The locked knee.

The acute locked knee is an orthopaedic emergency requiring prompt diagnosis and treatment. It can be classified as acute or chronic. The term 'locked knee' refers to a knee that demonstrates fixed flexion or which has a 'block' to complete extension. Some degree of active or passive extension may be achievable, but not full extension. The most frequent causes of a locked knee are a meniscal tear, rupture of the anterior cruciate ligament or loose bodies. Magnetic resonance imaging is the gold standard in diagnostic imaging. Knee arthroscopy is considered the gold standard in management. This article gives an overview of the presentation, assessment and management of the locked knee for core surgical, acute care common stem and emergency medicine trainees.

Telemedicine impact on post-stroke outpatient follow-up in an academic healthcare network during the COVID-19 pandemic.

BACKGROUND: The expansion of telemedicine associated with the COVID-19 pandemic has influenced outpatient medical care. The objective of our study was to determine the impact of telemedicine on post-acute stroke clinic follow-up. METHODS: We retrospectively evaluated the impact of telemedicine in Emory Healthcare, an academic healthcare system of comprehensive and primary stroke centers in Atlanta, Georgia, on post-hospital stroke clinic follow-up. We compared the frequency of 90-day follow-up in a centralized subspecialty stroke clinic among patients hospitalized before the local COVID-19 pandemic (January 1, 2019- February 28, 2020), during (March 1- April 30, 2020) and after telemedicine implementation (May 1- December 31, 2020). A comparison was made across hospitals less than 1 mile, 10 miles, and 25 miles from the stroke clinic. RESULTS: Of 1096 ischemic stroke patients discharged home or to a rehab facility during the study period, 342 (31%) had follow-up in the Emory Stroke Clinic (comprehensive stroke center 46%, primary stroke center 10 miles away 18%, primary stroke center 25 miles away 14%). Overall, 90-day follow-up increased from 19% to 41% after telemedicine implementation (p<0.001) with telemedicine appointments amounting for up to 28% of all follow-up visits. In multivariable analysis, factors associated with teleneurology follow-up (vs no follow-up) included discharge from the comprehensive stroke center, thrombectomy treatment, private insurance, private transport to the hospital, NIHSS 0-5 and history of dyslipidemia. CONCLUSIONS: Despite telemedicine implementation at an academic healthcare network successfully increasing post-stroke discharge follow-up in a centralized subspecialty stroke clinic, the majority of patients did not complete 90-day follow-up during the COVID-19 pandemic.

The neurogenic bladder: developing a consensus bladder and bowel management pathway for people with MS.

This article outlines how the bladder can be affected in neurological conditions such as multiple sclerosis (MS) and the impact this has on patient quality of life and NHS resources. A group of MS and bladder and bowel nurse specialists has developed consensus bladder pathways in the hope that all nurses in contact with patients who are likely to have neurogenic bladder symptoms become 'bladder aware'.

Suffering and divine impassibility.

Many theologians believe in the doctrine of divine impassibility: that God does not experience pain or pleasure from the actions of creation. However, the question inevitably touches upon our personal relationship and journey with God, a journey involving deep joys and pains. This discussion of divine impassibility relates to the medical profession, which seeks to heal the sick and comfort the dying.

Does a skin incision along Langer's lines reduce complications following fixation of displaced middle-third clavicle fractures?

INTRODUCTION: Internal fixation of displaced middle-third clavicle fractures is a widely used treatment but is frequently associated with post-operative complications. The aim of this study is to investigate whether or not using a skin incision along Langer's lines, as opposed to a traditional transverse incision, reduces complications. METHODS: We retrospectively reviewed data on 108 patients who underwent open reduction and internal fixation of mid-shaft clavicle fractures between 2014 and 2018. Either an oblique incision along Langer's lines or a transverse incision was used according to surgeon's preference. A pre-contoured diaphyseal locking plate was used in all cases. We collected data on fracture classification, minor complications (irritation from plate, chest wall numbness, superficial wound infection) and major complications (irritation from plate necessitating metalwork removal, periprosthetic fracture, deep infection, neurovascular injury and non-union). Statistical analysis was performed using multivariant regression analysis and Fisher's exact tests. RESULTS: Fifty-seven patients underwent fixation using the oblique incision and 51 via the transverse incision. Age, gender and fracture pattern in the two groups were comparable. There were 14 minor and 6 major complications in the oblique group. In the transverse group, there were 16 minor and 5 major complications. The major complication rate was 10.5% in the oblique group and 9.8% in the transverse group. The overall major complication rate was 10.2%. No statistically significant difference in the rate of complications between the two groups was identified. CONCLUSION: Based on our data, an incision following Langer's lines does not reduce the rate of complications following fixation of displaced middle-third clavicle fractures.

