Knowledge, Attitudes, and Willingness of Healthcare Workers in Iraq's Kurdistan Region to Vaccinate against Human Monkeypox: A Nationwide Cross-Sectional Study.

Although human monkeypox infections had not been recorded in the Kurdistan region of Iraq as of August 2023, the rapid growth of cases worldwide and the detection of monkeypox in neighboring Middle Eastern nations call for careful planning and timely response measures. Educating and empowering frontline healthcare workers (HCWs) so that they can act to curb the spread of monkeypox infections are core elements of primary prevention and protecting public health. Therefore, this study aimed to assess HCWs' knowledge and attitudes about monkeypox and their willingness to vaccinate against monkeypox. By employing a convenience sampling method, an online survey was disseminated via Google Forms between 1 November 2022 and 15 January 2023. The researchers utilized regression analyses to ascertain the factors associated with the three parameters: knowledge, attitude, and the willingness to vaccinate. A total of 637 HCWs were included in the analysis (ages ranged between 21 and 51 years). The mean overall scores were 8.18 of a max score of 16 (SD 3.37), 3.4 of 5 (SD 1.37), and 2.41 of 5 (SD 1.25) for knowledge, attitude, and willingness to vaccinate, respectively. A multivariate logistic regression analysis demonstrated that HCWs who had heard about monkeypox before 2022 rather than later had a higher level of knowledge (AOR: 4.85; 95% CI: 2.81-8.36; p < 0.001). In addition, those who had newly joined the workforce or had less than 1 year experience in practice had more positive attitudes about curbing monkeypox (AOR: 0.35; 95% CI: 0.20-0.59; p < 0.01) than those who practiced for longer. No significant predictors of willingness to vaccinate against monkeypox were identified. The research revealed that HCWs exhibited a relatively low level of monkeypox knowledge. They also had poor attitudes towards monkeypox vaccination and were therefore reluctant to receive the vaccines. Imparting knowledge about the infectious disease can cultivate better awareness and attitudes among HCWs as to their roles in mitigating the spread of an epidemic in the foreseeable future.

Survival of the Exeter V40 short revision (44/00/125) stem when used in primary total hip arthroplasty.

The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in 'cement-in-cement' revision cases. It has, however, been used 'off-label' as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR. We analyzed 328,737 primary THAs using the Exeter V40 stem, comprising 34.3% of the 958,869 from the start of the NJR to December 2018. Our exposure was the stem, and the outcome was all-cause construct revision. We stratified analyses into four groups: constructs using the 44/00/125 stem, those using the 44/0/150 stem, those including a 35.5/125 stem, and constructs using any other Exeter V40 stem. In all 328,737 THAs using an Exeter V40 stem, the revision estimate was 2.8% (95% confidence interval (CI) 2.7 to 2.8). The 44/00/125 stem was implanted in 2,158 primary THAs, and the ten-year revision estimate was 4.9% (95% CI 3.6 to 6.8). Controlling for age, sex, year of operation, indication, and American Society of Anesthesiologists grade demonstrated an increased overall hazard of revision for constructs using the 44/00/125 stem compared to constructs using other Exeter V40 femoral stems (hazard ratio 1.8 (95% CI 1.4 to 2.3)). Although the revision estimate is within the National Institute for Health and Care Excellence ten-year benchmark, survivorship of constructs using the 44/00/125 stem appears to be lower than the rest of the range. Adjusted analyses will not take into account 'confounding by indication', e.g. patients with complex anatomy who may have a higher risk of revision. Surgeons and patients should be reassured but be aware of the observed increased revision estimate, and only use this stem when other implants are not suitable.

Prosthetic joint infection of the knee - arthroscopic biopsy identifies more and different organisms than aspiration alone.

