The coronavirus disease clavicle study: a predictor of future trauma trends.

Background: Clavicle fractures are a common presentation to the emergency department after falls and sporting injuries. During 2020, the coronavirus disease 2019 (COVID-19) pandemic brought with it a long period of social isolation, resulting in a change of behavior patterns and, in return, the presentation of fractures to our local hospitals. The effects of this global pandemic on the presentation and management of clavicles were noted with particular interest to the change in mechanism and its future implications. Methods: We performed a longitudinal observational study in 10 hospitals in the North West of England, reviewing all patients presenting with a clavicle fracture during 6 weeks in the first peak of COVID-19 pandemic and compared these with the same period in 2019. Collection points included the patient demographics, fracture characteristics, mechanism of injury, and management. Results: A total of 427 clavicle fractures were assessed with lower numbers of patients presenting with a clavicle fracture during the COVID-2020 period (n = 177) compared with 2019 (n = 250). Cycling-related clavicle fractures increased 3-fold during the pandemic compared with the 2019 control group. We also noted an overall increase in clavicle fractures resulting from higher energy trauma as opposed to low energy or fragility fracture. We also found a faster time to surgery in the COVID cohort by 2.7 days on average when compared with 2019. Conclusions: Government restrictions and the encouragement of social distancing led to behavioral changes with a vast increase in cyclists on the road. This created a significant rise in clavicle fractures related to this activity. This is likely to be further driven by the government pledge to double cyclists on the road by 2025 in the United Kingdom. We forecast that this increase in cyclists, a behavior change accelerated by the pandemic, is a reliable predictor for future trauma trends.

Radiographic vs. MRI vs. arthroscopic assessment and grading of knee osteoarthritis - are we using appropriate imaging?

PURPOSE: Radiographs and MRI scans are commonly used imaging techniques in the assessment of knee osteoarthritis. However, it currently remains uncertain how good a representation of the actual condition of the knee joint these investigations provide. By comparing them against arthroscopic findings the aim of our study was to conclude how accurate these imaging techniques are at grading knee osteoarthritis. METHODS: This was a retrospective study looking at knee arthroscopies performed at a tertiary centre over a 5 year period. The Outerbridge grade given at arthroscopy was correlated with pre-operative radiograph and MRI scores, so as to assess the reliability of these imaging techniques at predicting the actual severity of knee osteoarthritis seen. RESULTS: Kellgren-Lawrence (KL) grading of radiographs was moderately correlated with Outerbridge grades from arthroscopy for the medial compartment of the knee (Spearman's rho (SR) 0.483, p < 0.001), with a milder correlation in the lateral compartment (SR 0.218, p = 0.003). MRI reporting of knee osteoarthritis was moderately correlated with Outerbridge grades in the medial compartment (SR 0.451, p < 0.001), mildly correlated for both the lateral (SR 0.299, p < 0.001) and patellofemoral joint compartments (SR 0.142, p = 0.054). KL and MRI grading was moderately correlated for the medial compartment (SR 0.475, p < 0.001) and mildly correlated for the lateral compartment (SR 0.277, p < 0.001). CONCLUSION: The ability of radiographs to represent the actual condition of knee osteoarthritis is underestimated. KL grading especially best represents the disease seen in the medial compartment of the knee joint, with a moderate correlation to Outerbridge scores given on arthroscopic assessment. We suggest that whilst MRI is a useful tool in the investigation of knee symptoms, it is often unnecessarily used in patients with OA, when in fact, radiographs alone would be sufficient. EVIDENCE LEVEL: III.

Changing to Removable Casts During the Coronavirus Pandemic-Has It Affected Outcomes for Distal Radius Fractures?

