The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Motion analysis of the glenohumeral joint during activities of daily living.

The shoulder complex has a larger range of motion (ROM) than any other joint complex in the human body, leaving it prone to numerous injuries. Objective kinematic analysis could yield useful functional insights that may assist clinical practice. Non-invasive optoelectronic motion analysis techniques have been used to assess the shoulders of five healthy subjects performing ROM tasks and 10 functional tasks of daily living. The four most demanding tasks - touching the side and back of the head, brushing the opposite side of the head, lifting an object to shoulder height and lifting an object to head height, required 78%, 60%, 61% and 71%, respectively, of the glenohumeral elevation necessary for full abduction in the scapular plane for the 10 shoulders. This has implications for clinical practice where maximum arm elevation is commonly used to determine a patient's ability to return to work and other everyday activities.

Scaphoid fracture due to rigid handcuffs.

Rigid handcuffs have been designed to allow ease of application and to allow better control of violent suspects by the police. This paper reports a case of scaphoid fracture sustained during inappropriate use of these handcuffs. The mechanism of injury described has been simulated for demonstration. Law enforcement officers and clinicians need to be aware of the risks of inappropriate use of these handcuffs.

[Lymphoscintigraphy and sentinel node biopsy in non-palpable breast cancer]. / Linfogammagrafía y biopsia del ganglio centinela en el carcinoma no palpable de mama.

OBJECTIVE: The aim of the study was to evaluate the efficacy of lymphatic mapping and sentinel node biopsy in non-palpable breast cancer (NPBC) patients in comparison with palpable breast cancer (PBC) patients. MATERIAL AND METHODS: 199 breast cancer patients were studied. Patients were classified into two groups: NPBC and PBC. Following sentinel node biopsy all patients underwent axillary lymphadenectomy. Surgery was performed at 4-24 h after peritumoral injection of 111MBq 99mTc-nanocolloid. Histological sentinel node analysis was performed by cytological imprinting and delayed study. The following parameters were analyzed in both groups: scintigraphic and surgical detection rates, true positives (TP), true negatives (TN), sensitivity (S), predictive negative value (PNV), false negative rate (FNR) and global precision (GP) of the technique. RESULTS: No significant differences were observed (p > 0.05) in either the lymphoscintigraphy or surgical sentinel node detection, or drainage to internal mammary chain (p = 0.211) in both groups. Metastatic axillary prevalence was lower in NPBC group (p = 0.019). Similar S, NPV and GP values (>90 %) and FNR (< or = 6 %) were found in both groups. CONCLUSIONS: The reliability of the technique is similar in both groups. Drainage is predominantly axilar. Drainage to internal mammary chain was more frequently seen in medial tumours and in NPBC. Metastatic axillary prevalence was lower in the NPBC group.

[Clinical utility of fused 67Ga SPECT/CT scan images in patients with lymphoma]. / Utilidad clínica de las imágenes de fusión 67Ga SPECT/TC en pacientes con linfoma.

AIM: The aim of this work is to show the clinical utility of the fused SPECT 67Ga/CT images in patients with lymphoma. MATERIAL AND METHOD: 44 patients (22 male) with lymphoma have been studied. 22 with Hodgkin's disease and 22 with non Hodgkin lymphoma. 59 studies were performed (33 thorax-cervical [T], 24 abdomen [A] and 2 skull-cervical area [SC]) with an hybrid gammacamera Millenium VG. We acquire consecutively a whole body scan, a SPECT and a CT, for its fusion with the SPECT, of the affects areas. The images were evaluated by two experts blinded, who classify the contribution of the fusion of images respect to the SPECT like: non changes, it improves the location or changes the extension of the injuries and it changes the staging. Final lesion location was confirmed by a high resolution CT performed within one month. RESULTS: 32/59 studies did not change the location or extension of the injuries (20T, 12A), 23/59 studies changed the location or extension of the injuries (12T, 9A and 2 SC) and on 4/59 the change of location induced a change of staging respect to showed by the SPECT. CONCLUSION: To make fused SPECT 67Ga/CT images in patients with lymphoma allows improving the diagnostic precision in a 46% of the cases, mainly in the abdominal, bone and of the diaphragmatic area studies.

Subdermal re-injection: a method to increase surgical detection of the sentinel node in breast cancer without increasing the false-negative rate.

