical presentation, laboratory values and imaging on admission. Primary outcome was mortality. Secondary outcomes included length of stay, time to death and development of acute kidney injury in the first 48-h.

RESULTS

The 1305 patients were hospitalized during the evaluation period. Mean age was 61.0 ± 16.3, 53.8% were male and 66.1% African American. Mean BMI was 33.2 ± 8.8 kg m^-2 . Median Charlson Comorbidity Index (CCI) was 2 (1-4), and 72.6% of patients had at least one comorbidity, with hypertension (56.2%) and diabetes mellitus (30.1%) being the most prevalent. ACE-I/ARB use and NSAIDs use were widely prevalent (43.3% and 35.7%, respectively). Mortality occurred in 200 (15.3%) of patients with median time of 10 (6-14) days. Age > 60 (aOR: 1.93, 95% CI: 1.26-2.94) and CCI > 3 (aOR: 2.71, 95% CI: 1.85-3.97) were independently associated with mortality by multivariate analyses. NSAIDs and ACE-I/ARB use had no significant effects on renal failure in the first 48 h.

CONCLUSION

Advanced age and an increasing number of comorbidities are independent predictors of in-hospital mortality for COVID-19 patients. NSAIDs and ACE-I/ARB use prior to admission is not associated with renal failure or increased mortality.

Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure

The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.

151 Associations of Testicular Size and Arterial Blood Flow with Sexual Development and Semen Characteristics in Dorper Rams Raised in a Subtropical Climate

Spectral Doppler (velocimetric) indices are important indicators of blood perfusion and physiological status of internal organs. Doppler ultrasound is used in andrology to assess the blood flow in the testicular arteries, aiding in the diagnosis of scrotal disorders and abnormal spermatogenesis. It was proposed that blood flow indices measured in the testicular artery, namely, blood flow resistance and pulsatility index, were significant predictors of semen quality in clinically healthy dogs. There is a paucity of studies on the associations of testicular morphology and blood flow dynamics with spermatogenesis in growing rams. Forty-five Dorper rams (24 rams aged 8 to 11 months and 21 rams aged 12 to 24 months) were examined using a portable ultrasound scanner connectecd to a linear-array 7.5-MHz transducer. Measurements of the testes were taken with built-in electronic calipers on images containing the largest cross-sectional area of each testicle in 3 planes (coronal, sagittal, and transverse). Colour and spectral Doppler scans were performed immediately after scrotal ultrasonography to detect the testicular arteries and record the following velocimetric indices: peak systolic velocity (PSV, cm/s), end-diastolic velocity (EDV, cm/s), resistive index (RI = [PSV – EDV)/PSV], and pulsatility index [PI = (SPV – EDV)/mean velocity] of the blood vessels. The length (9.7 ± 0.3 v. 9.0 ± 0.2 cm; mean ± SD) of the testes and scrotal circumference (33.3 ± 0.5 v. 31.8 ± 0.4 cm) were greater (P < 0.05) in sexually mature rams than in peri-pubertal rams. There were no differences (P > 0.05) between the 2 age groups of Dorper rams in mean values for blood flow indices measured in testicular arteries. Semen was collected by ejaculation into the artificial vagina from 38% (8/21) of post-pubertal rams and 21% (5/24) of peri-pubertal animals (Chi-squared test; P < 0.05). Semen volume was negatively correlated with PI of the testicular arteries (r = –0.57, P = 0.04). In summary, the attainment of sexual maturity in Dorper rams maintained in a subtropical climate was associated with significant elongation of testes but not with the changes in testicular volume and blood perfusion. Testicular artery PI was a significant predictor of semen volume in peri-pubertal and sexually mature rams. Based on this and several previous studies, B-mode ultrasonography combined with echotextural analyses of the epididymides and accessory sex glands and serum testosterone measurements provide more useful information on the progression of sexual maturation and present semen quality in rams than the ultrasonographic assessment of testicular dimensions and an array of blood flow indices.

