Intraoperative traction has a negligible time-dependent influence on patient-reported outcomes after hip arthroscopy: a cohort study.

The aim of this study is to determine if post-operative patient-reported outcome measures (PROMs) are influenced by hip arthroscopy traction duration. Patients from a local prospective hip arthroscopy database were retrospectively analyzed. Four hip-specific PROMs were utilized: modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific (HOS-SS), and international Hip Outcome Tool (iHOT). PROMs were collected pre-operatively and 6 months, 1 year and 2 years post-operatively. Two cohorts were created based on a cut-off corresponding to the 66th percentile for our patient cohort. Analyses were completed for each PROM at each post-operative interval with univariable statistics. Multivariable statistics were examined to identify the variables that were predictive of achieving post-operative minimal clinically important difference (MCID) at the 2-year follow-up. Overall, 222 patients met the inclusion criteria. The mean age was 32.4 ± 9.4 years, and 116 (52.3%) were female. The average traction time of the study population was 46.1 ± 12.9 min. A total of 145 patients were included in the short traction cohort (65%) with traction times of <50 min (66th percentile). No significant differences were found regarding PROM scores or MCID achievement rates between both cohorts at any post-operative period. In multivariable analyses, achievement of MCID was predicted by a decrease in traction time for all PROMs and pincer-type resection for mHSS, HOS-ADL and iHOT. There was no difference in PROMs and MCID achievement between longer and shorter traction time cohorts. On multivariable analysis, a decrease in traction time is predictive of MCID for all PROM scores and pincer-type resection was predictive of MCID for most PROM scores. Level of evidence: Level III, cohort study.

Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Cohort Study.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, the management of acute appendicitis shifted towards non-operative management in the United Kingdom (UK). The open approach was recommended over the laparoscopic approach due to the risk of aerosol generation and subsequent contamination. The aim of this study was to compare the overall management and surgical outcomes of the patients treated for acute appendicitis before and during the COVID-19 pandemic. MATERIALS AND METHODS: We performed a retrospective cohort study at a single district general hospital in the UK. We compared the management and outcome of the patients diagnosed with acute appendicitis before the pandemic, from March to August 2019, and during the pandemic, from March to August 2020. We looked at the patient demographics, methods of diagnosis, management, and surgical outcomes for these patients. The primary outcome of the study was the 30-day readmission rate. Secondary outcomes included length of stay and post-operative complications. RESULTS: Over the period of six months, a total of 179 patients were diagnosed with acute appendicitis in 2019 (Pre-COVID-19 pandemic, from March 1, 2019, to August 31, 2019) versus 152 in 2020 (during the COVID-19 pandemic, from March 1, 2020, to August 31, 2020). For the 2019 cohort, the mean age of the patients was 33 (range 6-86 years), 52% (n=93) were female, and the mean BMI was 26 (range 14-58). For the 2020 cohort, the mean age was 37 (range 4-93 years), 48% (n=73) of the patients were female, and the mean BMI was 27 (range 16-53). At the first presentation, in 2019, 97.2% of the patients (174 out of 179) received surgical treatment compared to 70.4% (107 out of 152) in 2020. Three per cent of the patients (n=5) were managed conservatively in 2019 (two out these failed conservative management) as compared to 29.6% (n=45) in 2020 (21 of these failed conservative management). Pre-pandemic, only 32.4% (n= 57, ultrasound (US) scan: 11, computer tomography (CT) scan): 45, both US and CT: 1) of the patients received imaging to confirm the diagnosis as compared to 53.3% during pandemic (n=81, US scan: 12, CT scan: 63, both US and CT: 6). Overall, the CT to US ratio increased. We found that during 2019, 91.5% (n=161/176) of the patients who received surgical treatment went through laparoscopic surgery as compared to only 74.2% (n=95/128) in 2020 (p<0.0001). Postoperative complications occurred in 5.1% (n=9/176) of the surgical patients in 2019 as compared to 12.5% (n=16/128) in 2020 (p<0.033). The mean length of hospital stay in 2019 was 2.9 days (range 1-11) versus 4.5 days in 2020 (range 1-57) (p<0.0001). The 30-day readmission rate was 4.5% (8/179) versus 19.1% (29/152) (p<0.0001). The 90-day mortality rate was zero for both cohorts. CONCLUSION: Our study shows that the management of acute appendicitis changed due to the COVID-19 pandemic. More patients went through imaging, especially CT scans for diagnosis and received non-operative management with antibiotics only. The open surgical approach became more common during the pandemic. This was associated with longer lengths of hospital stay, more readmissions, and an increase in postoperative complications.