PURPOSE: The aim of this study was to evaluate in breast cancer whether subdermal (SB) re-injection improves surgical detection (SD) of the sentinel node (SN) in patients with negative lymphoscintigraphy on peritumoral (PT) injection, without increasing the false-negative (FN) rate. METHODS: Group I comprised 261 patients with invasive breast cancer >3 cm and clinically negative axilla treated with primary chemotherapy. Axillary lymphadenectomy was performed in all of these patients. Group IA comprised 201 patients with PT injection, while group IB comprised 60 patients with SB injection in the tumour quadrant. Group II comprised 652 patients with breast cancer <3 cm; in 73 of these patients with negative lymphoscintigraphy, SB re-injection was performed. For lymphoscintigraphy, 37-55 MBq (99m)Tc-albumin nanocolloid in 1 ml was used for PT injection, and 18 MBq in 0.2 ml for SB injection. Five-minute images were obtained 2 h p.i. for PT injection and 20-30 min p.i. for SB injection. SD was performed 4 or 24 h p.i. Lymphoscintigraphic (LD), surgical and internal mammary (IM) detection rates were calculated. In group I, FN, negative predictive value (NPV) and accuracy (A) were calculated. Statistical analysis was performed using the chi-square test. RESULTS: In percentages, results were as follows: Group IA: SD: 84.1, FN: 13.6, NPV: 88.9, A: 78.6, IM: 14.5*. Group IB: SD: 90, FN: 0, NPV: 100, A: 90, IM: 1.7* (*p<0.025). Group II: PT injection only: LD: 82.4, SD: 94; PT injection+SB re-injection: LD: 90, SD: 98.5. SD was 97.8** in patients with positive lymphoscintigraphy and 58.5** when lymphoscintigraphy was negative (**p<0.001). CONCLUSION: For correct staging, including extra-axillary drainage, peritumoural injection should first be performed. When the SN is not visualised, and only in those cases, SB re-injection should be performed, which increases the SD rate without increasing the FN rate.

[First diagnostic choice in patients with high clinical suspicion of pulmonary thromboembolism: helical CT or ventilation/perfusion pulmonary scintigraphy?]. / Primera elección diagnóstica en pacientes con alta sospecha clínica de tromboembolismo pulmonar: gammagrafía de ventilación/perfusión pulmonar o tomografía computarizada helicoidal?

AIM: Comparative analysis about helical CT (ThC) vs ventilation-perfusion pulmonary scintigraphy (V/P Sc) diagnosis effectiveness, as a first diagnosis technique in patients with high clinical suspicion of pulmonary thromboembolism (PT). MATERIALS AND METHODS: Prospective study of 30 patients with high clinical suspicion and high Dimer-D levels (> 250 microg/l). The diagnosis was defined as anticoagulant therapeutic prescription and posterior clinical evolution. V/P Sc were performed to each patient within the next 48 h (an average of 14.8 h) after TCh, without anticoagulant treatment. We classified the scintigrams according to the PIOPED criteria and hTC images as positive, negative and indeterminated. RESULTS: In sixteen patients final diagnosis was PT: in 9 both techniques were positive; in 5 scintigraphy was positive with normal hTC and in 1, hTC was normal with negative scintigraphy. The last case was an indeterminated hTC with negative scintigraphy. In fourteen patients, final diagnosis was non-PT: in 6 both techniques were negative; in 7 scintigraphy was negative with positive hTC and in 1, both results were indeterminated. The sensitivity, specificity, positive predictive value, negative predictive value and efficiency were respectively 87.5, 100, 100, 87.5 and 93 % for V/P Sc and 62, 50, 58.8, 53.8 and 53 % for TCh. CONCLUSION: V/P Sc has better PT diagnosis reliability. It is recommended to do V/P Sc in all patients with high clinical suspicion of PT.

[Assessment of a neuroendocrine tumour by 111In-pentetreotid scintigraphy and PET with 18FFDOPA and 18F-FDG]. / Valoración de un tumor neuroendocrino mediante gammagrafía con 111In-pentetreótido y PET con 18F-FDOPA y 18F-FDG.

We present the case of a 67 year old patient diagnosed of a neuroendocrine carcinoid tumour of the small intestine. The tumour and subsequent metastases were resected previously by surgery, but a new recurrence was suspected. CT showed left adrenal enlargement. 18F-FDG PET was normal and 111In pentetreotide scintigraphy showed liver and left diaphragmatic uptake. 18F-FDOPA PET showed uptake foci in liver and left diaphragm and also in left adrenal gland, retro urinary bladder area and multiple foci in abdominopelvic region, suggesting a peritoneal carcinomatosis. 18F-FDOPA PET was the first imaging modality to assess the extensiveness of the disease that was confirmed six month later by CT. Neuroendocrine tumors are a heterogeneous group of neoplasia. They are studied by conventional radiologic and functional techniques of nuclear medicine. This case illustrates the need to use the different techniques and tracers according to the characteristics of the tumor to be studied to thus improve the diagnostic and prognostic performance.

