Determining the appropriate use of Technology Enabled Care Services (TECS) to manage upper-limb trauma injuries during the COVID-19 pandemic: A multicentre retrospective observational study.

BACKGROUND: The COVID-19 pandemic created a unique opportunity to explore the use of Technology Enabled Care Services (TECS), which remains novel for many service providers. This study assesses the factors that affect adaptation to remote monitoring of patients after upper-limb trauma injury. A standardised risk-stratified screening tool is further developed here to support clinical staff in both the determination of appropriate use of TECS and the optimisation of patient care. OBJECTIVES: 1: To explore the patient and injury factors that determine the appropriate use of TECS for patients with upper-limb injury. 2: To use these findings to refine a standardised screening tool for the appropriate choice of follow-up format. METHODS: A retrospective review of patient management was undertaken across three NHS upper-limb trauma units during the first UK COVID-19 lockdown. Data were collected, and themes were analysed across a number of predetermined categories. This was underpinned by a review of contemporary policy guidance and literature. RESULTS: A total of 85% of patients were offered an appropriate format of follow-up; this was defined by the ability to achieve desired patient-clinician goals and lack of complications. Key factors in determining appropriate follow-up included extent of injury, mental health considerations, and the need for face-to-face (F2F) assessment and treatment. CONCLUSION: Study findings demonstrate consistency between units in the factors determining the appropriate use of TECS. The refined screening tool provides a risk-stratified, standardised approach to the choice of follow-up format, F2F or TECS. It is hoped that this will support future clinical decision-making processes to ensure optimal patient care.

Defining clinical decision making in the provision of audio-visual outpatient care for acute upper limb trauma services: A review of practice.

The Covid-19 pandemic has accelerated the widespread adoption of technology-enabled care in the NHS.1 Moving into phase two of the response, the continuing use of audio-visual technology is expected, where appropriate, to be integral in the provision of safe, quality patient care.2 A clinical need therefore exists to identify when care can be safely delivered remotely using audio-visual technology and when there is a need for in-person contact.  At Salisbury Foundation Trust (SFT), during phase one of the NHS response to Covid-19, the decision to treat upper limb trauma patients in-person or remotely was made using clinical screening criteria. For many patients, audio-visual appointments offered a practical, time efficient way of accessing their reconstructive team for assessment, advice and post-operative care. However, a subset of patients was identified by the team as requiring at least one in-person consultation to minimize perceived clinical risk and to optimize quality outcomes.  In order to understand more fully the challenges and successes of technology-enabled care to date, a national survey of practice across hand units in the UK was conducted. We present here some of our key findings and propose the need to develop nationally agreed screening criteria to determine how and when technology enabled outpatient care can be used in the management of acute upper limb trauma. The results of this survey forms part of a series of projects currently underway looking at the efficacy of audio-visual care in upper limb trauma, including a multicentre observational study.

Physiolysis for correction of clinodactyly with delta phalanx: Early improvement.

Congenital clinodactyly known as "delta phalanx" is a congenital finger deviation caused by a middle phalanx abnormality. Progressive realignment can be achieved with normal growth through physiolysis according to Vickers. The purpose of this investigation was to identify the rate of correction in congenital clinodactyly following epiphyseal bar resection.We studied retrospectively 24 fingers in 14 patients aged from 14 months to 11 years old (y/o), operated on by two surgeons performing epiphyseal bar resection using a modified Vickers' method. Angle measurements were compared pre-operatively, at 1 year and at the final follow-up. The rate of correction was evaluated at each time point. The cohort was divided into two groups: surgery < 6 y/o and ≥ 6 y/o. Statistical analyses were conducted to compare the patient groups.The mean deviation decreased from 33° pre-operatively (20°-80°) to 17.2° (0°-40°) at 1 year after surgery. The deviation at the last follow-up decreased to 10.6° (0°-40°). Seventy percent of the operated fingers were completely corrected (angle ≤ 10°) at the latest follow-up visit. No difference was found regarding the age at surgery. There were two cases of premature fusion of the epiphyseal plates. Regardless of the patient's age, Vickers' procedure is a simple and effective solution for treating delta phalanx with early correction. Our data suggest that physiolysis is a successful surgery in patients up to 11 years old. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The first case of hourglass-like constriction neuropathy of a digital nerve.

Neuropathies of digital nerves are an infrequent phenomenon and their causes are most often mechanical. A rare cause of acute neuropathy is hourglass-like fascicular constriction of a nerve due to torsion. Although several cases of hourglass-like constriction have been described in the literature, none to our knowledge involved digital nerves. In this report, we present the first case of hourglass-like constriction of a digital nerve.

Ventilatory sparing strategies and swallowing pattern during bottle feeding in human infants.