Patients' experiences of self-identification, seeking support, and anticipation of potential relapse in multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) relapses are associated with increased disability, reduced quality of life and negative psychosocial impacts. However, they often go unrecognised; people with MS (MSers) may face barriers to self-identification of relapses or seeking support for them. The charity Shift.ms sought to better understand 1) MSers' challenges in self-identifying potential relapses, 2) where MSers' seek support for potential relapses, and 3) the impact of the anticipation of relapses on MSers' wellbeing and daily living. METHODS: Shift.ms developed a patient perspective 8-question pilot survey (included likert-style, multiple-choice, and optional free-text responses) and shared it with Shift.ms' international online community (n = 20,052). Descriptive quantitative analysis, and content analysis and thematic analysis of qualitative free-text responses were used. RESULTS: 1,737 MSers responded. Just under one third (29.9%) of MSers reported that it takes them 24 h or less to self-identify a potential relapse, while more than half (54.5%) reported that identification occurs within 48 h; 55% MSers felt that the "at least 24 h" clinical criterion of relapse classification was appropriate. Challenges to relapse self-identification included confounding background symptoms or infection, variability of relapse symptoms, and individualistic nature of MS. Fatigue was reported to be the most common symptom of relapse (75%), however fatigue was also the symptom most commonly mistaken for relapse (40%). Barriers to relapse self-identification were a shorter duration since MS diagnosis and a perceived lack of consensus around relapse classification. Respondents reported they most often seek relapse support/advice from healthcare professionals (HCPs) (37.1%), family/friends (32.1%), or not at all (16.9%). Rather than temporal criteria (i.e. the 24 h criterion), participants felt that severity of symptoms could play a more critical role in whether to seek support for a potential relapse. Barriers to seeking support/advice included variability in HCP advice and feelings of invalidation. Anticipation of relapses negatively impacted MSers wellbeing; led to reduced participation in activities, and the development of adjustment/coping strategies. Relapse triggers included stress, reduced self-care, infection/illness; 78.5% reported stress or anxiety had triggered relapse. CONCLUSIONS: These findings highlight difficulties MSers face in self-identifying relapses, barriers to accessing support, and impact of anticipation of relapses. They also highlight opportunities for improved MSer and HCP communication, dialogue and two-way education to help optimise patient access to relapse support and intervention.

Timing of Mouse Molar Formation Is Independent of Jaw Length Including Retromolar Space.

For humans and other mammals to eat effectively, teeth must develop properly inside the jaw. Deciphering craniodental integration is central to explaining the timely formation of permanent molars, including third molars which are often impacted in humans, and to clarifying how teeth and jaws fit, function and evolve together. A factor long-posited to influence molar onset time is the jaw space available for each molar organ to form within. Here, we tested whether each successive molar initiates only after a minimum threshold of space is created via jaw growth. We used synchrotron-based micro-CT scanning to assess developing molars in situ within jaws of C57BL/6J mice aged E10 to P32, encompassing molar onset to emergence. We compared total jaw, retromolar and molar lengths, and molar onset times, between upper and lower jaws. Initiation time and developmental duration were comparable between molar upper and lower counterparts despite shorter, slower-growing retromolar space in the upper jaw, and despite size differences between upper and lower molars. Timing of molar formation appears unmoved by jaw length including space. Conditions within the dental lamina likely influence molar onset much more than surrounding jaw tissues. We theorize that molar initiation is contingent on sufficient surface area for the physical reorganization of dental epithelium and its invagination of underlying mesenchyme.

Hip fractures in the young polytrauma patient: a review and the latest data from the UK.

Managing a hip fracture in a young adult patient in the setting of polytrauma is a particularly challenging prospect. In the UK between 2018 and 2020, 11,969 patients were recorded in the Trauma Audit and Research Network as a patient with polytrauma. Of these patients, 611 (5.1%) had a hip fracture. In this article, we discuss the initial assessment and management of these patients and common problems that are encountered and how the evidence available can help guide management.

Assisting the Investigation of Stranger Rapes: Predicting the Criminal Record of U.K. Stranger Rapists From Their Crime Scene Behaviors.

