Arthroscopic Hip Capsular Repair Improves Patient-Reported Outcome Measures and Is Associated With a Decreased Risk of Revision Surgery and Conversion to Total Hip Arthroplasty.

Purpose: To perform a systematic review to assess the effect of capsular repair compared with nonrepair on patient-reported outcome measures (PROMs) and conversion to total hip arthroplasty (THA) after hip arthroscopy in patients with femoroacetabular impingement syndrome. Methods: We initially searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PubMed databases, as well as ongoing clinical trials (https://clinicaltrials.gov), on December 15, 2022. The eligibility criteria were randomized controlled trials (Level Ⅰ) and prospective comparative studies (Level II) of patients who underwent capsular repair and nonrepair via hip arthroscopy with a minimum follow-up period of 2 years. We registered this protocol a priori on PROSPERO (identification No. CRD42021239306). We assessed the risk of bias using the Methodological Index for Non-randomized Studies (MINORS) appraisal tool. Results: This review included 5 studies with a total of 639 patients (270 with capsular repair [average age, 35.4 years; 41% female patients] and 369 with nonrepair [average age, 37.3 years; 38% female patients]). In the included studies, surgical procedures consisting of labral repair and pincer or cam osteoplasty were performed via hip arthroscopy. The modified Harris Hip Score was measured in all the included studies, and the standardized mean difference in PROMs for capsular repair versus nonrepair in the included studies was 0.42 (95% confidence interval [CI], 0.20 to 0.63). A sensitivity analysis of randomized controlled trials achieved consistent results (standardized mean difference in PROMs, 0.31; 95% CI, 0.02 to 0.60). Capsular repair was not associated with a reduction in revision surgery (risk difference, -0.02; 95% CI, -0.06 to 0.03; 26 of 270 patients with capsular repair vs 42 of 369 with nonrepair) but was associated with a reduction in conversion to THA (risk difference, -0.05; 95% CI -0.09 to -0.01; 12 of 270 patients with capsular repair vs 38 of 369 with nonrepair). The average Methodological Index for Non-randomized Studies (MINORS) score in the included studies was 20. Conclusions: Patients who undergo capsular repair in conjunction with other arthroscopic hip preservation techniques have better PROMs and a lower incidence of THA conversion. Level of Evidence: Level II, systematic review of Level I and II investigations.

Assessment of challenges inhibiting effective delivery of health care services among frontline Professional health workers during COVID 19 Lock down in Nigeria

This is a cross-sectional survey of challenges inhibiting health care service provision during COVID 19 lockdown. Data collected with a pretested online self-administered questionnaire included age, gender, occupation, place of practice, physical distance practices, utilization of telemedicine, income and other concerns that may have inhibited their practices during the COVID 19 lockdown. Data were analyzed using a statistical package for social sciences (SPSS) version 26.0 with the level of significance set at p<0.05. Chi square goodness of fit test was used to analyze the association between means and qualitative variables. Results: Response rate from 599 questionnaires was 481 (78%) with physiotherapists (n=108, 23%); nurses (n=106, 22%); doctors (n=86, 18%); laboratory technicians (n=87, 18%) and pharmacists (n=94, 19%); in public sector (n=318, 66%) and private practitioners (n=163, 34%). During the "lockdown" patients interacting with health professionals in private practice decreased except increases for laboratory technicians (11.91%) and pharmacists (68.35%). Social distancing was feasible by pharmacists and laboratory technicians, but interactions by nurses, physiotherapists and doctors were compromised. Telemedicine was used mostly by doctors (n=42, 48.8%), and physiotherapists (n=50, 46.3%). Health professionals experienced mental stress 428 (89%); anxiety 176 (37%); feared infection 333 (69%) and 232 (48%) of transmitting to their families; 307 (64 %) had challenges with personal protective equipment. Suggestions were: alternate accommodation or longer shifts with less working days 111 (37%); a hazard allowance 244 (51%) and counseling 238 (49%). Conclusion: Private practitioners reported a loss of income with all health professionals indicating the "lockdown" and COVID-19 compromised health delivery, health services, and individuals' health. Health professionals suggested a hazard allowance, alternate accommodation, and dedicated counseling for health professionals during the pandemic.

