The Use of Ketamine Sedation for the Treatment of Nail Bed Repairs in the Pediatric Emergency Department.

AIM: This study aimed to determine if sedation with ketamine is safe and effective for the treatment of nail bed injuries in the pediatric emergency department (PED). METHOD: A retrospective cohort study was carried out during a 9-month period in children aged between 18 months and 15 years, presenting to PED requiring nail bed repair. We documented complications of sedation, clinical outcome of the repair both immediate and at follow-up, and parental satisfaction at 4 months. A cost analysis was also undertaken. RESULTS: Ten repairs were performed. There were no serious adverse events. The average satisfaction score was 9.4/10. All patients were discharged from follow-up by 3 months. There was a cost saving of approximately £1500 per case. CONCLUSIONS: We have demonstrated nail bed injury repair facilitated by sedation with ketamine to be safe, effective, and cost efficient in the PED. This management strategy, brought to the fore during the COVID-19 pandemic, should be adopted widely in PEDs.

A Retrospective Evaluation and Review of Outcomes for Single- and Multilevel ACDF With a Zero-Profile Stand-Alone Cage Device With Integrated Instrumentation.

This study aimed to assess clinical and radiological outcomes associated with zero-profile stand-alone cages with instrumentation used for single- and multilevel anterior cervical discectomy and fusion (ACDF) operations. Many plate-cage ACDF systems have proven to be successful in producing high fusion rates and positive clinical outcomes. However, the anterior plating in traditional systems has been associated with complications such as dysphagia and mechanical accidents. A total of 190 patients underwent single- or multilevel ACDF surgeries with zero-profile polyetheretherketone cages containing integrated titanium instrumentation and screw fixation (one-level, n=31; two-level, n=65; three-level, n=71; four-level, n=23). Demographic information such as age and smoking status as well as postoperative outcomes were collected and analysed. Out of the 190 patients who underwent ACDF surgeries with a zero-profile stand-alone cage, none experienced any conditions or infections, and zero were readmitted postoperatively. Although traditional plate-cage systems yield high fusion rates in ACDF surgeries, zero-profile systems with integrated fixation have showcased impressive clinical and radiographic results in both single- and multilevel operations.

Interspinous Process (ISP) Devices in Comparison to the Use of Traditional Posterior Spinal Instrumentation.

A systematic literature review was conducted on studies comparing interspinous process (ISP) devices to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct), in terms of indications of use, complications, pain assessment, estimated blood loss, length of hospital stay, reoperation rates, and return to work. The objective was to analyze, evaluate and summarize the current published literature on the proposed efficacy and clinical and surgical long-term outcomes of the ISP device in comparison to the traditional posterior spinal instrumentation (pedicle screw-rod construct). The ISP device is a minimally invasive and less disruptive alternative to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct). However, very few published literature studies to date have reported the comparison of ISPs in terms of efficacy and clinical and surgical outcomes, to traditional posterior spinal instrumentation. A systematic literature review was performed in PubMed and Google Scholar to evaluate the results of published research that meet the defined inclusion and exclusion criteria and to analyze clinical indications and surgical outcomes of the ISP device compared to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct). Inclusion criteria included keywords such as "ISP device, ISP, posterior spinal instrumentation, pedicle screw fixation, bilateral pedicle screws, interbody fusion with posterior spinal instrumentation, lumbar spinal stenosis, and posterior lumbar stability." No exclusion criteria keywords were included in this literature review. ISPs provide a high degree of spinal stability in multiple planes, including a decreased range of motion restriction in flexion-extension, and comparable results to bilateral pedicle screw (BPS) in axial rotation. The use of the ISP device in adjunct with an interbody fusion, ensures less estimated operative blood loss (EBL), shorter operative time, less bony exposure without the need for extensive soft tissue or muscle retraction, a decrease in the rate of pseudoarthrosis, and a shorter length of hospital stay (LOHS) when compared to the traditional posterior instrumentation (pedicle screw-rod construct). Based on the various published literature reviews noted throughout this research paper, it is safe to conclude, that an ISP device that is accompanied by interbody fusion, including posterior approaches posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF); anterior approaches such as anterior interbody fusion (ALIF), and lateral approaches including direct lateral interbody fusion (DLIF), lateral lumbar interbody fusion (LLIF), extreme lateral interbody fusion (XLIF), is considered a credible and an effective minimally invasive option for the treatment of mild to moderate lumbar stenosis and stable low-grade spondylolisthesis (less than two) when compared to the traditional posterior spinal instrumentation of a pedicle screw-rod construct. Surgeons that are relatively new to the ISP technologies for spinal instrumentation would likely benefit from more clinical and surgical evidence of safety and efficacy in published peer-reviewed medical literature. Further clinical trials are needed to manifest the efficacy of ISPs regarding postoperative outcomes when compared to traditional posterior instrumentation techniques (pedicle screw-rod construct) with adjunct interbody fusions.