BACKGROUND: Prosthetic joint infection (PJI) causes significant morbidity and mortality following knee replacement surgery. Identifying causative organisms and antibiotic sensitivities is critical in increasing the chance of infection eradication. This study investigated whether biopsy alone was superior to aspiration alone for serological diagnosis in PJI following knee replacement. Secondly, we investigated whether biopsy identifies the same or new/different microbiological flora as aspiration. METHODS: Since December 2014, the Exeter Knee Reconstruction Unit (EKRU) has prospectively collated data regarding all PJIs referred from our local/regional network which have been reviewed via our Multi-Disciplinary Team (MDT). We identified and included consecutive patients from this MDT from Dec.2014-Mar.2020 and analysed their electronic records. Statistical analysis was performed using Stata. RESULTS: 65/100 patients studied had both pre-operative aspiration and biopsy. 31/65 (48%) had positive aspiration and biopsies. No aspirate samples were positive with corresponding biopsies negative. In 19/65 (29%) of infection positive patients, biopsy identified new (7) or additional (12) organisms not identified by aspiration. Aspiration had a sensitivity of 70%, specificity of 88%, positive predictive value of 90.3% and negative predictive value of 64.7%. Biopsy had a sensitivity of 97.5%, specificity of 88%, positive predictive value of 92.9% and negative predictive value of 95.7%. CONCLUSION: In 29% of confirmed PJI cases, arthroscopic biopsy identified either additional organisms in a polymicrobial PJI when compared to aspiration, or new positive results when aspiration alone was negative. This study demonstrates the benefits of arthroscopic biopsy for serological diagnosis in cases of knee PJI and aids treatment planning.

Diagnosis of knee prosthetic joint infection; aspiration and biopsy.

BACKGROUND: Prosthetic joint infection (PJI) is a significant cause of morbidity and mortality following knee replacement surgery. The diagnosis can be challenging and is based on a combination of clinical suspicion, radiographic findings and also biochemical/ microbiological investigations. Our Aim was to review the role of aspiration and biopsy in the diagnosis of PJI in Total Knee Arthroplasty (TKA). METHOD/RESULTS: Aspirated synovial fluid should be analysed by direct culture, via blood culture bottles, EDTA bottles for cell count and 'point of care' testing such as leucocyte esterase or alpha defensin. Synovial WCC and PMN cell percentage are important steps in diagnosis of both acute and chronic PJI. A minimum of 5 deep samples using a 5 clean instrument technique should be obtained and sent for tissue culture done either blind or arthroscopic. Formal fluoroscopic guided interface biopsy has also been described with excellent results. In a recent series of 86 TKRs preoperative arthroscopic biopsy group had a sensitivity of 100%, specificity of 94.7%, positive predictive value of 87.4% and a negative predictive value of 100%. CONCLUSION: In the presence of clinical suspicion with raised biomarkers, it is recommended that aspiration +/- biopsy with synovial fluid testing is performed. Direct culture and cell count are recommended. 'Point of care tests' such as Leucocyte Esterase testing should be considered. Duration of culture, including pathogen and host factors, should be discussed with a local microbiology/ID department in the context of a formal multi-disciplinary team.

Unplanned Clinic Attendance, Readmission, and Reoperation in the First 12 Months Postoperatively Following Hip Hemiarthroplasty for Acute Hip Fractures: Who Is At Risk?

Introduction Up to 19% of patients who undergo surgery for an acute hip fracture are readmitted to the hospital within three months of the index operation. We aimed to identify risk factors for unplanned clinic attendance, readmission, and mortality within the first 12 months postoperatively and subsequently determine if there is a role for routine follow-up. Method Patients greater than 65 years old who underwent hip hemiarthroplasty using an uncemented Thompson implant for treatment of a traumatic non-pathological hip fracture were identified from a prospectively maintained database at a single institution between August 2007 and February 2011. Patient demographics, comorbidities, place of residence, mobility status, unplanned attendance to an orthopaedic clinic with symptoms relating to the respective limb, readmission, and mortality were recorded. Regression analysis was performed using the IBM Statistical Package for Social Sciences (SPSS), version 24 (IBM SPSS Statistics, Armonk, NY) with P < 0.05 considered significant. Results Five hundred and fifty-four consecutive patients were identified. Unplanned clinic attendance was correlated to age (p = 0.000, B = -0.0159, 95% confidence interval (CI): -0.200 to -0.65), with patients between the ages of 65 - 70 years most likely to require unplanned clinic review postoperatively. The American Society of Anesthesiologists (ASA) grade (p = 0.019, 95% CI: 0.014 to 0.163) and frequency of unplanned outpatient attendance (p = 0.000, 95% CI: 0.120 to 0.284) were significantly associated with increased readmission within 12 months of the index procedure with patients who were regarded as ASA > 2 most likely to require readmission within the first postoperative year. Conclusion To our knowledge, this is the first piece of research that identifies causative factors for unplanned clinic attendance and acute readmission during the first postoperative year in acute hip fracture patients treated by hemiarthroplasty. Routine scheduled follow-up of patients based on risk stratification may be effective in reducing the financial burden of unplanned clinic attendance.