Informal gold miners with mercury toxicity: Novel asymmetrical neurological presentations.

Mercury is a highly toxic heavy metal that may cause neurological, respiratory, gastrointestinal and dermatological illnesses. Previously described neurological manifestations of mercury toxicity are symmetrical, and include a pancerebellar syndrome, generalised seizures and encephalopathy. Mercury is used in the gold mining process, and in artisanal or illicit gold mining, often without necessary protection. Here we describe the cases of two artisanal gold miners from western Johannesburg, South Africa, who presented with atypical neurological manifestations of mercury toxicity. Patient 1 presented with focal seizures, an asymmetrical cerebellar syndrome and an acute encephalopathy. Patient 2 had unilateral cerebellar ataxia. Both patients had toxic mercury levels, with no other cause identified for their symptoms. Patient 1 responded well to chelation therapy, but patient 2 refused admission and further medical treatment. The neurological manifestations of mercury toxicity are typically symmetrical, whereas our two patients presented with markedly asymmetrical features. It is important to maintain a high index of suspicion for mercury poisoning, even in patients with atypical and unilateral or asymmetrical presentations. A prompt diagnosis and the commencement of early chelation therapy have the potential to produce good outcomes.

The Ability of Family Physicians in the Caribbean to Promote Planetary Health Concepts and the Challenges of Implementing Changes in Practice

The global environment is rapidly changing and the subsequent effects on human health are devastating. Planetary Health is a field focused on characterizing the human health impacts of human-caused disruptions of Earth's natural systems. It has been determined that Family Physicians (FPs) are the best suited to advocate and raise awareness of Planetary Health. The purpose of this research is to assess FPs in the Caribbean, their knowledge of planetary health, their ability to implement planetary health concepts in their practice, and the challenges that may impede implementation.

The nasal tent: an adjuvant for performing endoscopic endonasal surgery in the Covid era and beyond.

PURPOSE: To propose a cost-effective reproducible barrier method to safely perform endoscopic endonasal surgery during the Covid-19 pandemic. METHODS: This manuscript highlights the use of a clear, cost-effective disposable plastic sheet that is draped as a tent over the operating area to contain aerolization of particles. This is then connected to a suction to remove airborne particles and thus reduce transmission of the virus. CONCLUSION: The use of a nasal tent is a simple and affordable method to limit particle spread during high-risk aerolisation procedures during the Covid era and beyond.

Otorrhoea - a parotid connection.

SUMMARY: A 36-year-old patient presented with an 18-month history of intermittent right parotid swelling accompanied by otorrhoea. The symptoms started subsequent to a palm leaf injury to the right ear. At right parotidectomy, a fistula connecting the right external auditory canal and the right parotid was demonstrated. A small fibrotic mass probably due to a remnant of the palm leaf was found intraoperatively. The symptoms resolved completely after the mass was excised by superficial parotidectomy, and the fistula closed spontaneously.

Trans-oral penetrating trauma to the neck: the innocuous pen cap and the value of CT Scan.

SUMMARY: A significant number of otorhinolaryngological emergency visits are caused by foreign bodies, and occasionally they can result in life-threatening injury. This report highlights the value of neck CT in the evaluation of suspected radiolucent foreign bodies penetrating the neck from the oral cavity. This guided the surgical approach to remove the foreign body safely without complication.

Why do Zenker's diverticulae occur more often on the left than the right side?

BACKGROUND: Zenker's diverticulum is a pharyngoesophageal outpouching of mucosa and submucosa through Killian's dehiscence. OBJECTIVE: To investigate the propensity for Zenker's diverticulum to occur on the left side by examining muscle thickness in Killian's dehiscence, and to explore correlations between muscle thickness, sex, height and age. METHODS: The study included 109 Caucasian cadavers, 52 male and 57 female. The mean thickest and thinnest measurements of left medial, left lateral, right medial and right lateral aspects of Killian's dehiscence were calculated. The paired student's t-test was used to determine significance. RESULTS: The average left muscle layer was significantly thinner than the right muscle layer, in both medial and lateral aspects. Furthermore, medial muscle thickness was significantly thinner than its respective lateral aspect for both the left and right sides. No correlations were found between muscle thickness and cadavers' sex, length or stature, or age. CONCLUSION: There was a significant difference in muscle thickness between the left and right sides of Killian's dehiscence. The findings suggest there is a reason why Zenker's diverticulum occurs predominantly on the left side. The study also showed a significant difference in muscle thickness between the medial and lateral aspects of Killian's triangle.

