The benefits and acceptability of virtual reality interventions for women with metastatic breast cancer in their homes; a pilot randomised trial.

BACKGROUND: Women with metastatic breast cancer (MBC) report debilitating physical and psychological symptoms, including fatigue, anxiety, and pain, that greatly impact their quality of life. Immersive virtual reality (VR) has been proposed as an adjunctive pain therapy for patients with cancer, and evidence suggests it may also decrease symptoms of anxiety and depression. The purpose of this pilot study was to assess whether VR should be pursued as a feasible and acceptable adjunctive therapy to alleviate physical and psychological symptoms in women with MBC. METHODS: We conducted a pilot study testing the acceptability and efficacy of VR interventions with MBC patients to improve quality of life and to produce enduring decreases in fatigue, pain, depression, anxiety, and stress. Participants completed two different week-long VR experiences, reporting the prevalence of symptoms immediately before and after each study week, and 48 h later. Linear mixed models including fixed effects (VR intervention, counterbalancing order, and study week) and random effects (participant) were used to assess the effect of immersive VR on all outcome measures. RESULTS: Thirty-eight women with MBC completed the VR interventions and were included in analyses. Significant improvements post-intervention and/or 48 h later were demonstrated for quality of life, fatigue, pain, depression, anxiety, and stress. Across the entire study period, these differences met the criteria of a clinically important difference for quality of life, fatigue, depression, and stress. Participants reported feelings of relaxation and enjoyment and were highly likely to use the interventions gain. CONCLUSIONS: Our results demonstrate that VR experiences offer enduring benefits to the physical and psychological well-being of women with MBC. VR interventions are a feasible and acceptable intervention that can be conducted in a patient's own home. Such interventions are worthy of future investigation as a novel approach to improving quality of life in a patient population that have often been overlooked. TRIAL REGISTRATION: Prospectively registered on 25th October 2019 with Australian New Zealand Clinical Trials Registry (ref: ACTRN12619001480178 ).

Poor Evertor Muscle Activity Is a Predictor of Recurrence in Idiopathic Clubfoot Treated by the Ponseti Method: A Prospective Longitudinal Study With a 5-Year Follow-up.

BACKGROUND: After successful primary correction of the deformity in idiopathic clubfoot with the Ponseti method, recurrence has been reported to affect up to 40% of children. So far, it has been difficult to predict which feet are at risk of recurrence, despite numerous studies investigating various potential risk factors. The foot abduction brace (FAB) has been the standard of care in preventing recurrence but, even with excellent compliance, recurrences still occur. Increasingly, evidence points to a congenital neuromuscular imbalance constituting the deforming forces present in clubfoot. Poor evertor muscle activity has been cited specifically as a potential risk factor for recurrence. The aim of this study is to evaluate whether poor evertor muscle activity on clinical examination can predict recurrence in idiopathic clubfoot at 5-year follow-up. METHODS: Data were collected prospectively on patients treated at our tertiary physiotherapy-led Ponseti service between 2010 and 2015. Hospital ethical approval was obtained. Sex, age, laterality, Pirani score, number of casts, brace compliance, and evertor activity were recorded. Evertor muscle activity was scored in a semiquantitative repeatable manner: 0, 0.5, or 1 as previously described. Recurrence was defined as deterioration of any of the 4 components of the deformity following a previously complete correction. RESULTS: In total, 104 patients (172 feet) were included in the study, 76 patients had good evertor activity, and 28 demonstrated poor evertor activity. The mean follow up was 62 months (range, 41 to 71 mo); 18.3% of the patients (19/104) had recurrence treated with repeat casting; 13.5% (14/104) of the patients required additional surgery following recasting. Recurrence was highly associated with poor evertor activity (P<0.01). CONCLUSIONS: Results at 5 years confirm that a semiquantitative evertor muscle activity assessment can predict recurrence and should be added to the routine clinical assessment in order to assist with individualizing patient's treatment strategies. LEVEL OF EVIDENCE: Level II.

The Effect of Prone and Supine Limb Positioning on the Radiographic Evaluation of Posterolateral Plate Fixation of the Posterior Malleolus.