Excised Femoral Heads in Hip Fracture Patients: Is Osteoporosis Worse Than Cancer?

Introduction Annually 80,000 hip fractures are treated at an estimated cost of two billion pounds. The 2011 guidance from the Royal College of Pathologists recommended all specimens where there is fracture through or below the articular surface should be examined to exclude/ identify an underlying cause (pathological fracture). The questions posed in this study are three-fold. Firstly, how does our practice for hip fracture patients comply with the above audit standards? Secondly, what is the prognostic significance of a past medical history of malignancy on survival? Thirdly, is there any other prognostic survival difference attributable to the diagnosis concluded from the histological analysis of the excised femoral head specimens? Methods A retrospective analysis of all hip fractures receiving joint arthroplasty was undertaken between January 2011 and March 2014. Mortality was recorded for a minimum follow-up of 30 months post-operatively. Each excised femoral head was histologically examined by a single consultant histopathologist, and all pre-operative X-rays were reviewed by a consultant radiologist. Histological diagnoses were recorded, and statistical analysis including Kaplan-Meier survival was performed. Results A total of 327 consecutive fractures were identified. Out of 187 specimens sent for analysis, only two revealed metastatic deposits in patients with known disseminated malignancy. A previous medical history of malignancy did not confer a significant increase in mortality over a five-year postoperative period (p = 0.42). A histological diagnosis of osteoporosis significantly increased mortality over a five-year postoperative period (p = 0.004). A comparative analysis found that patients with a histological diagnosis of osteoporosis had the poorest survival. Conclusion A histological femoral head analysis may diagnose previously undiagnosed osteoporosis, allowing the clinician to intervene in a disease process, which if left untreated, can lead to a significant increase in mortality.

Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression.

BACKGROUND: Subacromial impingement is common and frequently treated with arthroscopic subacromial decompression (ASD); however, its efficacy has recently been questioned. Poor surgical outcomes have been associated with anxiety and depression within other orthopedic subspecialties but not within this group of patients. We hypothesized that anxiety and depression are associated with worse outcomes after ASD. METHODS: A retrospective review of prospectively collected data was carried out of patients undergoing ASD. Inclusion criteria were short-term relief with injection therapy and presence of Hawkins sign. Rotator cuff tears were excluded. Patients completed the Oxford Shoulder Score (OSS), Hospital Anxiety and Depression Scale (HADS), and visual analog scale for pain before and after surgery in outpatient clinic follow-up at 6 weeks and by postal questionnaire at 6 months. RESULTS: The 86 patients who participated in the study were analyzed in 2 groups defined by HADS scores, group A being depressed and group B nondepressed. Both groups had less pain and improved OSS at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation (P < .01) between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation (P < .01) between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction (P < .05). CONCLUSION: Patients with HADS score >11 before ASD have worse outcomes. This should be taken into account when counseling patients for surgery.

Evolution of the hip fracture population: time to consider the future? A retrospective observational analysis.

