Risk stratifying gastric ulcers: development and validation of a scoring system.

Objective: Debate is ongoing regarding the need for universal endoscopic follow-up to ensure gastric ulcer healing. We aimed to assess the value of follow-up oesophago-gastro-duodenoscopies (OGDs) for gastric ulcer healing and stratify patients according to risk of malignancy by developing a risk score. Design/method: All patients in National Health Service (NHS) Lothian with an index OGD and a diagnosis of gastric ulcer between 1 January 2014 and 31 December 2018 were identified. Data were analysed with logistic regression to identify factors significantly associated with a diagnosis of cancer; a risk score was derived and externally validated. Results: 778 patients were identified and 60.3% (469/778) of patients had a follow-up OGD. 8.6% (66/778) of patients were diagnosed with cancer. No cases of cancer were found on follow-up OGD of a benign appearing ulcer with negative biopsies. Macroscopic suspicion of malignancy was present at index OGD in 100% (3/3) of those diagnosed with cancer on subsequent OGDs. Older age (p=0.014), increased ulcer size (p<0.001) and non-antral location (p=0.030) were significantly associated with malignancy. A risk score (area under the curve (AUC) 0.868, p<0.001, minimum score=0, maximum score=6) was derived from these variables. 78.0% of patients with malignant ulcers scored ≥3, only 15.8% with benign ulcers scored ≥3 (negative predictive value (NPV) 97.4%). External validation yielded an AUC of 0.862 (p<0.001) and NPV of 98.6%; 84.0% of those with malignant ulcers scored ≥3. Conclusion: Ulcers with a combination of macroscopically benign appearances, at least six negative biopsies and a low risk score do not necessarily need endoscopic follow-up.

Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study.

BACKGROUND: Health Economists in Denmark have reported poor outcomes and low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). In this setting it is important to evaluate outcomes following this commonly performed operation to justify undertaking it on our patients. The purpose of the study was to evaluate the effectiveness of ASAD for patients with SAIS and correlate clinical outcome with rate of return to work. METHODS: Prospective cohort study and retrospective review of data from the Nottingham Shoulder database. Inclusion criteria: Patients diagnosed clinically with SAIS by an experienced shoulder surgeon, who have failed conservative treatment (physiotherapy and sub-acromial injection), undergoing ASAD. Pre-operative and 6-month post-operative Oxford Shoulder Score (OSS) and Constant Score (CS) were compared. The rates of return to pre-operative work and hobbies were also analysed. Statistical analysis was carried out using the Wilcoxon signed rank test. RESULTS: 73 patients with OSS (51 also with CS documentation) were included. The improvement in median OSS between pre-operative (24) and 6-month follow-up (39) was +15 (Z = -6.726, p < 0.0001, T = 6, r = 0.55). The difference in median CS between pre-operative (39) and 6-month follow-up (67) was +28 (Z = -5.435, p < 0.0001,T = 6, r = 0.59). Improvement in median pain score was +5 (7,12, p < 0.0001) median ADL was +5.5 (10.5,16, p < 0.0001) median ROM was +13 (18,31, p < 0.0001) and median strength was +4 (3,7, p < 0.0001). 76% returned to their pre-operative level of work (mean time = 11.5 weeks post surgery). 79% returned to pre-operative hobbies at a mean of 11.8 weeks after surgery. CONCLUSION: There is a significant improvement in both subjective and objective outcome 6 months after ASAD in patients with SAIS who have had previous failed conservative treatment. The rate of return to work was good for these patients in contrast to that reported for Danish patients. ASAD is a successful method of treatment for patients with SAIS who have had an initial trial of failed conservative treatment.

Myositis ossificans of the humeral insertion of pectoralis major.

We report on a rare case of myositis ossificans of the humeral insertion of pectoralis major muscle following a single episode of trauma which, to our knowledge, has not previously been documented.

Protocol for the ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial: a pragmatic multi-centre randomised controlled trial of surgical versus non-surgical treatment for proximal fracture of the humerus in adults.

BACKGROUND: Proximal humeral fractures, which occur mainly in older adults, account for approximately 4 to 5% of all fractures. Approximately 40% of these fractures are displaced fractures involving the surgical neck. Management of this group of fractures is often challenging and the outcome is frequently unsatisfactory. In particular it is not clear whether surgery gives better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform this decision. METHODS/DESIGN: We aim to undertake a pragmatic UK-based multi-centre randomised controlled trial evaluating the effectiveness and cost-effectiveness of surgical versus standard non-surgical treatment for adults with an acute closed displaced fracture of the proximal humerus with involvement of the surgical neck. The choice of surgical intervention is left to the surgeon, who must use techniques that they are fully experienced with. This will avoid 'learning curve' problems. We will promote good standards of non-surgical care, similarly insisting on care-provider competence, and emphasize the need for comparable provision of rehabilitation for both groups of patients.We aim to recruit 250 patients from a minimum of 18 NHS trauma centres throughout the UK. These patients will be followed-up for 2 years. The primary outcome is the Oxford Shoulder Score, which will be collected via questionnaires completed by the trial participants at 6, 12 and 24 months. This is a 12-item condition-specific questionnaire providing a total score based on the person's subjective assessment of pain and activities of daily living impairment. We will also collect data for other outcomes, including general health measures and complications, and for an economic evaluation. Additionally, we plan a systematic collection of reasons for non-inclusion of eligible patients who were not recruited into the trial, and their baseline characteristics, treatment preferences and intended treatment. DISCUSSION: This article presents the protocol for a multi-centre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50850043.

Functional outcome of surgical treatment of symptomatic nonunion and malunion of midshaft clavicle fractures.

Disability caused by nonunited or malunited fracture of the midshaft clavicle is a rare condition that is expressed by local pain or neurovascular impairment. This condition is usually treated by reduction of the fracture and stable fixation with augmentation by autogenous bone graft. We evaluated the functional outcome in 13 patients who were treated by this method. The mean postsurgical follow-up was 41 months. In all patients, satisfactory osseous union was achieved. Only 46% of the patients returned to their previous professional and recreational activities. There was also evidence that the current Constant scores of the affected shoulders remained significantly lower than those of the normal contralateral side. Ten patients reported various degrees of pain, and only three patients were pain-free. We show that, although solid union after realignment of symptomatic nonunion or malunion of midshaft clavicle fractures is predictable, the patients can remain functionally impaired.