BOAST (British Orthopaedic Association Standards for Trauma & Orthopaedics) guidelines recommended that during the coronavirus pandemic most upper limb fractures should be treated conservatively, and removable casts should be used, where possible. As a result, our district general hospital started using a new soft combination (soft-combi) casting technique for conservative management of distal radius fractures (DRFs) in an attempt to reduce follow-up attendances. To assess if radiological outcomes of soft-combi casts are better or worse than previously used rigid casts for DRFs. Twenty DRFs treated with soft-combi casts were compared with 20 DRFs treated with the old rigid cast types. Radiological parameters were measured pre-manipulation, post-manipulation, at 2-week follow-up, and at final follow-up. Statistical analysis was performed to assess for significant differences seen at follow-up between the groups. The mean loss of volar angulation seen at 2-week follow-up was 4.9° for the rigid casts vs. 1.5° for the soft-combi casts (p = 0.158; 95% CI, - 8.17 to 1.38). The mean loss of radial height after 2 weeks was 0.2 mm vs 0.5 mm (p = 0.675; 95% CI, - 1.09 to 1.66), and the mean loss of radial inclination was 2.0° vs 1.0° (p = 0.349; 95% CI, - 2.96 to 1.07), respectively. The soft-combi casts appeared to be equally effective at maintaining the reduction of DRFs compared to their rigid counterparts, as no statistically significant difference was seen in our study. We can be reassured that continued use of these removable casts in the current climate is unlikely to have a detrimental effect on outcomes for DRFs.

Telemedicine with clinical decision support for critical care: a systematic review.

BACKGROUND: Telemedicine applications aim to address variance in clinical outcomes and increase access to specialist expertise. Despite widespread implementation, there is little robust evidence about cost-effectiveness, clinical benefits, and impact on quality and safety of critical care telemedicine. The primary objective was to determine the impact of critical care telemedicine (with clinical decision support available 24/7) on intensive care unit (ICU) and hospital mortality and length of stay in adults and children. The secondary objectives included staff and patient experience, costs, protocol adherence, and adverse events. METHODS: Data sources included MEDLINE, EMBASE, CINAHL, Cochrane Library databases, Health Technology Assessment Database, Web of Science, OpenGrey, OpenDOAR, and the HMIC through to December 2015. Randomised controlled trials and quasi-experimental studies were eligible for inclusion. Eligible studies reported on differences between groups using the telemedicine intervention and standard care. Two review authors screened abstracts and assessed potentially eligible studies using Cochrane guidance. RESULTS: Two controlled before-after studies met the inclusion criteria. Both were assessed as high risk of bias. Meta-analysis was not possible as we were unable to disaggregate data between the two studies. One study used a non-randomised stepped-wedge design in seven ICUs. Hospital mortality was the primary outcome which showed a reduction from 13.6 % (CI, 11.9-15.4 %) to 11.8 % (CI, 10.9-12.8 %) during the intervention period with an adjusted odds ratio (OR) of 0.40 (95 % CI, 0.31-0.52; p = .005). The second study used a non-randomised, unblinded, pre-/post-assessment of telemedicine interventions in 56 adult ICUs. Hospital mortality (primary outcome) reduced from 11 to 10 % (adjusted hazard ratio (HR) = 0.84; CI, 0.78-0.89; p = <.001). CONCLUSIONS: This review highlights the poor methodological quality of most studies investigating critical care telemedicine. The results of the two included studies showed a reduction in hospital mortality in patients receiving the intervention. Further multi-site randomised controlled trials or quasi-experimental studies with accompanying process evaluations are urgently needed to determine effectiveness, implementation, and associated costs. TRIAL REGISTRATION: PROSPERO CRD42014007406.

Dietary zinc reduces osteoclast resorption activities and increases markers of osteoblast differentiation, matrix maturation, and mineralization in the long bones of growing rats.