Innovative Method of Traction in a Bilateral Diaphyseal Femur Fracture in a Polytrauma Below-Knee Amputee.

While diaphyseal femoral shaft fractures are common, it is uncommon to see this injury in leg amputees. Traditionally, these fractures are internally fixed using a fracture table with reduction obtained by traction and adequate rotation exerted on a slightly abducted extremity. Special considerations need to be given in the management of patients with leg amputations. We report the case of a 24-year-old gentleman with bilateral diaphyseal femoral shaft fractures and a previous right below-knee amputation, who was transferred to our centre following a road traffic collision. We highlight important planning that needs to be undertaken for appropriate positioning, ease of reduction, and fracture fixation. We have reviewed the literature to highlight the methods that have been previously described and our use of skeletal traction through the amputation stump that can be utilised by other surgeons in challenging situations like this.

Milestones in stereotactic radiosurgery for the central nervous system.

INTRODUCTION: Since Lars Leksell developed the first stereotactic radiosurgery (SRS) device in 1951, there has been growth in the technologies available and clinical indications for SRS. This expansion has been reflected in the medical literature, which is built upon key articles and institutions that have significantly impacted SRS applications. Our aim was to identify these prominent works and provide an educational tool for training and further inquiry. METHOD: A list of search phrases relating to central nervous system applications of stereotactic radiosurgery was compiled. A topic search was performed using PubMed and Scopus databases. The journal, year of publication, authors, treatment technology, clinical subject, study design and level of evidence for each article were documented. Influence was proposed by citation count and rate. RESULTS: Our search identified a total of 10,211 articles with the top 10 publications overall on the study of SRS spanning 443-1313 total citations. Four articles reported on randomized controlled trials, all of which evaluated intracranial metastases. The most prominent subtopics included SRS for arteriovenous malformation, glioblastoma, and acoustic neuroma. Greatest representation by treatment modality included Gamma Knife, LINAC, and TomoTherapy. CONCLUSIONS: This systematic reporting of the influential literature on SRS for intracranial and spinal pathologies underscores the technology's rapid and wide reaching clinical applications. Moreover the findings provide an academic guide to future health practitioners and engineers in their study of SRS for neurosurgery.

Silicon Valley new focus on brain computer interface: hype or hope for new applications?

In the last year there has been increasing interest and investment into developing devices to interact with the central nervous system, in particular developing a robust brain-computer interface (BCI). In this article, we review the most recent research advances and the current host of engineering and neurological challenges that must be overcome for clinical application. In particular, space limitations, isolation of targeted structures, replacement of probes following failure, delivery of nanomaterials and processing and understanding recorded data. Neural engineering has developed greatly over the past half-century, which has allowed for the development of better neural recording techniques and clinical translation of neural interfaces. Implementation of general purpose BCIs face a number of constraints arising from engineering, computational, ethical and neuroscientific factors that still have to be addressed. Electronics have become orders of magnitude smaller and computationally faster than neurons, however there is much work to be done in decoding the neural circuits. New interest and funding from the non-medical community may be a welcome catalyst for focused research and development; playing an important role in future advancements in the neuroscience community.

A pilot study to assess the utility of a freely downloadable mobile application simulator for undergraduate clinical skills training: a single-blinded, randomised controlled trial.

BACKGROUND: Medical simulators offer an invaluable educational resource for medical trainees. However, owing to cost and portability restrictions, they have traditionally been limited to simulation centres. With the advent of sophisticated mobile technology, simulators have become cheaper and more accessible. Touch Surgery is one such freely downloadable mobile application simulator (MAS) used by over one million healthcare professionals worldwide. Nevertheless, to date, it has never been formally validated as an adjunct in undergraduate medical education. METHODS: Medical students in the final 3 years of their programme were recruited and randomised to one of three revision interventions: 1) no formal revision resources, 2) traditional revision resources, or 3) MAS. Students completed pre-test questionnaires and were then assessed on their ability to complete an undisclosed male urinary catheterisation scenario. Following a one-hour quarantined revision period, all students repeated the scenario. Both attempts were scored by allocation-blinded examiners against an objective 46-point mark scheme. RESULTS: A total of 27 medical students were randomised (n = 9 per group). Mean scores improved between baseline and post-revision attempts by 8.7% (p = 0.003), 19.8% (p = 0.0001), and 15.9% (p = 0.001) for no resources, traditional resources, and MAS, respectively. However, when comparing mean score improvements between groups there were no significant differences. CONCLUSIONS: Mobile simulators offer an unconventional, yet potentially useful adjunct to enhance undergraduate clinical skills education. Our results indicate that MAS's perform comparably to current gold-standard revision resources; however, they may confer significant advantages in terms of cost-effectiveness and practice flexibility. TRIAL REGISTRATION: Not applicable.

