Radiological evaluation before and after treatment with an osseointegrated bone-anchor following major limb amputation-a guide for radiologists.

Osseointegrated implants have been developed to allow direct skeletal fixation of a prosthesis as an alternative to traditional socket-fitted prostheses for patients who have suffered from a major limb amputation. The implants contribute to improvements in functional outcome and quality of life and radiological evaluation plays a crucial role in pre- and post-operative assessment. This article acts as a guide for radiologists who may be tasked with providing the radiological information required by surgeons and prosthetists. We also look at the radiological appearances of complications that may arise in patients treated with an osseointegrated implant. Plain X-rays are used to screen patients who wish to undergo treatment. Limb-length X-rays are then used to measure the length of any residual bone, and comparisons can be made with the normal side (if present). From this, decisions about the likely size of the implant and the need for further amputation can be made. CT scans enable accurate assessment of the medullary cavity and cortical thickness. Post-operatively, plain X-rays form the mainstay of the routine monitoring of the bone-implant interface. Potential complications include infection, aseptic loosening, mechanical fracture of the implant and periprosthetic fracture. Infection and aseptic loosening can be seen as a lucency at the bone-implant interface which (if left untreated) can lead to loss of the implant. Implant and periprosthetic fractures are radiographically obvious. Radiologists involved in the care of patients undergoing treatment with an osseointegrated implant should become familiar with the imaging requirements so they can contribute to optimal patient outcomes.

Quantitative and qualitative analysis of individual experiences post botulinum toxin injection - United Kingdom Survey.

Introduction: In the United Kingdom (UK), complications that arise following the administration of Botulinum Toxin are reported to the Medicines and Health Regulatory Agency (MHRA) via the Yellow Card Reporting Scheme. Over the past decade, there has been a significant increase in the number of non-surgical aesthetic procedures. Concerns have been raised that the MHRA is not fully capturing complications in terms of volume and impact on patients. Aim: This novel study explores the lived experiences of individuals who have experienced an adverse event following administration of Botulinum Toxin for aesthetic purposes. Using a combination of qualitative and quantitative methodologies, this analysis evaluates data relating to long-lasting physical, psychological, emotional, and financial sequelae of complications arising from cosmetic Botulinum Toxin injections in the UK. Methods: A mixed method, qualitative and quantitative approach was adopted to gain comprehensive insights into patients' experiences. A focus group which comprised patient representatives, psychologists, and researchers reached a consensus on a 17-question survey which was disseminated via social media channels. Deductive thematic analysis was used to analyse coded themes. Furthermore, for secondary analysis, sentiment analysis was used computationally as an innovative approach to identify and categorise free text responses associated with sentiments using natural language processing (NLP). Results: In the study, 655 responses were received, with 287 (44%) of respondents completing all questions. The mean age of respondents was 42.6 years old. 94.1% of respondents identified as female. In the sample, 79% of respondents reported an adverse event following their procedure, with the most common event being reported as 'anxiety'. Findings revealed that 69% of respondents reported long-lasting adverse effects. From the responses, 68.4% reported not having recovered physically, 63.5% of respondents stated that they had not recovered emotionally from complications, and 61.7% said that they have not recovered psychologically. In addition, 84% of respondents stated that they do not know who regulates the aesthetics industry. Furthermore, 92% of participants reported that their clinic or practitioner did not inform them about the Yellow Card Reporting Scheme. The sentiment analysis using the AFINN Lexicon yielded adjusted scores ranging from -3 to +2, with a mean value of -1.58. Conclusion: This is the largest survey in the UK completed by patients who experienced an adverse outcome following the aesthetic administration of Botulinum Toxin. Our study highlights the extent of the challenges faced by patients who experience an adverse event from physical, emotional, psychological, and financial perspectives. The lack of awareness of MHRA reporting structures and the lack of regulation within the UK's cosmetic injectables sector represent a significant public health challenge.

Cosmetic business mechanics in London: A cross-sectional analysis and audit of ASA compliance.

INTRODUCTION: The proliferation of providers and practitioners of cosmetic botulinum toxin and dermal filler has profound public health implications. The Advertising Standards Authority (ASA) regulates the use of advertising materials in the United Kingdom and prohibits the promotion of prescription-only medicines. AIMS: We aim to perform a cross-sectional analysis of the practitioners in London, UK to evaluate the distribution of clinics within Greater London, prices advertised for interventions, and compliance with the ASA code. We also aim to identify whether there are any differences in cost of botulinum toxin or dermal filler between the boroughs. METHODS: Between December 2021 and January 2022, we performed a systematic search using the internet search engine Google. Five searches were performed (1) [london] botox, (2) [london] botulinum toxin, (3) [london] anti wrinkle injection, (4) [london] filler, (5) [london] dermal filler. One hundred websites per search string were systematically reviewed and those which met the inclusion/exclusion criteria of each search string were included and analyzed. Each clinic's product/service range compliance with the ASA/CAP code was assessed. Any reference to Botulinum Toxin or anti-wrinkle injections was noted and analyzed. Further analysis would look to calculate price per milliliter (mL) of botulinum toxin and dermal filler per borough and to calculate whether there were any statistical differences between the 32 different London boroughs. RESULTS: A total of 500 websites were visited and evaluated. After removal of duplicates, a total of 233 independent clinics was identified. A total of 206 out of the 233 clinics sampled (88%) were in direct infringement of the enforcement notice through advertising a prescription medicine. The overall average cost per mL of dermal filler was £330.89 and there was a statistically significant variance across London boroughs (p < 0.05). The overall average cost per mL of Botulinum Toxin was £284.45 and the variance across London boroughs was close to significant (p = 0.058). CONCLUSION: This paper demonstrates poor compliance with the ASA/CAP guidelines and further provides an insight into the industry mechanics associated with aesthetic injectables in a major UK city, identifying regional variance in price and clinic density. The advertising of prescription-only medication may pose a potential risk to patients and will be an important consideration in proposed legislation to introduce licensing to the industry.

