A qualitative evaluation of internet information on hip and knee osteoarthritis.

BACKGROUND: Hip and knee arthritis are two of the most common conditions that result in referral to orthopaedic outpatient clinics. Many patients now use the internet to research their condition and to inform their decision about treatment options. This has implications for the process of informed consent. AIM: To assess the quality of patient information on the internet regarding hip and knee arthritis. METHODS: 'Hip arthritis' and 'Knee arthritis' were entered as search terms into a popular search engine. To adjust for temporal variation, the process was repeated one month and one year later. Of the 200 results analysed, 83 websites met the inclusion criteria. The quality of patient information presented on these websites was assessed using a validated scoring instrument by two independent observers. RESULTS: Most websites assessed were of poor quality; nearly half of all websites did not mention any risks or complications associated with surgical intervention for these conditions. CONCLUSIONS: As part of their professional obligation to provide a robust process of informed consent, clinicians should be aware of the variable quality of patient information available on the internet. As such, they should be prepared to advise their patients about quality websites where reliable information can be sought.

Penthrox enables quicker management of fractures, dislocations and more: learning lessons from expedited care of trauma patients during the COVID-19 pandemic.

INTRODUCTION: Methoxyflurane is an historical anaesthetic agent that has undergone a renaissance with the introduction of a smaller dose in a handheld 'Penthrox' device. The benefits of Penthrox include its ease of use, with disposable individual packets, and the need for less monitoring and staff, when compared with deeper sedation. The literature acknowledges its use for analgesia and in the management of anterior shoulder dislocation but in no other procedural orthopaedic circumstance. METHODS: Following institutional approval, we undertook a retrospective review of all incidences of Penthrox use to facilitate minor procedures within a 2-month period starting 24 March 2020. Time to procedure and success were recorded using the surrogate markers of patient attendance and x-Ray occurrence times. RESULTS: Some 101 Penthrox doses were given to 89 patients over 97 unique episodes between 24 March and 26 May 2020. No complications were recorded following the use of Penthrox during this period. Patient demographics were explored. Fracture manipulations and casting (n=54) had a 100% success rate in achieving adequate and safe reduction. Joint dislocations (n=34) were treated with varying success. Native elbow dislocations were reduced most successfully (4/4, 100%). Native shoulder dislocations were seen in 17 patients and successful relocation was seen in 11 cases, giving a success rate of 65%. CONCLUSIONS: This is the first study, outside anterior shoulder dislocations, to report on the efficacy of Penthrox within emergent orthopaedic scenarios. We have demonstrated Penthrox to be a safe tool for helping to manage trauma procedures in the emergency department.

Getting animated about trauma - Using video animation as part of informed consent.

INTRODUCTION: Trauma patients are often required to make an informed decision about surgery within a short space of time. Coming to terms with their injury may mean they have limited bandwidth for absorbing information, and it may be that they don't appreciate the risks and benefits of surgery discussed during consent. Current consent practice puts the emphasis on the clinician to ensure that all reasonable steps have been taken to explain risks and benefits to patients. We propose the use of video animations that patients can watch prior to surgery as a means of improving their understanding and overall experience. METHODS: The video script was written and evaluated so that a high standard was achieved using the "Discern" instrument. The experiences of a focus group of 5 patients were used to guide script content. Using GoAnimate (GoAnimate Inc., San Mateo) a video was made with voice over provided by local drama students. The video was shown to 30 consecutive patients over a 2 month period. We included any patient with an ankle fracture managed operatively who had been consented (form 1). Evaluation consisted of interview with patients consisting of 2 focussed questions and one open. Responses to the questions were collated and grouped into positive and negative descriptors. RESULTS: 68 (81%) positive descriptors were recorded from patients' interviews versus 16 (19%) negative. Positive descriptors related to improved retention, information giving, technical detail, consolidations of information given during consent. Negatives were caveats that video couldn't replace face-to-face consent, the degree of detail being off-putting and not adding anything to standard consent. CONCLUSION: The video was well received by patients with subjective improvements being made to their understanding, retention and sharing of technical detail. The face-to-face discussion between patient and doctor remains very important to them and the video should look to augment this.