Aim: To facilitate the posterolateral approach to the posterior malleolus patients are often positioned prone initially, then turned supine to complete fixation at the medial malleolus. We sought to define observed differences in the radiographic appearance of implants relative to the joint line, in prone and supine positions. Methods: A 3.5 mm tubular plate and a 3.5 mm posterior distal tibial periarticular plate were applied sequentially to 3 individual cadaveric legs, via a posterolateral approach. The tubular plate was positioned to simulate buttress fixation and the posterolateral plate placed more distally. Each limb was secured on a custom jig and radiographs were taken on a mobile c-arm fluoroscopy machine with a calibration ball. A series of prone AP, supine PA and mortise radiographs were taken. Prone radiographs were also taken in different degrees of caudal tilt to simulate knee flexion which occurs in practice, during intraoperative positioning. Plate tip-joint line distances were measured and Mann-Whitney U tests performed. Results: There was no statistically significant difference in plate tip-joint line distance when comparing equivalent prone and supine views (PA/AP or mortise). However, significant differences in apparent implant position were noted with alterations in caudal tilt. When taking a prone image, when the knee is flexed to 20 degrees, the plate tip will appear 6.5-8.5 mm more proximal than in the equivalent supine image where the knee is extended and the fluoroscopy beam is orthogonal to the anatomic axis of the tibia. Conclusion: Observed differences in radiographic appearance of metalwork in the prone and supine position are most likely due to knee flexion and the resulting variation in the angle of the fluoroscopy beam, rather than projectional differences between supine and prone views. Surgeons should be alert to this when analysing intraoperative images.

Preference for horizontal information in faces predicts typical variations in face recognition but is not impaired in developmental prosopagnosia.

Face recognition is strongly influenced by the processing of orientation structure in the face image. Faces are much easier to recognize when they are filtered to include only horizontally oriented information compared with vertically oriented information. Here, we investigate whether preferences for horizontal information in faces are related to face recognition abilities in a typical sample (Experiment 1), and whether such preferences are lacking in people with developmental prosopagnosia (DP; Experiment 2). Experiment 1 shows that preferences for horizontal face information are linked to face recognition abilities in a typical sample, with weak evidence of face-selective contributions. Experiment 2 shows that preferences for horizontal face information are comparable in control and DP groups. Our study suggests that preferences for horizontal face information are related to variations in face recognition abilities in the typical range, and that these preferences are not aberrant in DP.

Normal gaze processing in developmental prosopagnosia.

Two key functions in human face perception are gaze discrimination and identity recognition. Here we examine whether gaze discrimination can be intact when identity recognition is impaired in developmental prosopagnosia (DP). We ran a large sample of developmental prosopagnosics (DPs) with a series of gaze discrimination tasks that assess various mechanisms in gaze processing. Experiment 1 (N = 101 DP participants) investigates spatial processing using an abnormal eye gaze detection task and a Wollaston illusion task that measures perceptual integration of eye and head direction. Experiment 2 (N = 45 DP participants) investigates temporal processing using an adaptation task and a serial dependence task. Despite their deficits with identity recognition, DPs performed in the normal range across both experiments. These results demonstrate that gaze discrimination can be normal in DP, and that various mechanisms of gaze processing can be spared when identity recognition is impaired. Our findings clarify the highly selective nature of impairments in DP and provide support for neurocognitive models of face perception with distinct mechanisms for gaze and identity processing.

Fast saccades towards faces are robust to orientation inversion and contrast negation.

Eye movement studies show that humans can make very fast saccades towards faces in natural scenes, but the visual mechanisms behind this process remain unclear. Here we investigate whether fast saccades towards faces rely on mechanisms that are sensitive to the orientation or contrast of the face image. We present participants pairs of images each containing a face and a car in the left and right visual field or the reverse, and we ask them to saccade to faces or cars as targets in different blocks. We assign participants to one of three image conditions: normal images, orientation-inverted images, or contrast-negated images. We report three main results that hold regardless of image conditions. First, reliable saccades towards faces are fast - they can occur at 120-130 ms. Second, fast saccades towards faces are selective - they are more accurate and faster by about 60-70 ms than saccades towards cars. Third, saccades towards faces are reflexive - early saccades in the interval of 120-160 ms tend to go to faces, even when cars are the target. These findings suggest that the speed, selectivity, and reflexivity of saccades towards faces do not depend on the orientation or contrast of the face image. Our results accord with studies suggesting that fast saccades towards faces are mainly driven by low-level image properties, such as amplitude spectrum and spatial frequency.