During feeding, infants have been found to decrease ventilation in proportion to increasing swallowing frequency, presumably as a consequence of neural inhibition of breathing and airway closure during swallowing. To what extent infants decrease ventilatory compromise during feeding by modifying feeding behavior is unknown. We increased swallowing frequency in infants by facilitating formula flow to study potential ventilatory sparing mechanisms. We studied seven full-term healthy infants 5-12 days of age. Nasal air flow and tidal volume were recorded with a nasal flowmeter. Soft fluid-filled catheters in the oropharynx and bottle recorded swallowing and sucking activity, and volume changes in the bottle were continuously measured. Bottle pressure was increased to facilitate formula flow. Low- and high-pressure trials were then compared. With the change from low to high pressure, consumption rate increased, as did sucking and swallowing frequencies. This change reversed on return to low pressure. Under high-pressure conditions, we saw a decrease in minute ventilation as expected. With onset of high pressure, sucking and swallowing volumes increased, whereas duration of airway closure during swallows remained constant. Therefore, increased formula consumption was associated with reduced ventilation, a predictable consequence of increased swallowing frequency. However, when consumption rate was high, the infant also increased swallowing volume, a tactic that is potentially ventilatory sparing as a lower swallowing frequency is required to achieve the increased consumption rate. As well, when consumption rate is low, the sucking-to-swallowing ratio increases, again potentially conserving ventilation by decreasing swallowing frequency much more than if the sucking-to-swallowing ratio was constant.

Jejunal diverticulitis in a child.

Jejunal diverticular disease is rare and few cases have been documented in the literature. Here we report the first case of a child presenting with a perforated congenital jejunal diverticulum.

The association of serum total cortisol and pneumonia severity index.

OBJECTIVE: To study the relation between severity of pneumonia and serum cortisol level in a cohort of Egyptian patients. METHODS: All consecutive adult patients with community acquired pneumonia (CAP) admitted to Mansoura University Hospital, Mansoura, Egypt between March 2008 and December 2008 were considered for study inclusion. Exclusion criteria were patients with HIV infection, impaired immune systems, collagen vascular disease, interstitial pneumonia, chronic obstructive pulmonary disease (COPD), asthma requiring 10 mg of prednisolone at least daily, active malignant neoplasm, congestive heart failure (CHF), liver cirrhosis, or other causes of hypoproteinemia and septic shock. Pneumonia severity was scored at hospital admission according to pneumonia severity index (PSI) using the PORT criteria. The serum total cortisol was measured at hospital admission using ELISA. RESULTS: The present study comprised 23 adult patients with CAP: 14 male and 9 females with a mean age of 47 +/- 16.7 years. Total serum cortisol (mean 483.11 +/- 387.91 nmol/L) was positively correlated (p=0.012, R=0.576) with pneumonia severity as assessed by the PSI. Moreover, the total serum cortisol levels showed significantly negative correlation with arterial oxygen tension (R=-0.500, p=0.035), oxygen saturation % (R=0.450, p=0.029), and bicarbonate level (R=0.266, p=0.03), as well as a significant positive correlation with the extent of lung involvement (p=0.041). CONCLUSION: Total serum cortisol showed a significantly positive correlation with the severity of CAP assessed by the PORT index (PSI) in our study population. A single measurement of total serum cortisol may provide helpful information as the complex 20-variables, which are used in pneumonia severity index.

Potentiating action of PGF2 alpha and syntocinon on the pregnant human uterus.

PIP: The in vitro effects of administration of PGF2 alpha and syntocinon were studied using strips from pregnant human uteri collected at midtrimester, at term, and immediately postpartum as well as strips from a midtrimester pregnant cervix. It was found that when the 2 drugs are administered together a potentiating effect is achieved on the uterine strips but not on the cervical strips. The combined administration of low doses of PGF2 alpha and syntocinon may minimize or abolish the side effects of induced labor or abortion.^ieng

Ovarian structure in cases of primary and secondary infertility.

PIP: The present study was carried out to assess the ovarian structure in cases of primary infertility (PI), and secondary infertility (SI). 40 patients were selected from the infertility clinic of Al Azhar University hospital from those suspected to have ovarian abnormalities with history of amenorrhea or oligomenorrhea or those having enlarged ovaries on pelvic examination. Their ages ranged from 17 to 40 years; their husbands were generally in good health and fertile. 28 were suffering from PI and 12 from SI. Ovarian biopsy was taken in 20 patients by laparoscopic technique and 20 patients by wedge resection. At the same time endometrial biopsy was taken with a specimen of cervical mucus and vaginal cells to detect the presence or absence of ovulation. Evidence of recent ovulation was present in 57.1% of the cases of PI and 50% of the cases of SI. However, the ovarian structure was abnormal in 92.9% of the cases of PI and 83.3% of the cases of SI. Polycystic ovary was present in 71.4% of PI cases and in 58.3% of SI cases and was considered the most common ovarian abnormality in both groups, followed by sclerotic ovary, which was detected in 14.3% of PI cases and no SI cases. Other findings in both groups included tubo-ovarian abscess, ovarian fibroma and a serous cystadenoma.^ieng

Feeding responses to free-flow formula in term and preterm infants.