The nutritional influence of zinc on markers of bone extracellular matrix resorption and mineralization was investigated in growing rats. Thirty male weanling rats were randomly assigned to consume AIN-93G based diets containing 2.5, 5, 7.5, 15 or 30 microg Zn/g diet for 24 days. Femur zinc increased substantially as zinc increased from 5 to 15 microg/g diet and modestly between 15 and 30 microg/g (P<.05). By morphological assessment, trabecular bone increased steadily as dietary zinc increased to 30 microg/g. Increasing dietary zinc tended to decrease Zip2 expression nonsignificantly and elevated the relative expression of metallothionen-I at 15 but not 30 microg Zn/g diet. Femur osteoclastic resorption potential, indicated by matrix metalloproteinases (MMP-2 and MMP-9) and carbonic anhydrase-2 activities decreased with increasing dietary zinc. In contrast to indicators of extracellular matrix resorption, femur tartrate-resistant acid and alkaline phosphatase activities increased fourfold as dietary zinc increased from 2.5 to 30 microg Zn/g. Likewise, 15 or 30 microg Zn/g diet resulted in maximum relative expression of osteocalcin, without influencing expression of core-binding factor alpha-1, collagen Type 1 alpha-1, or nuclear factor of activated T cells c1. In conclusion, increased trabecular bone with additional zinc suggests that previous requirement estimates of 15 microg Zn/g diet may not meet nutritional needs for optimal bone development. Overall, the up-regulation of extracellular matrix modeling indexes and concomitant decrease in resorption activities as dietary zinc increased from 2.5 to 30 microg/g provide evidence of one or more physiological roles for zinc in modulating the balance between bone formation and resorption.

Hearts in adult offspring of copper-deficient dams exhibit decreased cytochrome c oxidase activity, increased mitochondrial hydrogen peroxide generation and enhanced formation of intracellular residual bodies.

The long-term effects of low dietary copper (Cu) intake during pregnancy and lactation on cardiac mitochondria in first-generation adult rats was examined. Rat dams were fed diets containing either low (1 mg/kg Cu) or adequate (6 mg/kg Cu) levels of dietary Cu beginning 3 weeks before conception and ending 3 weeks after birth. Cytochrome c oxidase (CCO) activity was 51% lower in isolated cardiac mitochondria from 21-day-old offspring of Cu-deficient dams than in the offspring of Cu-adequate dams. CCO activities in the cardiac mitochondria of 63- and 290-day-old offspring were 22% lower and 14% lower, respectively, in the offspring of Cu-deficient dams after they had been repleted with adequate dietary Cu from the time they were 21 days old. Electron micrographs showed that the size of residual bodies and the cellular volume they occupied in cardiomyocytes rose significantly between 63 and 290 days in the Cu-repleted offspring of Cu-deficient dams, but not in the offspring of Cu-adequate dams. The rate of hydrogen peroxide generation by cardiac mitochondria also was 24% higher in the 290-day-old repleted offspring of Cu-deficient dams than in the offspring of Cu-adequate dams. The increase in hydrogen peroxide production by cardiac mitochondria and in the relative volume and size of dense deposits in cardiomyocytes is consistent with increased oxidative stress and damage resulting from prolonged reduction of CCO activity in the offspring of Cu-deficient dams.

Manganese alters mitochodrial integrity in the hearts of swine marginally deficient in magnesium.

It was previously reported that pigs marginally deficient in magnesium (Mg) and fed diets high in manganese (Mn) died suddenly with signs of sudden cardiac death. Manganese, which has properties similar to Mg, may exacerbate Mg-deficiency and be accumulated by mitochondria resulting in ultrastructural damage. The objective of this study was to determine whether deaths of the type previously observed were mediated by adverse interactions of Mn and Mg resulting in ultrastructural damage to the myocardium, alterations in electrocardiographic recordings and tissue retention of Mn, Mg and calcium (Ca). Forty-eight pigs were fed one of six diets in a 2 X 3 factorial arrangement of Mg (100 or 1000 mg Mg/kg) and Mn (5, 50 or 500 mg Mn/kg) for 8 weeks. Left ventricle muscle samples were collected for examination by transmission electron microscopy. No differences in heart muscle ultrastructure were observed between pigs fed low and adequate dietary Mg. However, marked myocardial necrosis and mitochondrial swelling were observed in pigs fed high dietary Mn when combined with low Mg. Feeding low dietary Mg elevated minimum (P < 0.01), maximum (P < 0.05) and average (P < 0.001) heart rates. Low dietary Mg resulted in a 55% probability of a ventricular beat being recorded (P = 0.05) and lower Mg (P < 0.02) and Ca (P < 0.04) contents in heart atria and ventricles. These results suggest that high Mn, when fed in combination with low Mg, disrupts mitochondrial ultrastructure and is associated with the sudden deaths previously reported.

Primary, extranodal, follicular non-Hodgkin lymphoma of the gallbladder: case report and a review of the literature.