OBJECTIVE: To examine how the population with fractured neck of femur has changed over the last decade and determine whether they have evolved to become a more physically and socially dependent cohort. DESIGN: Retrospective cohort study of prospectively collected Standardised Audit of Hip Fractures of Europe data entered on to an institutional hip fracture registry. PARTICIPANTS: 10 044 consecutive hip fracture admissions (2000-2012). SETTING: A major trauma centre in the UK. RESULTS: There was a generalised increase in the number of admissions between 2000 (n=740) and 2012 (n=810). This increase was non-linear and best described by a quadratic curve. Assuming no change in the prevalence of hip fracture over the next 20 years, our hospital is projected to treat 871 cases in 2020 and 925 in 2030. This represents an approximate year-on-year increase of just over 1%. There was an increase in the proportion of male admissions over the study period (2000: 174 of 740 admissions (23.5%); 2012: 249 of 810 admissions (30.7%)). This mirrored national census changes within the geographical area during the same period. During the study period there were significant increases in the numbers of patients admitted from their own home, the proportion of patients requiring assistance to mobilise, and the proportion of patients requiring help with basic activities of daily living (all p<0.001). There was also a twofold to fourfold increase in the proportion of patients admitted with a diagnosis of cardiovascular disease, renal disease, diabetes and polypharmacy (use of >4 prescribed medications; all p<0.001). CONCLUSIONS: The expanding hip fracture population has increasingly complex medical, social and rehabilitation care needs. This needs to be recognised so that appropriate healthcare strategies and service planning can be implemented. This epidemiological analysis allows projections of future service need in terms of patient numbers and dependency.

Gastric band erosion, infection and migration causing jejunal obstruction.

Complications of laparoscopic adjustable gastric bands (LAGB) are well documented and may include migration, erosion, slippage, infection, pouch dilatation and, rarely, gastric perforation. We describe a rare case involving three such complications simultaneously, namely, gastric erosion, infection and migration through the pylorus-causing proximal jejunal obstruction. As LAGB is now the commonest performed bariatric procedure for the treatment of morbid obesity, we encourage the practising surgeon to be vigilant of these rare but potentially life-threatening complications.

Piriformis muscle metastasis from a rectal polyp.

Rectal cancers constitute over a quarter of all colorectal cancers. Spread of rectal cancer is usually to liver, lung and brain from high risk rectal cancers. Cases have rarely been reported of spread to soft tissue structures. Here we present a case of metastatic spread of a previously excised, early invasive adenocarcinomatous polyp to piriformis.

Defecation pain and coccydynia due to an anteverted coccyx: a case report.

INTRODUCTION: Defecation pain is a common problem with many etiologies implicated. Elucidating a cause requires a thorough medical history, examination and appropriate investigations, which may include endoscopy, barium enema, examination under anesthesia and magnetic resonance imaging or computed tomography. Coccydynia is a term used to describe pain in the region of the coccyx, often due to abnormal mobility of the coccyx. Non-surgical management options remain the gold-standard for coccydynia with surgery being reserved for complicated cases. CASE PRESENTATION: This is a case of a 67-year-old Caucasian man who presented with a two-and-a-half-year history of worsening rectal pain. CONCLUSION: To the best of our knowledge, we describe the first case in the literature of an abnormally mobile anteverted coccyx causing predominantly defecation pain and coccydynia, successfully treated by coccygectomy. When first-line investigations fail to elucidate a cause of defecation pain one must, in the presence of unusual symptoms, consider musculoskeletal pathologies emanating from the coccyx and an orthopedic consultation must then be sought for diagnostic purposes.

Calcium pyrophosphate dihydrate deposition in the trochanteric hip bursa presenting as acute hip pain.

Acute hip pain is a common reason for attendance to hospital. Immediate diagnoses include occult fractures, infectious and non-infectious inflammatory processes such as gout and pseudogout. Calcium pyrophosphate deposition disease (CPDD) is a rheumatological syndrome affecting articular cartilage and/or synovial fluid. It can occur as a clinical presentation (pseudogout) where calcium pyrophosphate dihydrate (CPPD) crystals are deposited within the joint space or radiographically, as chondrocalcinosis (CC), where CPPD crystals are deposited onto articular cartilages. Extraarticular manifestations of CPDD are rare. The authors report a case of CPPD deposition in the trochanteric bursa of a 35-year-old woman presenting as acute hip pain. The patient was treated successfully during arthroscopy with removal of the deposits and excision of the bursa. The patient remains well at 6 month follow-up.