Quality of Documentation in Paediatric Supracondylar Fractures: A Quality Improvement Project.

Introduction Supracondylar fractures are the most common elbow fractures in children. Their documentation and management must be done fully and correctly. This Quality Improvement Project (QIP) assessed the quality of documentation for paediatric supracondylar fractures admitted, in accordance with the British Orthopaedic Association Standards for Trauma (BOAST). Methods We present a case series of supracondylar fractures presenting to a single UK-based district general hospital from January 2018 - October 2021. We performed a quality improvement intervention starting in November 2020. The retrospective data prior to intervention (January 2018-November 2020) were deemed "pre-intervention". Prospective "post-intervention" data were collected from April to October 2021. After "pre-intervention" data analysis, an intervention in the form of a documentation proforma was developed and multidisciplinary teaching sessions were delivered. Post-intervention prospective data collection followed from April - October 2021. Results There were 48 and 26 patients in cycles one and two, respectively. The mean age was 6.4 (SD 3.5) and 6.5 (SD 2.7) years, respectively; 42/48 in cycle one and all 26/26 in cycle two required operative management. The mean time to surgery was 1.3 and 0.96 days, respectively. Post-intervention, cycle two showed a reduction in patients with "no neurovascular documentation" pre-reduction (17% vs 12%) and an increase in patients documented as having "neurovascular status intact" (NVI) (44% vs 69%). In post-operative documentation, there was an improvement in documentation with 73% of patients having a post-operative neurovascular assessment documented, versus 50% in the pre-intervention cohort. Conclusion This QIP provided some early improvement in the documentation but with room for future progress as the project continues. It showed proformas can be an effective tool in implementing positive change. It also highlights the need for continuous clinical education across the multidisciplinary teams managing trauma.

Common peripheral nerve entrapments in the upper limb.

Entrapment of peripheral nerves can occur as they travel through restrictive spaces. This nerve compression can result in a constellation of signs and symptoms, which are often called syndromes. Patients initially report pain, paraesthesia and numbness, followed by weakness and clumsiness and, ultimately, muscle wasting. The specific region of paraesthesia and pain and the specific muscle weakness is determined by the peripheral nerve involved and the location of the entrapment. Diagnosis is mainly based on history and examination. Further investigations are available for atypical presentations. Each syndrome has its own set of risk factors, but repetitive action and muscle overuse are commonly associated with most syndromes. The treatment is activity modification followed by steroid injection and finally surgical decompression for ongoing persistent symptoms or severe initial presentation. This article outlines the history, examination, possible investigations and management for common peripheral nerve entrapments of the median, ulnar and radial nerves.

Preconsultation Questionnaires for Patients Attending Elective Foot and Ankle Clinics: Is This the Way Forward in Outpatient Clinics?

Orthopaedic clinics can often be overbooked' busy and delayed appointments are a common sight in the National Health Service. We recognize this is becoming a growing problem that needs to be addressed; therefore, we have carried out a quality improvement project (QIP) that can save clinicians time. We have developed the "Stockport Foot and Ankle Questionnaire," a novel preconsultation questionnaire to gather information about patient history and symptoms. We found that the average time required for consultation reduced from a mean of 22 minutes, without questionnaires, to a mean of 15 minutes with the questionnaire, effectively saving 7 minutes per consultation. The preconsultation questionnaire in foot and ankle clinics is a novel technique to improve efficiency, productivity, and standardization in outpatient clinics. It is a patient-centered approach that identifies where effective changes can be implemented in how outpatient services are run. We recommend routine use of these questionnaires to save valuable clinician time.Levels of Evidence: Level II.

How Effective Are Telephone and Video Consultations in Shoulder and Elbow Clinics? Analysis Using an Objective Scoring Tool.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic resulted in disruptions of clinical services, which saw more clinics being conducted as telephone and videos. The study aimed to assess and compare the effectiveness of consultations, that is, telephone, video, and face-to-face (F2F) in a shoulder and elbow clinic. METHODS: A total of 84 clinic letters from a shoulder and elbow clinic at a district general hospital were analysed using the Ashford Clinic Letter Scoring System. Of these, 30 were F2F, 30 were telephone, and 24 were video consultations. The letters were analysed and scored based on four parameters, that is, whether a working diagnosis was formulated, relevant investigations were requested or available, a clear management plan was formulated, and whether the consultation was deemed valuable by both the clinician and patient. RESULTS: The mean score (out of a total possible of eight) for F2F was 7.967, 7.667 for video, and 7.333 for telephone consultations. Amongst new referrals, F2F performed the best, followed by video with telephone consultations scoring the lowest. With follow-up referrals, the performance of telephone and video consultations was similar but more inferior compared to F2F. Videos performed nearly as well as F2F when it came to formulating treatment plans for patients.  Conclusion: F2F consultations remain the gold standard in a shoulder and elbow clinic; however, careful stratification of patients into video, telephone, and F2F clinics can help in optimal delivery of care. These findings can be applied to other surgical specialties and medicine in general. Virtual clinics are viable and potentially cost-effective options to the traditional F2F.