We report the first case of isolated primary extranodal non-Hodgkin lymphoma follicular grade 2 limited to the gallbladder, found in the laparoscopic cholecystectomy specimen from a 70 year old woman with symptomatic cholelithiasis. The pericystic duct lymph node, surgical margins, and other lymph nodes, were not involved with lymphoma. According to the medical literature in English language, mucosa associated lymphoid tissue lymphoma (6 cases) is the most frequent type (38%) of primary gallbladder lymphomas (15 reported cases plus our case). Our case demonstrates that follicular lymphoma can be limited to the gallbladder, and confirm that it can occur in an organ normally devoid of lymphoid tissue.

Bioavailability of elemental iron powders to rats is less than bakery-grade ferrous sulfate and predicted by iron solubility and particle surface area.

Foods are fortified with elemental forms of iron to reduce iron deficiency. However, the nutritional efficacy of current, commercially produced elemental iron powders has not been verified. We determined the bioavailability of six commercial elemental iron powders and examined how physicochemistry influences bioavailability. Relative biological value (RBV) of the iron powders was determined using a hemoglobin repletion/slope ratio method, treating iron-deficient rats with repletion diets fortified with graded quantities of iron powders, bakery-grade ferrous sulfate or no added iron. Iron powders were assessed physicochemically by measuring iron solubility in hydrochloric acid at pH 1.0 and 1.7, surface area by nitrogen gas adsorption and surface microstructure by electron microscopy. Bioavailability from the iron powders, based on absolute iron intake, was significantly less than from FeSO4 (100%; P < 0.05) with the following rank order: Carbonyl (64%; Ferronyl, U.S.) > Electrolytic (54%; A-131, U.S.) > Electrolytic (46%; Electrolytic Iron, India) > H-Reduced (42%; AC-325, U.S.) > Reduced (24%; ATOMET 95SP, Canada) > CO-Reduced (21%; RSI-325, Sweden). Solubility testing of the iron powders resulted in different relative rankings and better RBV predictability with increasing time at pH 1.7 (R2 = 0.65 at 150 min). The prediction was improved with less time and lower pH (R2 = 0.82, pH 1.0 at 30 min). Surface area, ranging from 90 to 370 m2/kg, was also highly predictive of RBV (R2 = 0.80). Bioavailability of iron powders is less than bakery-grade ferrous sulfate and varies up to three times among different commercial forms. Solubility at pH 1.0 and surface area were predictive of iron bioavailability in rats.

Copper deficiency: A potential model for determining the role of mitochondria in cardiac aging.

Heart mitochondria experience age-related declines in cytochrome c oxidase (CCO) activity and increases in the generation of reactive oxygen species (ROS) that may contribute to loss of cardiac function and the development of disease that occur with advancing age. In a manner similar to aging, copper deficiency also suppresses heart CCO activity and has cardiovascular consequences related to increased peroxidation. Food restriction is often used as a tool to study oxidative mechanisms of aging and the present study examines the potential of copper deficiency to model the role of mitochondria in cardiac aging by determining if the effect of food restriction on CCO activity and oxidative stress in heart mitochondria parallels its effect on cardiac mitochondria during aging. Overall, copper deficiency severely inhibited CCO activity and increased both Mn superoxide dismutase (MnSOD) and glutathione peroxidase (GPX) in isolated heart mitochondria. However, a 20% reduction in food intake by copper-deficient rats increased CCO activity by 65% and decreased MnSOD activity by 25% but had no effect in rats fed adequate copper. Copper deficiency also reduced the carbonyl content of 80-100 kDa mitochondrial proteins, but the reduction in carbonyl content was unaffected by food restriction. Food restriction did, however, completely prevent the enlargement of cardiac mitochondria in copper-deficient rats. Together, these findings indicate that copper deficiency induces mitochondrial antioxidant enzyme activity and hypertrophy in cardiac tissue in response to reduced CCO activity and that food restriction may counteract these changes by reducing oxidative stress. Because the action of food restriction on CCO activity and mitochondrially generated oxidative stress are similar in copper deficiency and aging, copper deficiency may serve as a short-term model for studying the potential roles of mitochondria in cardiac aging.