A novel use of QR code stickers after orthopaedic cast application.

INTRODUCTION We present a novel solution to ensure that information and contact details are always available to patients while in cast. An information sticker containing both telephone numbers and a Quick Response (QR) code is applied to the cast. When scanned with a smartphone, the QR code loads the plaster team's webpage. This contains information and videos about cast care, complications and enhancing recovery. METHODS A sticker was designed and applied to all synthetic casts fitted in our fracture clinic. On cast removal, patients completed a questionnaire about the sticker. A total of 101 patients were surveyed between November 2015 and February 2016. The questionnaire comprised ten binary choice questions. RESULTS The vast majority (97%) of patients had the sticker still on their cast when they returned to clinic for cast removal. Eighty-four per cent of all patients felt reassured by the presence of the QR code sticker. Nine per cent used the contact details on the cast to seek advice. Over half (56%) had a smartphone and a third (33%) of these scanned the QR code. Of those who scanned the code, 95% found the information useful. CONCLUSIONS This study indicates that use of a QR code reassures patients and is an effective tool in the proactive management of potential cast problems. The QR code sticker is now applied to all casts across our trust. In line with NHS England's Five Year Forward View calling for enhanced use of smartphone technology, our trust is continuing to expand its portfolio of patient information accessible via QR codes. Other branches of medicine may benefit from incorporating QR codes as portals to access such information.

Enhanced recovery after surgery: An opportunity to improve fractured neck of femur management.

Introduction Approximately 67,000 hip fractures occurred in England, Wales and Northern Ireland in 2014, and annual hospital costs for fracture are around £1.1 billion. We review the potential scope for improving length of stay (LOS). Methods Hospital Episode Statistics data on non-elective admissions to 137 hospital trusts between November 2013 and October 2015 with a primary diagnosis of fractured neck of femur were analysed. The primary outcome was superspell LOS, which is the total LOS for all related spells for a single patient during an episode of care. Secondary outcomes were discharge to home, readmission at 28 days and in-hospital mortality. Results The mean observed LOS was 22.1±3.8 days (range 12.3-33.7 days). The range for case mix-adjusted expected LOS was 21.5-24.4 days. On average, 6.7±1.5% (range 3.6%-10.9%) of patients died while in hospital, at a relative risk of in-hospital mortality of 28.2-182.9. A mean of 12.3±3.2% (range 3.9% to 23.0%) of patients were readmitted at 28 days, at a relative relative risk of 34.8-203.2. Conclusions The wide range of observed LOS in our study is unlikely to be due to the case mix, as the case mix-adjusted range of LOS is less than 3 days, but rather due to local processes and pathways. There is therefore considerable scope for quality and efficiency of care improvements in our hospitals. We propose this could be best achieved if clinicians experienced in enhanced recovery focused on FNOF pathways.

Displaced intracapsular neck of femur fractures in the elderly: bipolar hemiarthroplasty may be the treatment of choice; a case control study.

Management of the mobile elderly patient who sustains an intra-capsular neck of femur fracture remains controversial. Current evidence is mixed as to whether total hip arthroplasty (THA), which confers higher surgical and dislocation risk, is significantly superior in function and in reduced rates of reoperation when compared to bipolar hemi-arthroplasty. A group of 110 patients with an intra-capsular NOF fracture who had undergone either THA or Bipolar hemi-arthroplasty and were still alive at the time of follow up were retrospectively identified and matched using the National Hip Fracture Database. Matching criteria included ASA, age, sex, pre-op mobility, pre-op AMTS and source of admission. Follow up was by postal questionnaire. Mean follow up was 24 months in both groups (Range; Bipolar 12-36 months, THA 12-38 months). There was no significant difference in pre-operative Tonnis grade, postoperative Oxford Hip Score (OHS) or Short Form 36 (SF-36) scores between the two groups. 12 dislocations in 5 patients occurred in the THA group and none in the bipolar group. 33/55 Bipolar patients were discharged to their own home compared to 35/55 in the THA group. None of the bipolar hemi-arthroplasties were revised to THA. Higher complication rates were experienced in the THA group with no increase in function.

