RHEUMATOLOGISTS BEWARE OF LOW ALP: A CASE OF HYPOPHOSPHATASIA MISDIAGNOSED AS FIBROMYALGIA, CAUSING LONG DIAGNOSTIC DELAY

BackgroundHypophosphatasia(HPP), a rare, inherited metabolic disease featuring low serum alkaline phosphatase (ALP) activity due to ALPL (encoding tissue non-specific alkaline phosphatase) gene mutation[1,2]. A wide-ranging clinical spectrum is often seen due to defective mineralisation affecting teeth, bones, joints and muscles[1]. This disease has a prevalence of 1/6370 in Europe and is often misdiagnosed and underdiagnosed with a diagnostic delay of more than ten years[1] The treatment is often supportive for milder cases and enzyme replacement therapy in severe cases.ObjectivesTo share this case to raise awareness among Rheumatologists.MethodsThis 58-year-old Caucasian female had her first HPP symptom as early eruption of deciduous teeth, along with recurrent dental infections and gum problems. She was diagnosed with flat feet at age five, had a big toe fracture at sixteen, followed by a metatarsal fracture. She experienced leg muscle cramps and aches, affecting her performance in sport during school life.At the age of thirty she began noticing weakness in arms and legs, which progressed over the years. She faced significant early morning stiffness along with painful ribs, hips, knees, shoulders, and small joints of feet when walking.She was diagnosed with Fibromyalgia at the age of forty-four. The following ten years she met numerous specialists including rheumatologist, pain specialist and physiotherapists. She was also diagnosed with early osteoarthritis, pernicious anaemia, hyperlipidemia, functional neurological syndrome, and central sensitization syndrome. She had multiple trials of steroids and opioids, all of which were stopped either due to side effects or inefficiency.A major flare of symptoms five years ago rendered her bedbound for three months, following which a chemical pathologist noticed a persistent low ALP levels and decided to investigate for HPP. It took another four years to complete these investigations due to the coronavirus pandemic.Currently, she is unable to weight bear or climb stairs and must stay indoors or in bed during flareup. She moved into a ground floor flat at the age of 54 and use a walking stick occasionally. By 58, she is unable to work and had given up her own business due to pain, weakness, and disability.ResultsOn clinical assessment, her height is 160 cm, faced difficulty getting up from chair, has an antalgic waddling gait, with a 6-minute walking distance of 60 metre, stopped after three minutes, and had a Brief Pain Inventory pain severity score of 7/10. Her ALP level is 24 U/L and PLP/PA ratio is 18.8 (ref < 5), and genetic testing showed heterozygous missense variant of ALPL gene mutation.ConclusionIt took more than forty years to reach a conclusive diagnosis of childhood onset HPP. Low ALP level is a signature of HPP and warrants investigations. Diagnosis can be challenging due to the rareness and variable presentation, however recognition of HPP features is crucial for timely referral, optimal disease management and potential improvement in quality of life.References[1]Högler W, Langman C, Gomes da Silva H, Fang S, Linglart A, Ozono K, Petryk A, Rockman-Greenberg C, Seefried L, Kishnani PS. Diagnostic delay is common among patients with hypophosphatasia: initial findings from a longitudinal, prospective, global registry. BMC Musculoskelet Disord. 2019 Feb 14;20(1):80. doi:10.1186/s12891-019- 2420-8. PMID: 30764793;PMCID: PMC6376686.[2]Injean P, Lee S, Downey C. Hypophosphatasia May Be Misdiagnosed as Fibromyalgia: A Single Center Experience []. Arthritis Rheumatol. 2020;72 (suppl 10). https://acrs.org//hypophosphatasia-may-be-misdiagnosed-as- ibromyalgia-a-single-center-experience/. Accessed January 14, 2023.[3]Lefever E, Witters P, Gielen E, Vanclooster A, Meersseman W, Morava E, Cassiman D, Laurent MR. Hypophosphatasia in Adults: Clinical Spectrum and Its Association With Genetics and Metabolic Substrates. J Clin Densitom. 2020 Jul-Sep;23(3):340- 48. doi: 10.1016/j.jocd.2018.12.006. Epub 2018 Dec 21. PMID: 30655187.Acknowledgements:N L.Disclosure of InterestsNone Declared.