Major trauma: Does weekend attendance increase 30-day mortality?

BACKGROUND: Differing mortality rates according to day of hospital admission is an area of debate, where a supposed increased rate of mortality with weekend admissions has been termed "the weekend effect". We sought to identify the 30-day mortality rates in major trauma patients attending our Major Trauma Centre (MTC) and the underlying reasons for these. METHODS: A retrospective review of data retrieved from the Trauma Audit and Research Network (TARN) database was undertaken for all patients attending between January 2013 and July 2015 with an Injury Severity Score of 9 or higher. 30-day mortality rates were calculated according to day of attendance. RESULTS: 1424 patients met the inclusion criteria. There was no significant difference in 30-day mortality between weekend attendances (7.8%) compared to those on a weekday (7.7%). 30-day mortality was highest in patients attending on Fridays (10.8%) and lowest in those attending on Sundays (5.5%). A significantly higher 30-day mortality rate was seen in patients attending on a Friday or Saturday (10.4%) compared to those attending Sunday to Thursday (6.6%) (RR 1.548). Patients with a head injury as their most serious injury on a Friday or Saturday were more likely to have GCS < 9 (34.7% vs 24.4%) and more likely to die (22.7% vs 12%) than those attending Sunday to Thursday. CONCLUSION: There is no significant difference in 30-day mortality when directly comparing weekday to weekend attendances. There is a significantly higher mortality on Friday and Saturday compared to remainder of the week which appears to be explained by a greater severity of head trauma. IMPLICATIONS: This study provides no evidence of a "weekend effect" in this MTC but the increased severity of and mortality from head injury identified on Friday and Saturday is a public health concern which warrants further investigation.

Using simulation to train orthopaedic trainees in non-technical skills: A pilot study.

AIM: To enhance non-technical skills and to analyse participant's experience of a course tailored for orthopaedic surgeons. METHODS: A Delphi technique was used to develop a course in human factors specific to orthopaedic residents. Twenty-six residents (six per course) participated in total with seven course facilitators all trained in Crisis Resource Management providing structured feedback. Six scenarios recreated challenging real-life situations using high-fidelity mannequins and simulated patients. Environments included a simulated operating suite, clinic room and ward setting. All were undertaken in a purpose built simulation suite utilising actors, mock operating rooms, mock clinical rooms and a high fidelity adult patient simulator organised through a simulation control room. Participants completed a 5-point Likert scale questionnaire (strongly disagree to strongly agree) before and after the course. This assessed their understanding of non-technical skills, scenario validity, relevance to orthopaedic training and predicted impact of the course on future practice. A course evaluation questionnaire was also completed to assess participants' feedback on the value and quality of the course itself. RESULTS: Twenty-six orthopaedic residents participated (24 male, 2 female; post-graduation 5-10 years), mean year of residency program 2.6 out of 6 years required in the United Kingdom. Pre-course questionnaires showed that while the majority of candidates recognised the importance of non-technical (NT) skills in orthopaedic training they demonstrated poor understanding of non-technical skills and their role. This improved significantly after the course (Likert score 3.0-4.2) and the perceived importance of these skills was reported as good or very good in 100%. The course was reported as enjoyable and provided an unthreatening learning environment with the candidates placing particular value on the learning opportunity provided by reflecting on their performance. All agreed that the course achieved its intended aims with realistic simulation scenarios. Participants believed patient care, patient safety and team working would all improve with further human factors training (4.4-4.6). and felt that NT skills learnt through simulation-based training should become an integral component of their training program. CONCLUSION: Participants demonstrated improved understanding of non-technical performance, recognised its relevance to patient safety and expressed a desire for its integration in training.

The management of segmental tibial shaft fractures: A systematic review.