Epidemiology and management trends of patients with severe sepsis and septic shock in Trinidadian Intensive Care Units: A prospective multicenter trial

Objectives: To investigate the epidemiology, management and predictors of mortality in severe sepsis. Design and Methodology: Prospective observational study in 4 Trinidadian Intensive Care Units (ICU) over a one year period August 2017-August 2018. Physiologic and treatment data was collected on admission to ICU and patients were followed up until ICU discharge and then at 28 days to determine mortality. Results: 163 patients fit the criteria for severe sepsis and were enrolled. Twenty-eight day and ICU mortality rate were 42% (68) and 34 % (56) respectively. Case distribution by the various hospitals were San Fernando General Hospital 62% (101), Port of Spain General Hospital 16% (26), Eric Williams Medical Sciences Complex 12.3% (20) and Sangre Grande Hospital 9.8% (16). The most common source of sepsis was pulmonary (54%) followed by abdominal (17%) and urological sepsis (14%). Acute Kidney Injury (AKI) was present in 71% (115) patients and 43% (46) of patients with stage 2 and above AKI received Renal Replacement Therapy (RRT) in the ICU. In the regression model, the only factors that were found to predict both 28 day and ICU mortality were stage 2 AKI [OR 6.2 (95% CI 1.7- 23.1, p = .007)], stage 3 AKI [OR 7.2 (95% CI, 2.1-24.0, p=.001)] , mean arterial pressure of < 60mmHg in the first 24 hours [OR 10.8 (95% CI 1.7-68.1, p= .001)], presence of either moderate-severe Acute Respiratory Distress Syndrome [OR 4.1 (95% CI 1.8 ­ 9.2, p = .002)] and Acute Physiology, Age, Chronic Health Evaluation (APACHE) II score [OR 1.08 (95% CI, 1.0-1.2, p=.039)]. Conclusion: Severe sepsis is associated with a high hospital mortality rate and this sepsis burden varies according to region. Limited access to RRT remains a problem in certain centers.

Does the Chronic Disease Assistance Program promote equity or increases the socioeconomic divide?

Objectives: The objective of the study was to assess the extent to which the Chronic Disease Assistance Programme (CDAP)was able to meet the needs of different risk groups within the Trinidad and Tobago population. The study sought to answer the research question how does the healthcare strategy of risk group segmentation (RGS) interact with the country context to create legitimacy for CDAP. It was hypothesised that the implementation of a RGS strategy improves CDAP's legitimacy to allocate and manage resources. Design and Methodology: A sample of 161 pharmacists were surveyed via face to face interviews and telephone calls using a convenient sampling method. The instrument determined the extent to which the six dimensions of RGS were utilized in CDAP and three performance construct were assessed. Two pharmacists from each pharmacy were interviewed to reduce common method bias. Descriptive measures such as mean, standard deviation and Pearson bivariate correlations for the purpose of simple summaries of the dominant views and relationships were done and hypothesis testing was conducted using three-stage hierarchical regression analysis. Results: RSG was seen as an empowering tool for the patients and was needed, but not addressed. It was found to be desirable but not implemented. Its non implementation reduced the socio-political legitimacy of the program. Conclusions: CDAP in its current form does not address the risk faced by various groups in Trinidad and Tobago. This has led to the socio-political legitimacy of the program being reduced. It may be inferred its ability to create true health equality is compromised.

Does the reporting of gastro-intestinal endoscopy meet the minimal terminology standard at King Edward VIII Hospital?