Supranormal nuclear content of 5 alpha-dihydrotestosterone in benign hyperplastic prostate of humans.

We investigated the concentration of nuclear and cytosolic 5 alpha-dihydrotestosterone and 3 alpha-androstanediol in benign prostatic hyperplasia (BPH) in men. The endogenous content of the androgens was quantitated by radioimmunoassay after isolation of the nuclear and cytosolic fractions by classical differential centrifugation techniques. The mean dihydrotestosterone content was about four-fold higher (P < .01) than normal in the nuclear fraction and two-fold higher (P = .05) in the cytosolic fraction in periurethral tissue from hyperplastic prostates. The mean 3 alpha-androstanediol values were approximately one-third of normal in both the nuclear (P < .01) and cytosolic (P < .01) fractions in glands with BPH. In BPH tissue the ratios of dihydrotestosterone to androstanediol content in both the nuclear and cytosolic fractions was significantly higher (P < .01) than the ratio in normal prostate. Our data suggest that elevated intranuclear dihydrotestosterone but not 3 alpha-androstanediol may be causally related to the development of BPH in aging men.

Effects of age and sex hormones on transition and peripheral zone volumes of prostate and benign prostatic hyperplasia in twins.

Benign prostatic hyperplasia has been shown to increase with age and be influenced by sex hormones. The relationship between aging and hormonal influences on growth of zones of the prostate is unresolved. We studied the relationship of age and sex hormones on volume of prostate zones in 214 male twins between 25 and 75 yr old. Volumes of the total prostate (TV), transition zone (TZ), and peripheral zones (PZ) were measured using transrectal ultrasound, and sex steroid concentrations were measured using RIA. Using transformed data corrected for age, TV (r = 0.54, P < 0.00001), TZ (r = 0.58, P < 0.00001), and PZ (r = 0.39, P < 0.00001) volumes increased with age. However, the PZ volume rose more rapidly than the TZ before age 50, and TZ showed a steeper increase after age 50 yr than the PZ volume. The TZ, PZ, and ratio TZ/PZ correlated significantly (r = 0.87, 0.90, and 0.52, respectively; P < 0.00001). After a TV exceeded 30 g, the rise of the PZ became attenuated, and the slope of the TZ became steeper. Age-adjusted sex hormone concentration was not evaluated in men with larger prostate volumes. Men with American Urological Association symptom scores above 10 had significantly (P < 0.001) larger total prostate volume (TV) and TZ volume, but not PZ volumes, than men with scores below 10. Prostate volumes correlated inversely with age-adjusted serum testosterone (T), dihydrotestosterone, sex hormone binding globulin, and sex hormone binding globulin-bound T concentrations. These results demonstrate that before age 50 yr or before a prostate weight exceeds 30 g, prostate growth may be mainly from enlargement of the PZ and after age 50, the TZ. In addition, elevated T and dihydrotestosterone concentrations do not predispose men to prostate enlargement or symptoms of benign prostatic hyperplasia.

Heritability of prostate-specific antigen and relationship with zonal prostate volumes in aging twins.

Both benign prostatic hyperplasia and prostate-specific antigen (PSA) have been shown to increase with age and with prostate volume in men, but the influence of heredity on these relationships is not completely understood. This study has two aims: 1) to investigate the inter-relationships of age, PSA, and various zonal measurements in the prostate; and 2) to assess the impact of heritable influences on total PSA. Eighty-four monozygotic twin pairs and 83 dizygotic twin pairs were studied, and serum total PSA, free PSA, and PSA-alpha1-antichymotrypsin were measured. Their prostate volumes [total (TV), transition zone (TZ), and peripheral zone) were quantitated using transrectal ultrasound. Total PSA is significantly correlated with all zonal prostate measurements (TZ, peripheral zone, TV, and TZ/TV) and with age. When linear regression was applied, only age and TZ were retained in the final model. The proportion of variability in total PSA explained by these two factors, however, is below 24%. In contrast, estimates of heritability show that approximately 45% of the variability in total PSA can be explained by inherited factors. Whereas age and TZ are linearly related to total PSA, their influence is much less than that of familial and genetic factors. It is uncertain whether these factors predispose also to prostate cancer or if they are independent of those, whether they confound the accuracy of using total serum PSA level as a diagnostic tool.