Genetic diversity measures of local European beef cattle breeds for conservation purposes.

This study was undertaken to determine the genetic structure, evolutionary relationships, and the genetic diversity among 18 local cattle breeds from Spain, Portugal, and France using 16 microsatellites. Heterozygosities, estimates of Fst, genetic distances, multivariate and diversity analyses, and assignment tests were performed. Heterozygosities ranged from 0.54 in the Pirenaica breed to 0.72 in the Barrosã breed. Seven percent of the total genetic variability can be attributed to differences among breeds (mean F(st) = 0.07; P<0.01). Five different genetic distances were computed and compared with no correlation found to be significantly different from 0 between distances based on the effective size of the population and those which use the size of the alleles. The Weitzman recursive approach and a multivariate analysis were used to measure the contribution of the breeds diversity. The Weitzman approach suggests that the most important breeds to be preserved are those grouped into two clusters: the cluster formed by the Mirandesa and Alistana breeds and that of the Sayaguesa and Tudanca breeds. The hypothetical extinction of one of those clusters represents a 17% loss of diversity. A correspondence analysis not only distinguished four breed groups but also confirmed results of previous studies classifying the important breeds contributing to diversity. In addition, the variation between breeds was sufficiently high so as to allow individuals to be assigned to their breed of origin with a probability of 99% for simulated samples.

Silicon metabolism. I. Some aspects of renal silicon handling in normal man.

Renal silicon handling was investigated in 23 healthy adults using electrothermal atomic absorption techniques. The mean urinary silicon excretion was 33.1 +/- 3.85 mg/day; the mean renal silicon clearance was 88.6 +/- 7.94 ml/min; the mean fractional excretion of silicon was 86.35 +/- 8.1%, and the mean urine silicon concentration was 0.265 micrograms/ml. Using multiple correlation analysis, the urinary silicon was found to be highly significantly correlated with the urine magnesium concentration (p less than 0.001) and also with urinary sodium and urinary osmolality (p less than 0.01). 24-hour urinary silicon excretion was highly significantly correlated with fractional excretion of silicon (p less than 0.001), sodium (p less than 0.001), phosphorus (p less than 0.001), magnesium (p less than 0.001), and osmolar load. In split urine studies in 7 subjects urinary silicon was correlated highly significantly with urinary magnesium in all 7 and with urinary osmolality, urine calcium, and urine creatine concentration in 6 of 7. There was a highly significant correlation between renal silicon clearance and fractional excretion of silicon (p less than 0.0005), with magnesium excretion (p less than 0.01), and with sodium excretion. It is suggested that ion pairing of orthosilicate and magnesium may explain some of these urinary findings.

Effect of inorganic phosphate on serum ionized calcium concentration in vitro: a reassessment of the "trade-off hypothesis".

The development of secondary hyperparathyroidism in uremia is thought to be due, in part, to the retention of inorganic phosphate which, as proposed by the "trade-off hypothesis", lowers serum ionized calcium by means of CaHPO4 complex formation. To study this hypothesis, free from hormonal or physiological influence, the effect of changes in inorganic phosphate concentration on calcium ion concentration was examined in vitro in serum and protein-free aqueous solutions. The findings of this study demonstrate that the mean change in ionized calcium in aqueous solution is -0.019 +/- 0.001 mM per 1 mM change in inorganic phosphate, and is not significantly different in serum where the mean change in ionized calcium is -0.018 +/- 0.003 mM per 1 mM change in inorganic phosphate. The results in both aqueous solutions and sera agree closely with values predicted from the K'CaHPO4. Based on these results, the serum inorganic phosphate would have to increase by 1.2 mM (3.7 mg%) before the serum ionized calcium would fall sufficiently (0.025 mM) to stimulate the parathyroid glands. These results indicate that an increase in serum inorganic phosphate to as great as 1 mM/liter does not produce a fall in serum ionized calcium by means of direct physicochemical CaHPO4 complex formation great enough to account for the development of secondary hyperparathyroidism.