BACKGROUND: The Minimal Standard Terminology (MST) was developed to standardise endoscopic reporting. This study is aimed at assessing current reporting at a tertiary hospital and whether it meets this Minimal Standard Terminology. METHOD: This was a retrospective observational study of upper endoscopy reports between January and December 2014. The data extracted were compared to the current reporting standard listed in the MST. To assess and grade the quality of reporting we developed a Gastrointestinal Reporting Score, which incorporates MST variables in addition to demographic details, indication for endoscopy, report legibility, sedation and the use of classification systems to describe pathology. Variables were classified as blank, partially complete or complete and assigned a score of 1-3. The reports were graded according to their overall score for all variables (Max 40) into Grade A (> 36), B (28-36) and C (< 28). RESULTS: There were 100 patients of which 58 were female. Thirty-seven per cent were from the 60-75 year age group. Fiftyfour endoscopies were performed by trainee specialists. Junior and senior consultants performed 36 and 9 upper endoscopies respectively. Indications for upper endoscopy were stated in 51 reports. The use of pre-procedural sedation was not stated in 51 reports. Four reports were illegible; one was conducted by a junior consultant, two by a fourth year trainee specialist and one by an unknown endoscopist whose name was illegible. Common classification systems for oesophagitis, gastropathy features, ulcer characteristics, and ulcer location are not routinely used. Based on the Gastrointestinal Reporting Score there were no Grade A reports, 16 Grade B and 84 Grade C reports. CONCLUSION: The MST is not routinely utilised in our setting and reports are incomplete. There is a need for optimal upper endoscopic reporting, incorporating the MST guidelines.

Lingual Fibrolipoma - A rare clinicopathological entity.

Lipoma is a relatively common benign tumour occurring at sites of the body which are rich in adipose tissue. Due to sparsity of adipose tissue within the oral cavity, lipoma rarely presents in this region. Fibrolipoma of the tongue is a rare lesion. There are only 14 cases reported in the literature. An 85-year-old patient presented with a painless mass on the tongue interfering with eating. There were no risk factors for malignancy and no family history of malignant diseases. Although intraoperatively the lesion was locally infiltrative, histopathology revealed a rare benign fibrolipoma. Mainstay of treatment is surgical excision, but the lesion may pose a dilemma for Surgeons as difficulties associated with removal, due to the fibrous and adherent nature of the growth to surrounding tissue, may be mistaken for a cancerous growth.

Medication Adherence and Health Insurance/Health Benefit in Adult Diabetics in Kingston, Jamaica.

OBJECTIVE: To determine the association between health insurance/health benefit and medication adherence amongst adult diabetic patients in Kingston, Jamaica. METHODS: This was a cross-sectional study. The target population was diabetics who attended the diabetic outpatient clinics in health centres in Kingston. Two health centres were selectively chosen in Kingston. All diabetic patients attending the diabetic clinics and over the age of 18 years were conveniently sampled. The sample size was 260. An interviewer-administered questionnaire was utilized which assessed health insurance/health benefit. Adherence was measured by patients' self-reports of medication usage in the previous week. The Chi-squared test was used to determine the significance of associations. RESULTS: Sample population was 76% female and 24% male. Type 2 diabetics comprised 93.8%. More than 95% of patients were over the age of 40 years. Approximately 32% of participants were employed. Approximately 75% of patients had health insurance/health benefit. Among those who had health insurance or health benefit, 71.5% were adherent and 28.5% were non-adherent. This difference was statistically significant (χ2 = 6.553, p = 0.01). Prevalence of medication non-adherence was 33%. CONCLUSIONS: AIn Kingston, diabetic patients who are adherent are more likely to have health insurance/health benefit (p = 0.01).

A new method for scoring financial conflicts of interest.