Extracorporeal piezoelectric lithotripsy in unanesthetized children.

Extracorporeal piezoelectric lithotripsy is an effective method for treating renal pelvic stones in children. Treatment with the Wolf lithotriptor is essentially painless and can be performed without anesthesia on an outpatient basis. Real-time ultrasound is used to localize stones. In a 1-year period at the University of Utah, extracorporeal piezoelectric lithotripsy was administered to eight children with nine renal units. Of the eight children, aged 5 to 17 1/2 years, only two required sedation and only one received retreatment. No stents were placed. At 1 month posttreatment, all children were stone-free, and no significant complications occurred.

Suprarenal neurilemoma.

Retroperitoneal neurilemomas are rare tumors. They are usually asymptomatic, grow to a large size, and generally undergo cystic degeneration before they are discovered. There may be a palpable flank mass. Almost invariably excretory urography shosw renal or ureteral deviation, and arteriography usually reveals an avascular mass. We present a brief review of the literature and 2 case reports of suprarenal neurilemoma, a site of occurrence not previously reported. One suprarenal neurilemoma occurred in a two-year-old child. The other was removed from a fifty-two-year-old man, and in this case a thoracoabdominal approach was helpful.

Coma from hyponatremia following transurethral resection of prostate.

Even though hyponatremia may occur following transurethral resection of the prostate (TURP), only 14 patients of a large TURP population deteriorated to a comatose state as a result of hyponatremia. These patients were generally older, with larger prostates, and longer resection times than the average for transurethral resection of the prostate. They also consistently had serum sodium levels postoperatively of near 120 mEq./L. or below. It was noted that obtundation can occur immediately or be delayed several hours. Even though no deaths occurred, awareness of the possibility of post-TURP hyponatremia and prompt treatment with hypertonic saline were shown to reduce morbidity significantly.

Surgical approach to large müllerian duct cysts.

Failure of the müllerian duct system to undergo complete involution in the male embryo may result in cystic dilation of these remnants. When these cysts attain great size, they may become paopable abdominally and cause voiding symptoms. A case is presented and the operative approach described. A suprapubic approach affords the best exposure for the complete removal of large müllerian duct cysts.

Single-stage transrectal transsphincteric (modified York-Mason) repair of rectourinary fistulas.

Over the past eleven years we have repaired seven rectourinary fistulas using a modified York-Mason transrectal transsphincteric approach. The simplicity of this one-stage procedure has demonstrated its cost effectiveness compared with the standard three-stage procedure (colostomy and cystotomy, fistula repair, and colostomy takedown).

Staging of localized prostatic carcinoma by pelvic lymphadenectomy: technique using sequential, unilateral extraperitoneal incisions.

A technique for sequential, unilateral, extraperitoneal pelvic lymphadenectomy is described. The procedure is advocated for staging patients with localized prostatic carcinoma in whom all laboratory test results for metastases are negative and in whom definitive radiation therapy or radical prostatectomy is contemplated. This procedure allows complete excision of the regional lymphatic drainage of the prostate with minimal surgical morbidity.

Heritability of the symptoms of benign prostatic hyperplasia and the roles of age and zonal prostate volumes in twins.

OBJECTIVES: Both benign prostatic hyperplasia and lower urinary tract symptoms (LUTS) have been shown to increase with age in men, but a causal relationship between prostate volume and symptoms has not been established. This study had two aims, to investigate the inter-relationships of age, symptoms, and various zonal measurements in the prostate and to assess the impact of heritable influences on symptom score. METHODS: Eighty-three monozygotic twin pairs and 83 dizygotic twin pairs were studied to determine age and LUTS as assessed by the American Urological Association symptom score. Their prostate volumes (total, transition zone, and peripheral zone) were measured by transrectal ultrasound. RESULTS: There was significant evidence of pairwise correlation between transition zone and symptom score (P = 0.04) and between age and symptom score (P = 0.03). Age also showed significant correlation with all volume measurements. Heritability appears to account for 82.6% of the variability in symptom score in men older than 50 years. CONCLUSIONS: This study provides evidence that age and transition zone volume play a role in LUTS, but also that their influence is not strong. Estimates of heritability suggest that hereditary factors contribute substantially to LUTS.