OBJECTIVES: Although introducing freely flowing formula into the infant's mouth is a common feeding practice, its effect on feeding behavior is largely unknown. We evaluated the effects of free flow of formula from the nipple on infant feeding activity (sucking, swallowing, ingestion rate) and documented potential adverse behaviors such as cough, restless behavior, drooling, apnea, and bradycardia. METHODS: We studied 13 preterm and 7 term infants. During a feeding, bottle pressure was adjusted every 2 to 3 minutes to increase or decrease free flow from the nipple. RESULTS: Increase in free flow of formula from the nipple caused rapid increases in suck and swallow frequency in term and preterm infants and increased ingestion rate. The response was reversed by decreasing flow and was repeatable throughout the feeding. Peak suck and swallow rates were highest in term infants. Although drooling increased with increased milk flow, no effect of flow on coughing, restless behavior, or apnea was observed. CONCLUSIONS: Free-flow formula is a potent stimulus for feeding activity in both preterm and term infants and is not associated with increased apnea or other adverse behaviors. The ability of the infant to divert excess formula flow by drooling is an efficient airway protective behavior. Reduced maximum suck and swallow frequency may be a primary basis for slow feeding in preterm infants.

Effect of high lipid diet and allopurinol on the development of experimentally induced arthritis in rats.

Male albino rats were fed a high lipid diet for 5 consecutive weeks. We studied the development of paw inflammation after an injection with Freund's complete adjuvant. Increasing the lipid content of the diet significantly increased the rate of paw inflammation. Also the effect on this process of oral administration of a xanthine oxidase inhibitor (allopurinol, 50 mg/kg) for 15 consecutive days was studied. Results indicated that inflammation was significantly inhibited by allopurinol.

Inherited immunoregulatory dysfunction in extrinsic bronchial asthma.

We studied 119 members of 22 asthmatic multiplex families. Included were: 44 parents (seven were asthmatics), 48 asthmatics (23 were undergoing an attack at the time of sampling), and 27 normal siblings. The following investigations were carried out on all subjects: 1) detection of total T lymphocytes, helper cells, and suppressor cells, using monoclonal antibodies (OKT3, OKT4, and OKT8), 2) study of nonspecific T-lymphocyte blast transformation induced by PHA, and 3) HLA-A, B, and DR antigen determination using the microcytotoxicity technique. The results were compared with normal ranges and data for a normal group and statistically and genetically analyzed. They indicate that: 1) the number of T cells was low in asymptomatic asthmatics and normal in asthmatics in attack; 2) there were fewer helper and normal suppressor cells (that is, a low H:S ratio) in asymptomatic asthmatics, and a normal amount of helper and suppressor cells (a normal H:S ratio) in those experiencing an attack; 3) there was a percentage of lymphocyte transformation in both groups of asthmatics; 4) whereas the T-helper cells increased, there was no change in the number of suppressor cells during an attack, which points to deficient function of suppressor cells; 5) the disorder is inherited and the gene controlling this dysfunction is HLA-linked and probably dominant.

Diagnostic significance of Schistosoma mansoni proteins Sm31 and Sm32 in human schistosomiasis in an endemic area in Egypt.

We performed a series of ELISAs to evaluate the diagnostic significance of two Schistosoma mansoni proteins, Sm31 (cysteine proteinase, cathepsin B) and Sm32 (asparaginyl endopeptidase). Our study populations were chosen from two villages in an endemic area close to Alexandria. Using fusion proteins MS2-Sm31 and MS2-Sm32 as antigens, 70% and 78.9%, respectively, of patient sera from 134 parasitologically confirmed cases reacted positively. The percentage of seropositivity increased to 84.5% when parasite-derived proteins Sm31 and Sm32 were used. The serum levels of antibodies to these two proteins in recombinant or native forms do not correlate with intensity of infection and hence are detected even when egg counts are low, which makes proteins Sm31 and Sm32 useful antigens in the identification of S. mansoni infected cases, particularly in endemic areas in Egypt.

Radioprotectant Activity of Dicopper(II) Tetrakis(3,5- Diisopropylsalicylate) and Manganese(II) bis(3,5- Diisopropylsalicylate) Alone and in Combination.

Dicopper(ll) tetrakis(3,5-diisopropylsalicylate), (Cu(II)(2)(3,5-DIPS)(4), manganese(II) bis(3,5-diisopropylsalicylate), Mn(II)3,5-DIPS)(2) or combinations of them were used to treat gamma-irradIated mice in examining the possibility that combination treatments might be more effective in increasing survival than treatment with either complex alone. Doses of 0, 10, 20, or 40 mumol of each complex per kilogram of body mass were administered subcutaneously in a factorial design before 9 Gy gamna irradiation, an LD(90) dose of irradiation. Doses of 0, 10, 20, or 40 mumol Cu(II)(2)(3, 5-DIPS)(4) per kg of body mass produced 12, 28, 28, or 36 % survival, respectively, while doses of 0, 10, 20, or 40 mumol (II)(3), 5-DIPS)(2) per kg of body mass prduced 12, 36, 20, or 24 % survival, respectively. However, the combination of 20 mumol Cu(II)(2)(3, 5-DIPS)(4) and 10 mumol Mn(II)(3, 5-DIPS)(2) produced the greatest survival, 48 %, which was 300 % greater than vehicle-treated mice (P=0.01). It is concluded that specific combination treatments can be used to maximize survival of lethally irradiated mice.