Stereotactic modulation of blood-brain barrier permeability to enhance drug delivery.

Drug delivery in the CNS is limited by endothelial tight junctions forming the impermeable blood-brain barrier. The development of new treatment paradigms has previously been hampered by the restrictiveness of the blood-brain barrier to systemically administered therapeutics. With recent advances in stereotactic localization and noninvasive imaging, we have honed the ability to modulate, ablate, and rewire millimetric brain structures to precisely permeate the impregnable barrier. The wide range of focused radiations offers endless possibilities to disrupt endothelial permeability with different patterns and intensity following 3-dimensional coordinates offering a new world of possibilities to access the CNS, as well as to target therapies. We propose a review of the current state of knowledge in targeted drug delivery using noninvasive image-guided approaches. To this end, we focus on strategies currently used in clinics or in clinical trials such as targeted radiotherapy and magnetic resonance guided focused ultrasound, but also on more experimental approaches such as magnetically heated nanoparticles, electric fields, and lasers, techniques which demonstrated remarkable results both in vitro and in vivo. We envision that biodistribution and efficacy of systemically administered drugs will be enhanced with further developments of these promising strategies. Besides therapeutic applications, stereotactic platforms can be highly valuable in clinical applications for interventional strategies that can improve the targetability and efficacy of drugs and macromolecules. It is our hope that by showcasing and reviewing the current state of this field, we can lay the groundwork to guide future research in this realm.

Improving maternal confidence in neonatal care through a checklist intervention.

Previous qualitative studies suggest a lack of maternal confidence in care of their newborn child upon discharge into the community. This observation was supported by discussion with healthcare professionals and mothers at University College London Hospital (UCLH), highlighting specific areas of concern, in particular identifying and managing common neonatal presentations. The aim of this study was to design and introduce a checklist, addressing concerns, to increase maternal confidence in care of their newborn child. Based on market research, an 8-question checklist was designed, assessing maternal confidence in: feeding, jaundice, nappy care, rashes and dry skin, umbilical cord care, choking, bowel movements, and vomiting. Mothers were assessed as per the checklist, and received a score representative of their confidence in neonatal care. Mothers were followed up with a telephone call, and were assessed after a 7-day-period. Checklist scores before as compared to after the follow-up period were analysed. This process was repeated for three study cycles, with the placement of information posters on the ward prior to the second study cycle, and the stapling of the checklist to the mother's personal child health record (PCHR) prior to the third study cycle. A total of 99 mothers on the Maternity Care Unit at UCLH were enrolled in the study, and 92 were contactable after a 7-day period. During all study cycles, a significant increase in median checklist score was observed after, as compared to before, the 7-day follow up period (p < 0.001). The median difference in checklist score from baseline was greatest for the third cycle. These results suggest that introduction of a simple checklist can be successfully utilised to improve confidence of mothers in being able to care for their newborn child. Further investigation is indicated, but this intervention has the potential for routine application in postnatal care.

Clinical and surgical applications of smart glasses.

BACKGROUND: With the increased efforts to adopt health information technology in the healthcare field, many innovative devices have emerged to improve patient care, increase efficiency, and decrease healthcare costs. A recent addition is smart glasses: web-connected glasses that can present data onto the lenses and record images or videos through a front-facing camera. OBJECTIVE: In this article, we review the most salient uses of smart glasses in healthcare, while also denoting their limitations including practical capabilities and patient confidentiality. METHODS: Using keywords including, but not limited to, ``smart glasses'', ``healthcare'', ``evaluation'', ``privacy'', and ``development'', we conducted a search on Ovid-MEDLINE, PubMed, and Google Scholar. A total of 71 studies were included in this review. RESULTS: Smart glasses have been adopted into the healthcare setting with several useful applications including, hands-free photo and video documentation, telemedicine, Electronic Health Record retrieval and input, rapid diagnostic test analysis, education, and live broadcasting. CONCLUSIONS: In order for the device to gain acceptance by medical professionals, smart glasses will need to be tailored to fit the needs of medical and surgical sub-specialties. Future studies will need to qualitatively assess the benefits of smart glasses as an adjunct to the current health information technology infrastructure.