INTRODUCTION: Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures. METHOD: A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data. RESULTS: Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'. DISCUSSION: The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available. CONCLUSION: IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem.

Increase in quality and quantity of orthopaedic studies from 2002 to 2012.

PURPOSE: To compare the level of evidence of orthopaedic studies published in 2002 and 2012 to determine whether the quality and quantity of studies have increased. METHODS: The top 10 orthopaedic journals in 2002 and 2012 were identified, according to the Thomson Reuters impact factor. The level of evidence of each clinical article between January and June in 2002 and 2012 were determined by 2 senior orthopaedic trainees, according to the Oxford Centre for Evidence-based Medicine 2011 Levels of Evidence. Basic science articles, case reports, and non-systematic reviews were excluded. The proportions of papers designated to each level of evidence in 2002 and 2012 were compared, as was the mean level of evidence of studies in 2002 and 2012. RESULTS: In 2002, 379 clinical articles were identified and their level of evidence was level 1 (n=3), level 2 (n=67), level 3 (n=71), and level 4 (n=238). In 2012, 642 clinical articles were identified and their level of evidence was level 1 (n=26), level 2 (n=113), level 3 (n=167), and level 4 (n=336). The proportion of level 4 articles decreased from 62.8% in 2002 to 52.3% in 2012 (p=0.001), whereas the proportion of level 1 articles increased from 0.8% to 4.1% (p=0.002) and level 3 articles increased from 18.7% to 26.0% (p=0.008). The mean level of evidence improved from 3.44 in 2002 to 3.27 in 2012 (p=0.002). CONCLUSION: The quality and quantity of orthopaedic studies have increased from 2002 to 2012, but most studies remained of a low level of evidence.

Human Coronavirus 229E Remains Infectious on Common Touch Surface Materials.

UNLABELLED: The evolution of new and reemerging historic virulent strains of respiratory viruses from animal reservoirs is a significant threat to human health. Inefficient human-to-human transmission of zoonotic strains may initially limit the spread of transmission, but an infection may be contracted by touching contaminated surfaces. Enveloped viruses are often susceptible to environmental stresses, but the human coronaviruses responsible for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) have recently caused increasing concern of contact transmission during outbreaks. We report here that pathogenic human coronavirus 229E remained infectious in a human lung cell culture model following at least 5 days of persistence on a range of common nonbiocidal surface materials, including polytetrafluoroethylene (Teflon; PTFE), polyvinyl chloride (PVC), ceramic tiles, glass, silicone rubber, and stainless steel. We have shown previously that noroviruses are destroyed on copper alloy surfaces. In this new study, human coronavirus 229E was rapidly inactivated on a range of copper alloys (within a few minutes for simulated fingertip contamination) and Cu/Zn brasses were very effective at lower copper concentration. Exposure to copper destroyed the viral genomes and irreversibly affected virus morphology, including disintegration of envelope and dispersal of surface spikes. Cu(I) and Cu(II) moieties were responsible for the inactivation, which was enhanced by reactive oxygen species generation on alloy surfaces, resulting in even faster inactivation than was seen with nonenveloped viruses on copper. Consequently, copper alloy surfaces could be employed in communal areas and at any mass gatherings to help reduce transmission of respiratory viruses from contaminated surfaces and protect the public health. IMPORTANCE: Respiratory viruses are responsible for more deaths globally than any other infectious agent. Animal coronaviruses that "host jump" to humans result in severe infections with high mortality, such as severe acute respiratory syndrome (SARS) and, more recently, Middle East respiratory syndrome (MERS). We show here that a closely related human coronavirus, 229E, which causes upper respiratory tract infection in healthy individuals and serious disease in patients with comorbidities, remained infectious on surface materials common to public and domestic areas for several days. The low infectious dose means that this is a significant infection risk to anyone touching a contaminated surface. However, rapid inactivation, irreversible destruction of viral RNA, and massive structural damage were observed in coronavirus exposed to copper and copper alloy surfaces. Incorporation of copper alloy surfaces in conjunction with effective cleaning regimens and good clinical practice could help to control transmission of respiratory coronaviruses, including MERS and SARS.