Davies, Wittebrood, and Jackson (1997) were among the first to investigate whether offense behaviors are predictive of criminal history, with the findings of their paper then utilized by the National Crime Agency (NCA) Behavioral Investigative Advisors (BIAs) when assisting rape investigations. The aim of the study was to replicate this seminal paper with a larger contemporary sample of U.K. stranger rapists as identified by NCA. Data from 474 adult male stranger rapists were obtained in relation to 22 crime scene behaviors and nine preconviction variables. Results indicated significant differences between the Davies et al. original data set and this contemporary data set in both the behaviors and the preconvictions they displayed. The contemporary sample was significantly less likely to use sighting precautions, use violence, and take fingerprint precautions. This sample was also significantly less likely to have any of the preconviction crime types, with the exception of drugs offenses. When exploring the current data set of stranger rapists, statistical analyses indicated a number of key offense behaviors that were able to predict the criminal history of stranger rapists. However, contrary to previous research, no behaviors were found to be associated with sexual offense preconvictions. The results highlight that behaviors and characteristics of stranger sex offenders have changed since the 1990s. The implications for practice are discussed.

An interfaith dialogue with Sir William Osler: crossing the divide of COVID-19 pandemic.

With the recent COVID-19 pandemic and George Floyd protests, the USA (US) has become extensively polarized across social and political divides. The COVID-19 pandemic has left tens of thousands dead and several million American citizens without work. Furthermore, the months of quarantine and uncertainty with the COVID-19 virus impacted the economic stability and health of Americans. In recent weeks, the divides have only deepened with the death of George Floyd from police brutality, which ushered in worldwide protests addressing racial, social, and law enforcement issues for minority groups. Both developments have ushered in unprecedented challenges for addressing social disparities while controlling the spread and devastation of the COVID-19 pandemic. With social media and mass communication, polarization between opposing groups has only deepened the divide. An inclusive dialogue that recognizes the intellectual and interpersonal boundaries of opposing groups would provide an avenue towards mutual understanding and further collaboration towards a common goal and solution. A physician that exemplified many aspects interfaith dialogue in his clinical practice and personal life was the late Sir William Osler. This will be accomplished through a fictional dialogue between Sir William Osler and Dr. Mark Webb.

Interfaith Dialogue and Sir William Osler.

None: In recent years, the US has become extensively polarized across social, political, and religious divides. As the cultural, political, and social divides continue to grow, the medical establishment has shown similar divisions between clinicians and patients. However, an inclusive dialogue that recognizes the intellectual and interpersonal boundaries of opposing groups and traditions would provide an avenue toward mutual understanding and further collaboration toward a common goal and solution. One such method for building bridges between opposing groups can be found in interfaith dialogue. The goal of interfaith dialogue is not merely to exchange pleasantries but also to develop a mutual collaboration addressing moral and ethical issues with a unified voice. This is achieved through moving beyond separation and suspicion, inquiring more deeply, sharing both the easy and the difficult parts, moving beyond safe territory, and exploring spiritual practices from other traditions. A physician who exemplified many aspects interfaith dialogue in his clinical practice was the late Sir William Osler. Through examining Osler's application of interfaith dialogue, we may develop a framework by which clinicians can actively build new bridges and dialogue between their patients and society.

Preserving the chondrolabral junction reduces the rate of capsular adhesions.

The operative treatment of pincer-type femoroacetabular impingement (FAI) has become an increasingly more common procedure. Classically, the labrum is incised at the chondrolabral junction (CLJ), or a concurrent tear is extended to allow access to the acetabular rim facilitating acetabuloplasty. The labrum is subsequently repaired using suture anchors. More recently, acetabuloplasty has been performed without incising the labrum and negating the need to use suture anchors. The aim of this study is to determine whether preserving the CLJ reduces the incidence of revision hip arthroscopy for the treatment of capsulolabral adhesions. This retrospective study compared two cohorts of patients undergoing hip arthroscopy for pincer-type FAI from August 2002 to April 2015. The groups analysed were patients undergoing acetabuloplasty with labral repair (LR) and those with no labral repair (NLR). The revision rates and causes for revision were compared using the χ2 analysis. There were 1010 cases in total. Acetabuloplasty with LR was performed in 546 hips (519 patients), while acetabuloplasty with NLR was performed in 464 hips (431 patients). In the LR group, there were 54 (9.9%) revisions, 25 (46%) of which were due to capsulolabral adhesions. The NLR group had 36 (7.8%) revisions with six (17%) due to capsulolabral adhesions. Preserving the CLJ, thereby avoiding the need for drilling and the insertion of suture anchors, when performing an acetabuloplasty for pincer-type FAI, significantly reduces the rate of symptomatic adhesions requiring revision arthroscopy.

3-Dimensional fasciectomy: A highly efficacious common ground approach to Dupuytren's surgery.