Transformation of an independent sector treatment centre to a regional trauma centre during COVID pandemic

ContextOn the 11th March 2020, the WHO declared SARS-CoV-2 (COVID) outbreak a global pandemic. Healthcare facilities in the UK faced an unprecedented challenge of managing the outbreak, whilst maintaining basic healthcare services such as cancer and trauma. The NHS and independent sector partnership allowed a safe work stream, a relationship that continues now to support the elective recovery coming out of the pandemic.Issue/ChallengeReorganisation of healthcare provision led to the transformation of Practice Plus Group (PPG) hospital, Ilford to a green site for Barking Havering and Redbridge NHS University Trust (BHRUT) trauma service from 30/03/2020 to 10/06/2020. PPG Hospital had to rise to the challenge mobilising quickly from an elective service to a trauma unit serving a local population of over 1 million. The hospital transformed over one weekend, mobilising staff and equipment to deliver a trauma service. Their service went on to exemplify gold standard treatment of the very sick. The unit responded, adapted and developed outpatient clinics, plaster room, trauma ward and theatres to manage COVID-negative trauma cases that BHRUT received.Assessment of issue and analysis of its causesClinical staff had to upskill to take on the very sick (ASA 4) who may require end organ support, to carry out trauma surgery and procedures that were never performed before at the unit. Surgeons and surgical trainees from the trust became part of the multidisciplinary collaboration whilst the senior leaders developed a strong relationship to ensure good governance throughout the period. All of PPG staff had to get involved in ward care. Staff were trained with regards to personal protective equipment (PPE), Aerosol generating procedures (AGPs), pressure area care and applying traction to realign bones as some of the examples. The staff involved came from the following groups: theatre staff, outpatient staff, the anaesthetic consultants, ward staff, endoscopy, pharmacy, physio, housekeeping, infection control and portering.ImpactConsultant anaesthetists had a steep learning curve to both update their trauma knowledge and sharpen their skills. The guidelines of fracture hips were reviewed. The weekly teaching meetings’ topics were all about anaesthesia for emergency surgery, trauma and COVID. Anaesthetic work rota modified to provide a suitable recovery time following long days in theatres. The necessity of rest periods improves immunity.InterventionThere were some logistic hurdles, including the lack of availability of a suitable meeting facility that can accommodate a large number of attendees. There was a need to have a combined meeting with the BHRUT team in the red zone. On the first day, the meeting was carried out on the ‘ZOOM’ platform on smart phones. Within a couple of days. The trauma meeting was held in the capacious theatre reception, using a wall-mounted big screen for audio-visual display. This allowed better communication with all clinical teams including orthopaedic surgery, anaesthesia, nursing and coordinators.Involvement of stakeholders, such as patients, carers or family members:The PPG team implemented the pillars of clinical governance to improve the quality of care. The virtual monthly morbidity meeting included clinicians from all disciplines. A brief update of previous monthly data was reviewed. An initial internal audit showed that the average anaesthetic start time was 09:39. 19 lists (out of 23, 83%) started even after 09:15. The identified causes for this delay included late sending time, and the patient not being ready at the ward due to longer pre-operative checks and staff shortage. A ‘Golden Patient' was not always identified. A collaborative multi-disciplinary approach aimed to streamline the admission processes to ensure availability of both the surgical team and the patient to ensure a prompt theatre start. A repeat audit confirmed that the average anaesthetic start time has become 09:03. Only four out of 24 lists had an anaesthetic start time of 09:15 or later (17%). Th t is an Improvement of 69%.Key MessagesAs COVID created so much pressure on BHRUT, we quickly formed a positive can do working relationship both clinically and managerially to set up the Trauma service in just a few days. The 30 day mortality rate of patients with fracture neck of femur was less than the national average. This positive approach has enabled us to continue working together to help ease pressure off the lengthy patient waiting lists in Orthopaedics and General Surgery.Lessons learntPPG was proud to receive many compliments from patients and BHR staff. A patient wrote ‘I am so humbled and impressed by the amazing team-work and skill of the staff here that I want to congratulate you on what is an outstanding success amongst all the many stories coming out of the corona pandemic. Watching the way in which staff from so many different departments and skills bases are coming to this ward and learning nursing techniques with humility and patience as well as bonding in an upbeat, joyful team is something I will always remember. A surgical trainee mentioned The Independent Sector Treatment Centre (ISTC) team has been absolutely excellent so far. They have made us feel welcome and have worked hard to optimize the service'. This COVID cooperation paved the way for the ongoing cooperation between BHR and PPG, Ilford.Measurement of improvementThe outcome data shows that the service was able to successfully manage fractured neck of femur with better outcomes against national KPI. During the period from 30/03/20 to 10/06/2020, 85 patients had surgery for an emergency fracture neck of femur (Table 1). At PPG, the 30 days mortality rate was 3.5%. The national mortality rate for patients with fracture neck of Femur was 6.1%.75 patients with fracture neck of femur had surgical fixation within 36 hours.Strategy for improvementCollaborative cooperation between NHS and PPG led to set up of new pathways, governance and processes that enable patients to be transferred directly to us as well as creating capacity for BHRUT surgeons to operate in our hospital, supported by our theatre and ward teams.