Prostate size in hypogonadal men treated with a nonscrotal permeation-enhanced testosterone transdermal system.

OBJECTIVES: This study examined the effects of testosterone replacement using a nonscrotal testosterone transdermal (TTD) system on prostate size and prostate-specific antigen (PSA) levels in hypogonadal men. METHODS: As part of an open-label, multicenter study, prostate volume as measured by transrectal ultrasound and PSA were assessed in 29 hypogonadal men during treatment with intramuscular testosterone enanthate (+TE), followed by 8 weeks of androgen withdrawal (-T), and then during 1 year of therapy with Androderm Testosterone Transdermal System, a nonscrotal permeation-enhanced TTD system (+TTD). RESULTS: Mean prostate volume decreased significantly from the +TE period (17 g) compared with the -T period (14 g) (P < 0.001). Prostate volume increased significantly from the -T period compared with the +TTD period (18 g) (P < 0.001). Maximum prostate size, comparable to that measured during +TE (P = 0.125), was reached by month 3 of +TTD therapy; prostate volume did not increase further during the remaining 9 months of +TTD therapy. Prostate volume correlated with age (P < 0.01) during all three periods of observation (+TE: r = 0.69; -T: r = 0.64; and +TTD: r = 0.55). No patient developed symptomatic benign prostatic hyperplasia during the treatment period. PSA levels decreased during androgen withdrawal compared with levels measured during +TE treatment (P < 0.001) and rose with resumption of androgen therapy with TTD (P < 0.006). However, PSA levels during +TTD replacement remained significantly lower (P < 0.001) than during +TE replacement. CONCLUSIONS: Physiologic testosterone replacement in hypogonadal men was achieved using the TTD system. Prostate size during therapy with TTD was comparable to that reported for normal men. In these men treated with TTD, PSA levels were also within the normal range.

A simple and effective technique for increasing pregnancy rates in couples with retrograde ejaculation.

Seven of 12 patients with retrograde ejaculation, who had at least occasional samples with reasonable sperm numbers and motility, underwent a protocol including luteinizing hormone-timed, intrauterine insemination with washed sperm recovered from the urine. Seven pregnancies have occurred to date in six patients; the one other patient is still early in the protocol period. The described technique for collecting sperm, ovulation timing, sperm recovery, and washing and intrauterine insemination are relatively simple and cost-effective and appear to be effective in contributing to pregnancies in many couples with retrograde ejaculation.

A comparison of the penetration of human sperm into bovine and artificial cervical mucus.

Our studies demonstrate that ACM can replace BCM in assessing the ability of spermatozoa to interact with viscous fluids. The use of ACM should provide a more standard batch of "mucus" for testing purposes in laboratories that use these techniques.

The effect of single-density bovine serum albumin columns on sperm concentration, motility, and morphology.

Experiments were conducted to determine whether single-density albumin columns could be used to improve sperm motility and morphology. Semen samples from 92 men seen at a fertility evaluation clinic were analyzed for count, motility, and morphology and centrifuged. An aliquot of the resuspended sample was then layered on top of 1 ml of a 7.5% solution of bovine serum albumin (BSA). Another aliquot was layered on top of a 10% BSA column. After 60 minutes, the sperm penetrating the bottom two thirds of the albumin layer were isolated and analyzed for count, motility, and morphology. The sperm count after exposure to both 7.5% and 10% BSA columns decreased to approximately 60% of the preisolation counts. Sperm motility was not altered by column separation at either albumin concentration, but sperm morphology significantly improved with both columns. The single-density albumin separation technique therefore improved morphology and had no effect on motility, and a reasonable number of sperm were retained after separation. Albumin separation techniques could be utilized to improve samples with morphology defects before use with artificial insemination or in vitro fertilization. It is uncertain whether this procedure would result in a higher pregnancy rate.