BACKGROUND: Numerous Dupuytren's fasciectomy techniques have been described, each associated with unique surgical challenges, complications and recurrence rates. We describe a common ground surgical approach to Dupuytren's disease; 3-dimensional fasciectomy (3DF). 3DF aims to address the potential contributors to the high recurrence rate of Dupuytren's disease and unite current limited fasciectomy practice that varies considerably between surgeons. METHODS: We describe the 3DF principles; raising thin skin flaps (addressing dermal involvement), excising diseased palmar fascia with a 3-5 mm clearance margin (treating highly locally recurrent conditions) and excising the vertical septae of Legueu and Juvara (providing deep clearance, hence addressing all potentially involved pathological tissue). The surgical outcomes between traditional limited fasciectomy (LF) and 3DF are compared. RESULTS: From the 786 operations included (n=585), postoperative recurrence rates were significantly lower for the 3DF group (2/145, 1.4%) than the LF group (72/641, 11.2%) (P=0.001), and the time to recurrence was significantly longer (5.0±0 years vs. 4.0±0.2 years; P<0.0001). With recurrence excluded, there were no differences between the postoperative complication rates for 3DF (5/145, 3.5%) and LF (41/641, 6.4%) (P=0.4). CONCLUSIONS: Our results suggest that 3DF leads to lower recurrence rates and a longer disease-free period for patients, without increasing complications. 3DF provides a safe, efficacious, common ground surgical approach in the treatment of Dupuytren's flexion deformity.

Functional results following high tibial osteotomy: a review of the literature.

INTRODUCTION: High tibial osteotomy (HTO) is an operation used to treat patients with medial compartment knee osteoarthritis. The United Kingdom Knee Osteotomy Registry (UKKOR) has been set up to gather contemporaneous data on HTO throughout the patient journey. UKKOR uses a variety of patient-reported outcome measures (PROMs) to gauge the surgical outcome. AIM: The aim of this review is to analyse the published literature that has used PROMs to assess the outcomes following HTO. METHODOLOGY: Two searches of the literature were performed and compiled highlighting 95 articles of interest. After screening and manual additions, 23 manuscripts were reviewed and appraised using the appropriate Critical Appraisal Skills Programme Checklist (Kai et al. in PLoS Med 4(11):1766-1775, 2007). RESULTS AND DISCUSSION: There is a variety of published literature on HTO with a varied approach to the use of PROMs. Their use has increased recently, and studies have demonstrated that they are appropriate assessment tools for monitoring outcomes following HTO. In all of the studies that compared pre-operative to post-operative PROMs, there have been significant improvements. However, the data are varied due to differing study designs which in some instances have significant limitations. CONCLUSION: PROMs are effective ways to measure outcomes following HTO. They can also be useful in predicting outcome. The heterogeneity of the data and limitations of the study designs limit the transferability of the data. It is therefore important to analyse data from a multi-surgeon, multi-centre source that uses robust and constant pre- and post-operative PROMs.

Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications.

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

Provision of total hip replacement for displaced intracapsular hip fracture and the outcomes: audit of local practice based on NICE guidelines.

INTRODUCTION: Hip fractures are becoming an increasing public health issue due to an ageing population (1). Total hip replacements (THR) produce better outcomes in certain patients who were functioning independently before the injury (2). We aimed to assess whether the management of intracapsular hip fracture is carried out in accordance with the National Institute for Health and Care Excellence (NICE) hip fracture guidance (1) and the outcomes with regards to performing THRs on those patients who fulfil the described criteria. METHOD: Data was collected retrospectively from the 1st April 2012 to 31st March 2013 from all fractured neck of femur patients admitted to our hospital. RESULTS: Of the 382 patients fit for an operation, 78 (20.4%) met with the NICE hip fracture guidance for a total hip replacement. Of those eligible, 32 (41.0%) did receive a THR and 4 (2.8%) patients of the 142 not eligible for a total hip replacement also received a THR. DISCUSSIONS: Of those eligible for a THR, the patients who underwent that procedure had a significantly lower mortality rate compared to those who underwent a hemiarthroplasty (0% versus 19.6% at 1 year, p = 0.007). However, those who did not meet the NICE criteria but underwent a THR had the worst mortality rate (50% at 30 days and 1 year). The provision rate of THR in displaced intracapsular hip fracture is low at 41.0% for those who met the NICE criteria. The results suggest that the decision process when determining if a patient should undergo THR for a fractured neck of femur is multifactorial.

Prospects for narrowing bounds on Earth's equilibrium climate sensitivity.