NEUTROPHIL TO LYMPHOCYTE RATIO (NLR) PREDICTS FRACTURE IN PATIENTS ON LONG-TERM GLUCOCORTICOID

BackgroundLong-term glucocorticoid (GC) exposure leads to systemic bone loss and fracture. In addition, GC is known to increase white blood cell (WBC) amount and change the distribution of differential count (DC). Neutrophil-to-Lymphocyte ratio (NLR) has been studied as an optimal marker of subclinical inflammation, predicting the prognosis of cardiovascular diseases, cancers and even covid-19 infection. For patients under long-term GC exposure, the hemogram change might be a potential parameter to predict prognosis.ObjectivesThis pilot study aims to investigate if GC related WBC-DC change, including NLR, is associated with future fractures during 3 years follow-up.MethodsThis retrospective study is based on a registry, conducted in Kaohsiung Chang Gung Memorial Hospital, Taiwan, from September 2014 till April 2021, aimed to monitor bone mineral density (BMD) changes and fractures in patients with autoimmune diseases. All recruited patients were followed at least 3 years and took X-ray images annually to capture new fragility fracture, including morphometric vertebral fractures. We screened participants who used GC continuously at least 3 months before the index day. We recorded the complete blood count (CBC) and WBC-DC values at least twice during the period of 3 months before and after the index day, and excluded patients who were febrile, under infection status, diagnosed as cancers or cardiovascular diseases at the index day. The NLR was calculated by the absolute neutrophil count divided by absolute lymphocyte count individually.ResultsA total of 346 participants were enrolled in current study, and 101 (29.2%) suffered from new fragility fracture in 3 years. Among patients with fracture and non-fracture, conventional fracture risk factors, such as age, BMD, and previous fracture remained significantly different, while the WBC revealed no difference (Table 1). Nevertheless, the absolute neutrophil and lymphocyte count were significantly higher and lower in the fracture group, respectively, and no difference in the monocyte, eosinophil, and basophil count. We compared different WBC ratio, and NLR is significantly higher in the fracture group, providing the odds ratio of 1.24 (95% confidence interval 1.07-1.44, p=0.005). Figure 1 showed that the observed fracture risk raised as the NLR values increased.ConclusionIn patients under long-term GC, NLR might be a helpful marker to predict fracture, and higher NLR indicates higher fracture risks.Figure 1.Observed fracture rate is associated with baseline NLR[Figure omitted. See PDF]Table 1.Demographic characteristics of enrolled patients on long-term glucocorticoid.Fracture N=101No-Fracture N=245p-valueAge63.7 ± 9.056.5 ± 9.6<0.001*Sex(women)89(88.1)210(85.7)0.55BMI24.1 ± 3.923.4 ± 3.90.14Previous Fracture64(63.4)55(22.4)<0.001*Total hip BMD0.738 ± 0.1330.790 ± 0.1220.001*Femoral neck BMD0.575 ± 0.1130.626 ± 0.109<0.001*Lumbar BMD0.841 ± 0.2000.855 ± 0.1500.49WBC7.3 ± 2.16.9 ±1.70.14Hemoglobin12.8 ± 1.512.9 ± 1.40.33Platelet239.2 ± 64.7247.9 ± 71.40.30Neutrophil67.3 ± 9.764.3 ± 9.70.009*Lymphocyte24.3 ± 8.726.6 ± 9.50.04*Monocyte6.2 ± 1.86.3 ± 1.60.52Eosinophil1.8 ± 1.81.9 ± 1.30.77Basophil0.4 ± 0.20.4 ± 0.20.18NLR (Neutrophil to lymphocyte)3.3 ± 1.72.8 ± 1.40.004*NMR (Neutrophil to monocyte)11.9 ± 4.511.0 ± 3.60.04*LMR (Lymphocyte to monocyte)4.2 ± 1.74.5 ± 1.90.20AcknowledgementsThis work was supported by funding grant CMRPG8J0331 from the Chang Gung Memorial Hospital (https://www.cgmh.org.tw).Disclosure of InterestsNone Declared.