[Interest using 3D ultrasound and MRI fusion biopsy for prostate cancer detection]

INTRODUCTION

The strategic therapy for prostate cancer depends on histo-pronostics data, which could be upgraded by obtaining targeted biopsies (TB) with MRI (magnetic resonance imagery) fusion 3D ultrasound.

OBJECTIVES

To compare diagnostic yield of image fusion guided prostate biopsy using image fusion of multi-parametric MRI (mpMRI) with 3D-TRUS.

MATERIALS AND METHODS

Between January 2010 and April 2013, 179 consecutive patients underwent outpatient TRUS biopsy using the real-time 3D TRUS tracking system (Urostation™). These patients underwent MRI-TRUS fusion targeted biopsies (TB) with 3D volume data of the MRI elastically fused with 3D TRUS at the time of biopsy.

RESULTS

A hundred and seventy-three patients had TBs with fusion. Mean biopsy core per patient were 11.1 (6-14) for SB and 2.4 (1-6) for TB. SBs were positive in 11% compared to 56% for TB (P<0.001). TB outperformed systematic biopsy(SB) in overall any cancer detection rate, detection of clinically significant cancer (58% vs. 36%), cancer core length (6.8mm vs. 2.8mm), and cancer rate per core (P<0.001). In multivariable logistic regression, with TB we have more chance to find a clinically significant cancer (OR:3.72 [2-6.95]). When both TRUS and MRI are positive, there is 2.73 more chance to find a clinically significant cancer.

CONCLUSION

MR/TRUS elastic fusion-guided biopsies outperform systematic random biopsies in diagnosing clinically significant cancer. Ability of interpretation of real-time TRUS is essential to perform the higher level of MR/US fusion and should be use for active surveillance.

LEVEL OF PROOF

4.

An oral lesion as the primary clinical manifestation of sarcoidosis

An oral lesion as the first clinical presentation of sarcoidosis is extremely rare. We present the case of a 39-year-old woman who was referred to the oral and maxillofacial surgery department with a persistent asymptomatic nodular lesion in the hard palate. This was located adjacent to a grossly carious upper first molar and a provisional diagnosis of chronic periapical granuloma was made. An incisional biopsy of the lesion was carried out, which unexpectedly revealed the presence of a non-caseating granulomatous inflammatory reaction. A referral was sent to the respiratory medicine team and a diagnosis was later confirmed of stage II sarcoidosis. This case report highlights the need for clinicians to be aware of all possible causes of oral lesions, including rare manifestations of underlying systemic disease.

Out of sight, out of mind? A national survey of paediatricians in Ireland regarding Fetal Alcohol Spectrum Disorders

Fetal Alcohol Spectrum Disorders (FASDs) are one of the major causes of preventable developmental delay. There is no register of children with FASDs in Ireland. Up to 81% of Irish women report drinking alcohol during the periconceptual period or pregnancy. We aimed to evaluate self-reported knowledge and practice of doctors working in paediatrics in Ireland with regards to FASDs and alcohol consumption during pregnancy. We circulated a survey to all paediatric doctors in Ireland, either enrolled in specialist training or registered as trainers. Fifty-six respondents (31.3%) were unaware of the existence of FASDs. Sixty-two (34.6%) believed most patients with FASDs have dysmorphic features. Seventy-three respondents (40.8%) routinely ask about maternal alcohol consumption during pregnancy in the context of developmental delay. Thirty-one respondents (17.3%) stated that mild alcohol intake in the third trimester of pregnancy is safe. Our survey suggests prenatal alcohol exposure may not be routinely considered in the evaluation of children with developmental delay by paediatric doctors in Ireland.