BACKGROUND: There is a large and consistent body of evidence showing that research sponsored by for-profit industries tends to have pro-industry conclusions in comparison with similar research or re-analyses not funded by industry. Disclosure of financial conflicts via statements is presently the standard method for notification of potential biases. However, many journals are not consistent in publishing financial conflicts of interest (FCoI) statements. Furthermore, even when divulged, disclosure merely shifts the burden of evaluating conflicts to readers and the general public. Moreover, there has been an absence of a means of quantifying FCoI. OBJECTIVES: To propose a solution for the question: What are we doing about FCoI that continue to compromise the integrity of the scientific enterprise? METHODS: The FCoI Scale was developed for scoring and comparing FCoI and describing potential biases. RESULTS: The FCoI Scale consists of a score that may be expressed in whole numbers and decimal fractions, correlated to descriptive terms for potential biases and examples of financial conflicts at 11 levels. CONCLUSIONS: The FCoI score (FCoIS) provides a means for a more uniform and concise method of disclosure compared to statements, while at the same time permitting flexibility. It encourages the disclosure of relevant information and transparency in the reporting of financial conflicts. The FCoI Scale has the potential to become the standard basis for measuring, reporting, and comparing financial conflicts, suitable for disciplines in science, medicine, and beyond.

Local public knowledge of blood donation systems in Trinidad and Tobago and in other places

OBJECTIVE: To investigate the Trinidad and Tobago (TRT) public’s knowledge of donation procedures locally and in the United States (USA) and United Kingdom (UK) and its effect on willingness to donate blood locally. DESIGN AND METHODS: A cross sectional study was conducted on a convenience sample from adults in TRT concerning knowledge and attitudes towards blood donation. Data was collected using an interviewer-administered questionnaire. 529 responses were received. Analysis was performed using SPSS Statistics 21. Chi-squared testing was done to determine statistical significance. RESULTS: Of 529 respondents, 141 (26.7%) had donated previously, 34 (6.4%) had been excluded and 354 (66.9%) had never donated. 76.8% of those who had donated did so for a friend or family member. 53.6% of respondents rated their knowledge of TRT’s system, and 86.2% rated that of the US and UK, as ‘poor’ or ‘very poor’. Knowledge of the local system was directly correlated to willingness to donate blood in TRT (p<0.001). No relation was found concerning knowledge of the foreign systems and local willingness to donate (p=0.423). Factors deemed most ‘likely’ or ‘very likely’ to influence people to donate included: if donation was for an ill family member (87.7%) or friend (77.9%); if the blood donation system in place was a replacement system (70.9%) and if more information was given to the public about blood donation (67.3%). CONCLUSION: Public knowledge of the blood donation system of TRT affected willingness to donate while knowledge of the US and UK systems had no effect.

Experience with a gonadotrophin-releasing hormone agonist prior to myomectomy--comparison of twice- vs thrice-monthly doses and a control group.

The aim of this randomised prospective study was to investigate the impact of preoperative gonadotrophin-releasing hormone agonist (GnRHa) compared with a control group with myomectomy. A total of 36 women (n = 36, group 1) with fibroids were randomised to receive either two monthly doses (n = 18/36, group 1a) or three monthly doses of goserelin (n = 18/36, group 1b) prior to myomectomy. The 32 women who received no treatment (group 2) comprised the controls. All patients had similar demographic features. There were no significant differences among the three groups with respect to: (1) mean intraoperative blood loss; (2) preoperative and postoperative blood transfusion or (3) length of hospital stay. The only advantage of administering GnRHa prior to myomectomy for symptomatic fibroids in our population was a higher haemoglobin level prior to surgery among the women who received three doses of the drug.

Brief Images: Massive pericardial effusion.

Significant pericardial effusions are an uncommon but very important disorder in childhood. In our patient, cross-sectional imaging demonstrated a massive pericardial effusion. The underlying etiology here was connective tissue disease causing recurrent pericardial effusion. An associated left-sided pleural effusion was noted. Clinicians must be aware of this disorder in the pediatric age group, performing a thorough evaluation in all children with large pericardial effusions, and managing appropriately.

Retinopathy in subjects with type 2 diabetes at a tertiary diabetes clinic in Durban, South Africa: Clinical, biochemical and genetic factors.