Assessment of the Efficacy of Telephone Medicine Consultations in Trauma and Orthopaedics During COVID-19 Using the Ashford Clinic Letter Score.

During the coronavirus disease 2019 (COVID-19) pandemic, our aim was to protect staff and patients, therefore, face-to-face clinics were converted to telephone clinics. We retrospectively compared two groups of patients: those seen in traditional clinics pre-COVID-19 and those who had telephone clinics during the pandemic. The mean Ashford Clinic Letter Score (ACLS) for the face-to-face clinic letters was 6.7, and the letters from both groups of telemedicine appointments scored better; the first group scoring 7.1 and the second 7.45. The pandemic allowed us to show that telephone clinics are effective and can be superior to traditional clinics in a specific set of patients.

Fracture of tibial tuberosity in an adult with Paget's disease of the bone - An interesting case and review of literature.

INTRODUCTION: Paget's disease of the bone is a non-malignant skeletal disorder characterized by focal abnormalities in bone remodelling at one or more skeletal sites. Pathological fractures occurring from trivial injuries are a well-known clinical presentation in patients with Paget's disease. An avulsion fracture of the tibial tuberosity is an infrequent injury and has an extremely low occurrence in adults, with only a few cases reported in literature. We describe a case of a patient with undiagnosed Paget's Disease of the bone, sustaining a pathological avulsion fracture of the tibial tuberosity. CASE REPORT: A 54-year-old male presented with right knee pain after his knee gave way whilst standing in the goal area during a game of football, twisting his right ankle and falling. Plain radiographs of the knee revealed an avulsion fracture of the tibial tuberosity with abnormal modelling of the proximal half of the tibia. An MRI confirmed a diagnosis of Paget's disease of the bone. The patient underwent open reduction internal fixation. At 3 months follow up, the patient had good knee range of motion from 0 to 100 degrees and by 6 months he had returned to his usual activities. CONCLUSION: We describe a unique case of tibial tuberosity avulsion fracture in an adult with PDB. Treatment was successful with cannulated screws and tension band wiring. Patients with PDB who fracture present with diagnostic and operative challenges, it is vital to progress with caution in the postoperative rehabilitation phase.

Rare presentation of De Garengeot hernia in a 77-year-old woman.

A 77-year-old woman presented with a rare surgical phenomenon known as De Garengeot hernia. This unique presentation occurs due to the presence of a vermiform appendix in a femoral hernia sac. The patient presented with right-sided groin pain and a partially reducible hernia; she was otherwise haemodynamically stable and denied fevers, nausea and vomiting. The diagnosis was confirmed with CT which demonstrated a right-sided femoral hernia containing a perforated tip of the appendix. The patient urgently underwent an open appendectomy and open right femoral hernia repair using the modified McEvedy's incision.

Acute Compartment Syndrome of the Leg Following Injury to Perforating Branch of Peroneal Artery After a Severe Ankle Sprain in a Pediatric Patient - A Case and a Review of Literature.

INTRODUCTION: Acute compartment syndrome (ACS) of the leg is seen most often following severe fractures, crush injuries, burns, tight casts, or dressings but rarely after ankle sprains. Very few cases have been found in the literature of compartment syndrome developing after ankle ligament disruptions. We report a case of ACS secondary to an ankle sprain in a 10-year-old child. CASE REPORT: A 10-year-old girl presents to the emergency department after jumping on an in-ground trampoline and slipping onto the surrounding grass and twisting her right ankle. This was followed by immediate swelling of her ankle. In the emergency department, her examination was notable for compartment syndrome. Although there was significant swelling around the ankle, she had good pulses in dorsalis pedis and posterior tibial vessels and normal sensations in her foot. A radiograph demonstrated an undisplaced fracture of medial malleolus with possible disruption of lateral ligament complex of the ankle. The patient was admitted, and the leg became more swollen the following morning with significant increase in pain levels and foot turned cold and purple with weak pulses. She had a delayed capillary refill time and reduced sensation in common peroneal nerve distribution over lateral aspect of foot and tense anterior and lateral compartments of the leg. Therefore, she was taken to theater and a standard open fasciotomy of the leg was performed through a longitudinal incision on the lateral side of leg and compartments decompressed. Fasciotomy revealed a large hematoma in the leg extending into the ankle joint and an avulsed perforating branch of peroneal artery. Postoperatively pain improved, passive toe stretching was no longer painful and she was immobilized in a below-knee plaster cast. CONCLUSION: ACS of leg is often associated with high-energy trauma and rarely seen after ankle injuries. To the best of our knowledge, this is the first reported case of compartment syndrome developing in a pediatric patient following inversion sprain of ankle, leading to rupture of perforating peroneal vessel in the leg.