The concept of Earth's Equilibrium Climate Sensitivity (ECS) is reviewed. A particular problem in quantifying plausible bounds for ECS has been how to account for all of the diverse lines of relevant scientific evidence. It is argued that developing and refuting physical storylines (hypotheses) for values outside any proposed range has the potential to better constrain these bounds and to help articulate the science needed to narrow the range further. A careful reassessment of all important lines of evidence supporting these storylines, their limitations, and the assumptions required to combine them is therefore required urgently.

The impact of parametrized convection on cloud feedback.

We investigate the sensitivity of cloud feedbacks to the use of convective parametrizations by repeating the CMIP5/CFMIP-2 AMIP/AMIP + 4K uniform sea surface temperature perturbation experiments with 10 climate models which have had their convective parametrizations turned off. Previous studies have suggested that differences between parametrized convection schemes are a leading source of inter-model spread in cloud feedbacks. We find however that 'ConvOff' models with convection switched off have a similar overall range of cloud feedbacks compared with the standard configurations. Furthermore, applying a simple bias correction method to allow for differences in present-day global cloud radiative effects substantially reduces the differences between the cloud feedbacks with and without parametrized convection in the individual models. We conclude that, while parametrized convection influences the strength of the cloud feedbacks substantially in some models, other processes must also contribute substantially to the overall inter-model spread. The positive shortwave cloud feedbacks seen in the models in subtropical regimes associated with shallow clouds are still present in the ConvOff experiments. Inter-model spread in shortwave cloud feedback increases slightly in regimes associated with trade cumulus in the ConvOff experiments but is quite similar in the most stable subtropical regimes associated with stratocumulus clouds. Inter-model spread in longwave cloud feedbacks in strongly precipitating regions of the tropics is substantially reduced in the ConvOff experiments however, indicating a considerable local contribution from differences in the details of convective parametrizations. In both standard and ConvOff experiments, models with less mid-level cloud and less moist static energy near the top of the boundary layer tend to have more positive tropical cloud feedbacks. The role of non-convective processes in contributing to inter-model spread in cloud feedback is discussed.

A Reliable and Rapid Multiplex RT-PCR Assay for Detection of Two Potyviruses and a Pararetrovirus Infecting Canna Plants.

Canna plants are subject to serious virus diseases. The three most common viruses identified in canna plants are Bean yellow mosaic virus, Canna yellow mottle virus, and Canna yellow streak virus. Recent studies indicate that canna plants are commonly infected with more than one virus. Thus, the efficient control of these viruses in canna plants requires the availability of a reliable method for detecting mixed virus infection. This report presents a two-step multiplex reverse-transcription polymerase chain reaction (RT-PCR) that was developed to simultaneously detect two potyviruses and one pararetrovirus genome. We optimized the method for nucleic acid isolation for managing a large population of samples, and the primer concentrations to ensure sensitivity and reliability of the assay, and determined the detection limit in simplex and multiplex RT-PCR assays using plasmid controls and nucleic acids isolated from virus-infected plants. Combined with an automated method for total nucleic acid isolation, this multiplex RT-PCR procedure could be routinely used for virus detection in research and diagnostic laboratories.

Reliable Detection for Bean yellow mosaic virus, Canna yellow streak virus, and Canna yellow mottle virus in Canna Varieties with Red Foliage.

Cannas grow from rhizomes to produce colorful foliage that ranges from deep burgundy, bronze, green, purple veined, and variegated. Bean yellow mosaic virus (BYMV), Canna yellow streak virus (CaYSV), and Canna yellow mottle virus (CaYMV) are problematic viruses infecting cannas. Their disease characteristics have been reported in green-leaved varieties. This study investigated if rhizome planting stocks can be a source of virus infection. PCR and RT-PCR tests identified BYMV, CaYSV, and CaYMV sequences in 20 canna rhizomes and newly emerging leaves. Immunosorbent electron microscopy tests identified filamentous potyvirus particles in rhizome and leaf tissue. In addition, disease characteristics were examined in a subset of red-leaved varieties 'Australia', 'Burning Ember', and 'Red Futurity' planted in pots in the greenhouse. Plants were assigned identifying codes, visual disease ratings, and samples were taken for RT-PCR and PCR virus detection assays. Statistical analysis was carried out to compare disease ratings with RT-PCR and PCR test results. Visual assessment was found to be not a reliable indicator of virus infection in 'Australia' and 'Burning Ember' plants. 'Red Futurity' produced the most obvious pattern of mosaic disease and virus symptoms were easier to identify in this variety. This study demonstrated that visual assessment was an ineffective method for disease identification for the red-leaved varieties. Growers would be well advised to utilize molecular testing to identify infected plants to aid in the clean-up of the crop.