AIM: To determine the prevalence of clinical and laboratory variables and genetic polymorphisms in association with diabetic retinopathy (DR) in subjects with type 2 diabetes attending a tertiary referral diabetes clinic in Durban, South Africa. METHODS: Cross-sectional study on 292 Indian and African patients with type 2 diabetes (71.5% women). The presence of DR was determined by direct ophthalmoscopy. Clinical and laboratory data were collected and polymorphisms in the NOS3 (rs61722009, rs2070744, rs1799983) and VEGF (rs35569394, rs2010963) genes were determined. RESULTS: DR was present in 113 (39%) subjects. Those with DR were older (60.6 ± 9.6 vs. 55.4 ± 12.9 years, p = 0.005), had longer duration diabetes (18.5 ± 8.8 vs. 11.9 ± 9.2 years, p < 0.0001), higher HbA1c (9.2 ± 1.8 vs. 8.8 ± 1.7%, p = 0.049), serum creatinine (106.3 ± 90.2 vs. 75.2 ± 33.4 µmol/l), triglycerides (2.1 ± 1.2 vs. 1.9 ± 1.6 mmol/l, p = 0.042), proteinuria (72% vs. 28%, p = 0.001), and used more insulin (78% vs. 39% p = 0.0001), anti-hypertensive (95% vs. 80%, p = 0.0003) and lipid-lowering therapy (70% vs. 56%, p = 0.023). There was no association between DR and any of the NOS3 or VEGF gene polymorphisms studied, although there were ethnic differences. After adjustment, diabetes duration (OR 1.05, 95% CI 1.01-1.08), presence of proteinuria (OR 4.15, 95% CI 1.70-10.11) and use of insulin therapy (OR 3.38, 95% CI 1.60-7.12) were associated with DR. CONCLUSION: Hyperglycemia, duration of diabetes and proteinuria are associated with DR in Indian and African patients in South Africa, whereas NOS3 and VEGF gene polymorphisms were not associated with DR.

Organic compounds in water extracts of coal: links to Balkan endemic nephropathy.

The Pliocene lignite hypothesis is an environmental hypothesis that has been proposed to explain the etiology of Balkan endemic nephropathy (BEN). Aqueous leaching experiments were conducted on a variety of coal samples in order to simulate groundwater leaching of organic compounds, and to further test the role of the Pliocene lignite hypothesis in the etiology of BEN. Experiments were performed on lignite coal samples from endemic BEN areas in Romania and Serbia, and lignite and bituminous coals from nonendemic regions in Romania and the USA. Room temperature, hot water bath, and Soxhlet aqueous extraction experiments were conducted between 25 and 80 °C, and from 5 to 128 days in duration. A greater number of organic compounds and in higher concentrations were present in all three types of leaching experiments involving endemic area Pliocene lignite samples compared to all other coals examined. A BEN causing molecule or molecules may be among phenols, PAHs, benzenes, and/or lignin degradation compounds. The proposed transport pathway of the Pliocene lignite hypothesis for organic compound exposure from endemic area Pliocene lignite coals to well and spring drinking water, is likely. Aromatic compounds leached by groundwater from Pliocene lignite deposits in the vicinity of endemic BEN areas may play a role in the etiology of the disease. A better understanding of organic compounds leached by groundwater from Pliocene lignite deposits may potentially lead to the identification and implementation of effective strategies for the prevention of exposure to the causative agent(s) for BEN, and in turn, prevention of the disease.

Limitations and plausibility of the Pliocene lignite hypothesis in explaining the etiology of Balkan endemic nephropathy.

BACKGROUND: Balkan endemic nephropathy (BEN) is a chronic, tubulointerstitial renal disease often accompanied by urothelial cancer that has a lethality of nearly 100%. INTRODUCTION: One of the many factors that have been proposed to play an etiological role in BEN is exposure to organic compounds from Pliocene lignite coal deposits via the drinking water in endemic areas. OBJECTIVES: The objective of this study was to systematically evaluate the role of the tenets of the Pliocene lignite hypothesis in the etiology of BEN in order to provide an improved understanding of the hypothesis for colleagues and patients alike. METHODS: A comprehensive compilation of the possible limitations of the hypothesis, with each limitation addressed in turn is presented. RESULTS: The Pliocene lignite hypothesis can best account for, is consistent with, or has the potential to explain the evidence associated with the myriad of factors related to BEN. CONCLUSIONS: Residents of endemic areas are exposed to complex mixtures containing hundreds of organic compounds at varying doses and their potentially more toxic (including nephrotoxic) and/or carcinogenic metabolites; however, a multifactorial etiology of BEN appears most likely.