Neonatal referrals to the coroner service: a short survey on current practice

In Ireland, coroners are required by law to ascertain the details of potentially unexplained deaths. The Coroner's Acts (1962 and 2005) detail deaths which must be notified to the coroner. We surveyed current practice regarding the notification of the Coroner Service following neonatal deaths by telephone interview of senior clinical nurse managers of paediatric units with neonatal inpatients. Five of 21 units (23.8%) reported that all neonatal deaths would prompt contact with the Coroner Service, with four more units (19%) reporting that unexpected neonatal deaths would be referred. Nine units (42.9%) reported that referral was at the discretion of the consultant involved while three units (14.3%) do not refer neonatal deaths to the coroner.

The outcome of scapulothoracic arthrodesis using cerclage wires, plates, and allograft for facioscapulohumeral dystrophy

BACKGROUND

Scapulothoracic arthrodesis is a recognized treatment for impaired shoulder function in patients with facioscapulohumeral dystrophy (FSHD) and is traditionally performed with autograft. The purpose of the study was to report our experience with scapulothoracic arthrodesis in patients with FSHD using allograft, rather than autograft, with particular respect to the effect of fusion on preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores; forced vital capacity (FVC); and complications.

MATERIALS AND METHODS

The early results of 14 consecutive scapulothoracic arthrodeses in FSHD patients with cerclage wires, plates, and allograft (fresh-frozen femoral heads) are reported. DASH scores were recorded preoperatively and 6 months postoperatively. Preoperative and 6-month FVCs were compared. The surgical technique is described.

RESULTS

Eleven patients underwent 14 fusions. The mean follow-up period was 29 months (range, 6-50 months). Forward flexion improved from 70° to 115° (P = .001) and abduction from 68° to 109° (P = .007). The DASH score improved from 48 points to 34 points (P = .005). FVC decreased from 98% to 92% of predicted (P = .021), although this was not clinically significant. One patient required revision for nonunion, and metalwork was removed in 5 scapulae. A postoperative chest infection developed in 1 patient and a pleural effusion in another. One brachial plexus palsy occurred, which had almost completely resolved by 27 months postoperatively.

CONCLUSION

Scapulothoracic arthrodesis can be performed successfully with allograft. The nonunion and complication rates are similar to those in the existing literature. A small decrease in FVC does occur but not to a clinically significant level.

A low energy paediatric clavicle fracture associated with acute brachial plexus injury and subclavian artery compression

Paediatric clavicle fractures are common injuries presenting to orthopaedic surgeons. The majority of these represent midshaft low energy fractures, which in the vast majority of cases are treated non-operatively and recover rapidly. The main indications to consider operative intervention include high energy of injury, >2cm shortening, open fractures and associated vascular or neurological injuries. Brachial plexus (BP) injuries are uncommon with variable outcomes. They often result from high energy motorcycle related accidents with potentially fatal associated injuries such as vascular disruption. Their management is complex, requiring expertise, and they are therefore usually managed in supraregional centres.

We present a unique case of a low energy midshaft clavicle fracture in a paediatric patient in whom there was an acute BP injury and subclavian artery compression that has not been described previously.

The relationship between vitamin D and chemotherapy-induced toxicity - a pilot study

BACKGROUND

There are anecdotal data that lower levels of vitamin D may be associated with increased levels of toxicity in individuals receiving chemotherapy; we therefore wished to investigate this further.

METHODS

From a cohort of over 11 000 individuals, we included those who had vitamin D levels (serum 1,25(OH)(2)D3) measured before and during chemotherapy. They were analysed for side effects correlating Chemotherapy Toxicity Criteria with vitamin D levels, normalising data for general markers of patient health including C-reactive protein and albumin.

RESULTS

A total of 241 (2% of the total cohort) individuals entered the toxicity analysis. We found no overall difference in toxicity effects experienced by patients depending on whether they were vitamin D depleted or had sufficient levels (P=0.78).

CONCLUSION

This pilot study suggests routine vitamin D measurement during treatment does not appear to be necessary in the management of chemotherapy-induced toxicity.