Inter- and intra-observer reliability of radiological grading systems for knee osteoarthritis.

INTRODUCTION: Radiographs are the first-line investigation for knee osteoarthritis (OA). Antero-posterior (AP) and Rosenberg views have demonstrated varying sensitivities in detecting severe OA. There is a multitude of radiological grading systems described. The aim of this study was to assess four commonly used grading systems in terms of inter- and intra-observer reliability and correlate the results with patient-reported symptom severity. MATERIALS AND METHODS: This study included 100 patients who had undergone both AP and Rosenberg X-ray views of the knee and evaluated using four radiological grading systems. These included Kellgren & Lawrence (K&L), International Knee Documentation Committee (IKDC), Ahlbäck and Fairbank. Evaluations were performed by two observers, independently, at two separate time points, 8 weeks apart. The data was then statistically analysed and inter- and intra-observer reliability calculated. RESULTS: A significant difference was found between AP and Rosenberg views for all four grading systems (p < 0.001). Both inter- and intra-observer reliability were highest for IKDC (0.79 and 0.86 respectively) and lowest for Fairbank (0.20 and 0.27 respectively). No statistically significant correlation was found between any grading system and the Oxford knee score (OKS). CONCLUSION: IKDC was found to be the most reliable grading system and Fairbank was the least. The Rosenberg view was overall more sensitive at detecting severe OA than the AP view. Radiological findings did not correlate with patient-reported symptoms (OKS).

Babchi oil-induced phytophotodermatitis mimicking burn injury.

Babchi (Psorylea corylifolia) is occasionally used by patients as a herbal treatment in conditions such as psoriasis and vitiligo, due to its anti-inflammatory, anti-oxidant and immune-modulatory properties (Shrestha et al., 2018; Chopra et al., 2013). Due to its psoralen containing furocoumarins, it has the potential to induce photosensitive reactions. We present the first reported case of Babchi-induced phytophotodermatitis in the UK, presenting as sunburn.

C-reactive protein: a prognostic indicator for sudden cardiac death post-myocardial infarction.

The inflammatory component of ischaemic heart disease (IHD) is well recognised. An elderly male, following primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI), had, otherwise unexplained, severely elevated C-reactive protein (CRP) prior to sudden cardiac death (SCD). Post-mortem showed only old infarct, no re-stenosis, and no evidence of inflammation elsewhere. The levels of CRP in this case are much higher than those documented previously in IHD. Current guidelines advocate for implantable cardioverter defibrillator (ICD) implantation after acute coronary syndrome (ACS) only in the context of left ventricular ejection fraction <35%, therefore, this patient would not qualify. Multiple risk-stratification tools have been developed to widen ICD prescription after ACS, but have not yet been integrated into the National Institute for Health and Care Excellence (NICE) guidelines. This case is a poignant reminder that we must widen ICD prescription, and CRP should be considered as a likely predictor.