Impaired mitochondrial functions contribute to 3-bromopyruvate toxicity in primary rat and mouse hepatocytes.

A compound with promising anticancer properties, 3-bromopyruvate (3-BP) is a synthetic derivative of a pyruvate molecule; however, its toxicity in non-malignant cells has not yet been fully elucidated. Therefore, we elected to study the effects of 3-BP on primary hepatocytes in monolayer cultures, permeabilized hepatocytes and isolated mitochondria. After a 1-h treatment with 100 µM 3-BP cell viability of rat hepatocytes was decreased by 30 % as measured by the WST-1 test (p < 0.001); after 3-h exposure to ≥200 µM 3-BP lactate dehydrogenase leakage was increased (p < 0.001). Reactive oxygen species production was increased in the cell cultures after a 1-h treatment at concentrations ≥100 µmol/l (p < 0.01), and caspase 3 activity was increased after a 20-h incubation with 150 µM and 200 µM 3-BP (p < 0.001). This toxic effect of 3-BP was also proved using primary mouse hepatocytes. In isolated mitochondria, 3-BP induced a dose- and time-dependent decrease of mitochondrial membrane potential during a 10-min incubation both with Complex I substrates glutamate + malate or Complex II substrate succinate, although this decrease was more pronounced with the latter. We also measured the effect of 3-BP on respiration of isolated mitochondria. ADP-activated respiration was inhibited by 20 µM 3-BP within 10 min. Similar effects were also found in permeabilized hepatocytes of both species.

Fatigue and Depression in Iranian Amyotrophic Lateral Sclerosis Patients in Tehran in 2012.

INTRODUCTION: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease with a progressive and rapid course. Fatigue and depression are common among ALS patients. The aim of this study was to determine the relationship between depression and fatigue in Iranian ALS patients. METHODS: In this 2012 cross-sectional study, 40 ALS patients, including 22 females and 18 males, were selected through consecutive relapsing-remitting, and 40 age- and gender-matched health controls (HCs) were recruited from Loghman Hakim Hospital in Tehran, Iran. The Persian version of the Fatigue Severity Scale (FSS-Per) questionnaire and depression substance of Hospital Anxiety and Depression Scale (HADS) were used to assess fatigue and depression. Data were analyzed using the Kolmogorov-Sminov Test, Levene's test, Independent Samples t-test, and Pearson product-moment correlation coefficient. RESULTS: We identified a significant and positive relationship between fatigue and depression in patients with ALS (p=0.000). Furthermore, the scores of fatigue and depression in ALS patients were higher than in non-ALS patients. CONCLUSION: The results indicated that there was a relationship between fatigue and depression in ALS patients and that early intervention services can improve these symptoms. Further studies are suggested to investigate the direction of such relationship.

Is microvascular abnormality a new endophenotype in schizophrenia?

BACKGROUND: A new method of assessment of microvascular abnormality in living schizophrenic subjects via retinal imaging was described by Meier et al. (2013). The principal aim of this review is to summarise the relevant knowledge and suggest further avenues of research into this topic. SUBJECT AND METHODS: On 20th April 2015, we carried out a search using the computer database system PubMed by using keywords "microvascular AND schizophrenia". RESULTS: Out of the 17 articles found, only seven were relevant. They are generally consistent with the hypothesis of microvascular pathology and brain inflammation as part of the pathogenesis in schizophrenia. It is important to stress that all studies of brain microvasculature in schizophrenia to date have been post mortem findings, apart from the work by Meier et al. (2013) which is related to retinal imaging in living subjects. CONCLUSIONS: Based on the literature, we suggest the following research and clinical avenues: Firstly, to assess whether microvascular abnormality found via retinal imaging, fulfils the criteria for the schizophrenia endophenotype. Secondly, to examine retinal imaging in high-risk individuals for schizophrenia. Thirdly, to determine whether the fMRI findings and cognitive abilities of schizophrenia patients in both longitudinal as well as cross-sectional studies, is associated with the microvascular abnormalities assessed by the retinal imaging. Fourthly, to determine if there is a correlation between microvascular retinal pathology and the positive or negative schizophrenia symptoms. Furthermore, to determine if childhood maltreatment results in any abnormities in retinal imaging. Lastly, to analyse the genetic background of schizophrenia retinal microvascular pathology and to apply anti-inflammatory agents in the treatment and prevention of schizophrenia if brain vasculitis is confirmed.