Stable Cortical Body Maps Before and After Arm Amputation.

Neuroscientists have long debated the adult brain's capacity to reorganize itself in response to injury. A driving model for studying plasticity has been limb amputation. For decades, it was believed that amputation triggers large-scale reorganization of cortical body resources. However, these studies have relied on cross-sectional observations post-amputation, without directly tracking neural changes. Here, we longitudinally followed adult patients with planned arm amputations and measured hand and face representations, before and after amputation. By interrogating the representational structure elicited from movements of the hand (pre-amputation) and phantom hand (post-amputation), we demonstrate that hand representation is unaltered. Further, we observed no evidence for lower face (lip) reorganization into the deprived hand region. Collectively, our findings provide direct and decisive evidence that amputation does not trigger large-scale cortical reorganization.

Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis.

BACKGROUND: Botulinum toxin A (BoNT-A) injections are a popular non-surgical procedure for facial rejuvenation. Its increase in popularity and utilization is met with limited regulations, potentially posing a significant risk to patient safety and public health. OBJECTIVES: The authors sought to assess the safety profile of cosmetic glabellar and forehead BoNT-A injections and evaluate BoNT-A type on complication rate. METHODS: A systematic search of MEDLINE and EMBASE was performed for studies reporting complications after cosmetic BoNT-A in the glabellar or in the forehead region in the glabellar or in the forehead region. A random effects meta-analysis was carried out to assess complication rate. Where there were sufficient randomized-controlled trials, a network meta-analysis was performed. RESULTS: Of 556 identified articles, 24 were included in the final quantitative analysis, with 4268 BoNT-A injection sessions and 1234 placebos. Frequently observed treatment-related complications in the BoNT-A intervention group included headache, local skin reactions, and facial neuromuscular symptoms. The overall BoNT-A complication rate was 16%. The odds ratio of developing complications from abobotulinum toxin injections compared with placebo was 1.62 (1.15, 2.27; P > 0.05) and that from onabotulinum toxin injections compared with placebo was 1.34 (0.52, 3.48; P > 0.05). In 30% of the studies, the injectors were doctors, whereas the training status of the practitioner was not reported in the remaining 70%. CONCLUSIONS: Cosmetic BoNT-A injections in the glabellar and forehead region appear to be safe, and most complications are mild and transient. Nevertheless, the literature demonstrates heterogeneous reporting of complications and a lack of consistency of the definition of treatment-related complications.

A consecutive series of targeted muscle reinnervation (TMR) cases for relief of neuroma and phantom limb pain: UK perspective.

BACKGROUND: Studies have suggested that targeted muscle reinnervation (TMR) can improve symptoms of neuroma pain (NP) and phantom limb pain (PLP) in patients. OBJECTIVES: Our primary objective was to measure changes in NP and PLP levels following TMR surgery at 4-time points (baseline, 3, 6- and 12-months postoperatively). Secondary aims included identification of the character and rate of any surgical complications and patients' satisfaction with TMR. METHODS: A retrospective review of outcomes of 36 patients who underwent TMR surgery to treat intractable NP and/or PLP after major amputation of an upper (UL) or lower limb (LL) at a single centre in London, UK over 7 years. The surgical techniques, complications, and satisfaction with TMR are described. RESULTS: Forty TMR procedures were performed on 36 patients. Thirty patients had complete data for NP and PLP levels at all pre-defined time points. Significant improvements (p<0.01) in both types of pain were observed for both upper and LL amputees. However, there were varying patterns of recovery. For example, UL amputees experienced worsening of PLP in the first few months post-operatively whereas surgical complications were more common in LL cases. Patients were overwhelmingly satisfied with the improvements in their symptoms (90%). CONCLUSIONS: TMR surgery appeared to relieve both NP and PLP although the retrospective nature of this study limits the strength of this conclusion. However, complication rates were high, and it is crucial for surgeons and patients to fully understand the course and outcomes of this novel surgery prior to undertaking treatment.

Pedicled ipsilateral anterolateral thigh (ALT) with flow-through to a secondary contralateral-free ALT flap for coverage of large thigh, trochanteric, and gluteal area defects: A case report.