Observational analysis of BOA free-papers (2001): from presentation to publication and comparison with the American Academy of Orthopaedic Surgeons (AAOS)

AIM

The objectives of this study were to: determine the presentation to publication conversion rate (PPCR) in peer-reviewed indexed journals of free papers and posters presented at 12-14th September 2001 British Orthopaedic Association (BOA) annual meeting and to compare the publication rate with the American Academy of Orthopaedic Surgeons (AAOS) meeting in 2001.

METHODOLOGY

We looked at all presentations including both podium and poster presentations at British Orthopaedic Association meeting held in 2001 and assessed for subsequent publication as full-text article with a fixed PubMed search protocol. Once the abstract was identified as being published, we noted the name of the journal, citation, and time to presentation. The level of evidence was assigned for each abstract along the guidelines published by the centre for evidence-based medicine, Oxford, UK. This conversion rate was compared with the presentation to publication rate for the AAOS meeting in 2001.

RESULTS

A total of 179 abstracts were presented at the 2001 BOA meeting. 65 of these were published as full-text articles in 30 different journals. The overall publication rate was 36.3%. The publication rate of the papers presented at AAOS annual meeting 2001 was 49% (367/756). The mean time from presentation to publication was 18.6 months (±9.4 months). Three fourths of them were published after 2 years of presentations (63% for AAOS). Majority of studies were either level III or IV. 14 full-text articles were published in Journal of Bone and Joint Surgery British (JBJS Br) and 8 in the Injury Journal.

CONCLUSIONS

This is the first study reporting the publication rate of presentations for BOA meeting and comparing it with the publication rate of AAOS meeting in 2001. The publication rate of BOA presentations is much lower than the AAOS meeting. We believe the publication rate is an important tool in judging the quality of research work and the reputation of a scientific meeting with higher conversion rates suggesting better quality. Thus, more stringent selection criteria need to be introduced so that the selected abstracts can withstand peer-view for publication as full-text articles.

[A novel technique for distal ureterectomy and bladder cuff excision]

INTRODUCTION

We describe a novel endoscopic approach and provide a literature review for the "en bloc" dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum.

MATERIALS AND METHODS

The procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen.

RESULTS

The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6hours and 15minutes. The bladder cuff time was 45minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3.

CONCLUSION

The distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy.

Is peri-articular multimodal drug infiltration in knee arthroplasty safe when used in conjunction with autologous retransfusion drains?

INTRODUCTION

Adequate peri-operative analgesia following total knee arthroplasty (TKA) promotes earlier rehabilitation but remains problematic because of the drug side-effects. Peri-articular multimodal drug infiltration (PMDI) has been developed as an alternative strategy to avoid such complications. Autologous retransfusion drains reduce the need for peri-operative allogenic blood transfusions and the consequent risk. There is a theoretical risk of local anaesthesia toxicity when these systems are used concurrently. We performed a review of current practice to quantify this risk.

PATIENTS AND METHODS

A series of 10 patients undergoing TKA by the senior author (CAB) had drain fluid analysed for the concentration of ropivacaine. At the same time, the patients completed a questionnaire to establish the presence of ropivacaine-induced side-effects.

RESULTS

The ropivacaine level in the retransfusion blood was less than 10 mg in all patients. This concentration was a factor of 6 below the published safe level. Three patients had minor neurological disturbances which recovered spontaneously and quickly. There were no cases of significant cardiovascular compromise.

CONCLUSIONS

The theoretical risk of local anaesthesia toxicity when these systems are used together is negligible and we conclude that peri-articular multimodal drug infiltration is safe in conjunction with the use of autotransfusion drains.

Lyme disease: an unusual case of peripheral nerve palsy

Lyme disease is a vector-borne multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi sensu lato. This disease is frequently seen in North America and to a lesser degree in Europe. However, its presence in England is uncommon and we present a case in which the patient developed a palsy of the common peroneal nerve.