Reconstruction of the trochanteric area can be difficult in extensive defects postsarcoma resection. It requires a robust flap. In reconstructing the upper thigh, trochanteric, and gluteal area, a pedicled anterolateral thigh (ALT) flap is a good option. If the defect extends further than the pivot point of a single pedicled ALT, this can be used a flow-through for a secondary free flap. Here we describe a case of a 66-year-old gentleman with a 25 cm × 15 cm defect in the trochanteric and gluteal area where a single pedicled ALT was insufficient for coverage and hence a second ALT from the contralateral leg is anastomosed to the distal runoff of the descending branch of the lateral circumflex femoral vessel of the pedicled ALT, using it as the flow-through donor vessel. This method requires less time if a second free flap is required and a smaller range of dissection, and it also facilitates anastomosis, as the vessel can be brought to the surface for anastomosis while supine before inset. The patient healed with no complications and received radiotherapy to the area. On 1-year follow-up, the area has healed well despite some contraction secondary to the radiotherapy. Using the pedicled ALT as a flow-through for a second free flap is a useful adjunct to large defects in the gluteal and trochanteric area, which is a difficult area to reconstruct with limited donor vessels.

Necrotizing fasciitis of the periorbital region: from presentation to reconstructive journey.

Periorbital necrotizing fasciitis is a very rare condition with a UK incidence of 0.24 cases per million per annum. Outcomes can range from disfigurement to sight loss and even death. Debridement is crucial when sight or life is threatened and the subsequent reconstructive stages can be challenging. We describe two cases of periocular necrotizing fasciitis demonstrating the progression of the disease as well as the surgical debridement for both pre-septal and post-septal disease and the reconstructive steps leading to outcome. Level of evidence: Level V, therapeutic study.

The association of hypothalamic-pituitary-adrenal axis activity and blood pressure in an Afro-Caribbean population.

Hyperactivity of the hypothalamic-pituitary-adrenal axis (HPAA) resulting from fetal programming may play a role in the development of high blood pressure (BP) in black people. We assessed the diurnal salivary cortisol profile in children with and without increased BP and evaluated their mother's HPAA. In a cross-sectional study, 20 Afro-Caribbean children (mean age 9.6 years) with higher blood pressures and 20 children with lower blood pressures were chosen from a prospective study of 569 mothers and children in Jamaica. Daytime salivary cortisol profiles were collected in the children and their mothers. The mothers were also assessed for features of the metabolic syndrome. Children with higher BP had higher mean morning salivary cortisol concentrations than those with lower BP (7.9 S.D. 1.9 vs. 4.5 S.D. 2.4nmol/l; p=0.03). Their mothers also had increased morning salivary cortisol concentrations (9.9 S.D. 1.8 vs. 5.5 S.D. 2.5nmol/l; p=0.02), but no changes in fasting glucose, insulin, lipids, BP or adiposity. Maternal and offspring cortisol concentrations correlated significantly (r=0.465, p=0.004). Maternal cortisol concentrations were significantly associated with the child's BP. We conclude that Afro-Caribbean children with higher BP have higher morning salivary cortisol concentrations. The children's cortisol concentrations correlate significantly with the mother's cortisol concentrations. These findings suggest that the HPAA may play a role in the development of raised BP in Afro-Caribbean people.

Surface expression of Fc epsilon RI on Langerhans' cells of clinically uninvolved skin is associated with disease activity in atopic dermatitis, allergic asthma, and rhinitis.

BACKGROUND: Fc epsilon RI expressed on the surface of human epidermal Langerhans' cells facilitates uptake of IgE-associated allergens and plays a pivotal role in the pathogenesis of atopic dermatitis. Seminal results from studies investigating Langerhans' cell Fc epsilon RI in skin biopsy sections or epidermal cell suspensions demonstrate the highest receptor expression in lesional skin of patients with active atopic dermatitis. OBJECTIVE: We sought to investigate and localize Fc epsilon RI expression on Langerhans' cells within a minimally disturbed tissue environment in clinically uninvolved skin and to compare receptor expression between healthy donors and patients with atopic dermatitis or other allergic diseases. METHODS: Intact epidermal sheets from skin suction blisters, immunofluorescently stained with Langerhans' cell markers and anti-Fc epsilon RI alpha (mAbs 15E5 and 22E7) or anti-IgE, were examined by means of confocal microscopy. Samples incubated with anti-Fc epsilon RI alpha before or after cell fixation-permeabilization were compared to discriminate between cytoplasmic and membrane localization. RESULTS: Cytoplasmic Fc epsilon RI alpha chain was found in Langerhans' cells from all donors, irrespective of atopic status. Surface Fc epsilon RI-bound IgE was detected in the skin of individuals with active atopic dermatitis and in the skin of those with active asthma or rhinitis. No surface Fc epsilon RI was expressed in the skin of patients with a clinical history of atopic dermatitis, asthma, or rhinitis whose disease was in remission or in the skin of nonatopic individuals. CONCLUSION: In clinically uninvolved skin, Langerhans' cell-surface Fc epsilon RI expression is not only linked to atopic dermatitis but is also generally associated with allergic disease. This supports the concept of a systemic regulatory mechanism associated with active allergic disease, which is further aggravated by local inflammation in atopic skin lesions.