Alcohol consumption and maxillofacial fractures in times of Covid-19: a cross-sectional study in a cuban university hospital / Consumo de alcohol y fracturas maxilofaciales en tiempos de Covid-19: un estudio transversal en un hospital universitario cubano

Introduction: The consumption of alcoholic beverages reduces the body's ability to deal with dangerous situations and exposes people to trauma. Objective: To determine the association between the consumption of alcoholic beverages and the characteristics of maxillofacial fractures treated at a Cuban university hospital in the context of COVID-19. Material and Methods: An observational, analytical, and cross-sectional study was carried out in the Maxillofacial Surgery unit at the "Carlos Manuel de Céspedes" General University Hospital during the year 2020. Prevalence ratios, 95% confidence intervals and p-values were obtained using generalized linear models. Results: In 58.23% of the cases, fractures were related to the consumption of alcoholic beverages. The fundamental etiology was interpersonal violence (47.75%), regardless of the consumption of alcoholic beverages. There was a prevalence of patients with nasal fractures (n=98; 55.06%), among which, 35.71% had consumed alcoholic beverages at the time of the trauma. Being male (p=0.005), the lack of university studies (p=0.007), the need for surgical treatment (p<0.001), the fractures of the zygomaticomaxillary complex (p=0.023), and the traumas that occurred during the weekends (p<0.001) or during the month of June (p=0.029) were factors associated with a higher frequency of fractures related to the consumption of alcoholic beverages. There was a lower frequency of fractures associated with alcohol consumption during the months of January (p=0.006) and March (p=0.001). Conclusion: Six out of ten cases were under the influence of alcoholic beverages. There was a greater number of young and male patients, mainly due to interpersonal violence.

Introducción: La ingestión de bebidas alcohólicas disminuye la capacidad del organismo para enfrentar situaciones de peligro y lo predispone a sufrir traumatismos diversos. Objetivo: Determinar la asociación entre el consumo de bebidas alcohólicas y las características de las fracturas maxilofaciales atendidas en un hospital universitario cubano en el contexto de la COVID-19. Material y Métodos: Estudio observacional, analítico y transversal realizado en el servicio de Cirugía Maxilofacial del Hospital General Universitario "Carlos Manuel de Céspedes" durante el 2020. Se obtuvieron razones de prevalencia, intervalos de confianza a 95% y valores p mediante modelos lineales generalizados. Resultados: En el 58.23% de los casos las fracturas se relacionaron con la ingestión de bebidas alcohólicas. La etiología fundamental fue la violencia interpersonal (47.75%), independientemente del consumo o no de bebidas alcohólicas. Predominaron los pacientes con fracturas nasales (n=98; 55.06%), en los que el 35.71% había consumido bebidas alcohólicas en el momento del trauma. El sexo masculino (p=0.005), la carencia de estudios universitarios (p=0.007), la necesidad de tratamiento quirúrgico (p<0.001), las fracturas del complejo cigomático-maxilar (p=0.023), los traumas sucedidos durante los fines de semanas (p<0.001) o durante el mes de junio (p=0.029) fueron factores asociados a una mayor frecuencia de fracturas relacionadas con el consumo de bebidas alcohólicas. Hubo menor frecuencia de fracturas asociadas a este consumo durante los meses de enero (p=0.006) y marzo (p= 0.001). Conclusión: Seis de cada diez casos estuvieron bajo los efectos de la ingestión de bebidas alcohólicas. Existió una mayor afectación de pacientes jóvenes, masculinos, a causa principalmente de la violencia interpersonal.

Single Institute Audit of Maxillofacial Trauma Cases Before and During COVID-19 Pandemic.

Study Design: In the year 2020, we saw the emergence of severe acute respiratory syndrome coronavirus 2 causing COVID-19 into a full blown pandemic. This resulted in constraints on healthcare resources, and the attention was shifted to reduce cross contamination and prevent spreader events. Maxillofacial trauma care was also affected similarly, and most of the cases were managed by closed reduction whenever possible. A retrospective study was conducted to document our experience in treating maxillofacial trauma cases before and after nationwide lockdown due to COVID-19 pandemic in India. Objective: The objective of the study was to compare the effect of pandemic in reported pattern of mandibular trauma and the result of closed reduction procedures in the management of single or multiple fractures in mandible during this time period. Methods: The study was conducted in the Department of Oral and Maxillofacial Surgery, Maulana Azad institute of Dental Sciences, Delhi, for a period of 20 months, that is, 10 months before and after nationwide lock down which was effective from 23rd March 2020 due to COVID-19 pandemic. The cases were grouped into Group A (those reporting from 1st June 2019 to 31st March 2020) and Group B (those reporting from 1st April 2020 to 31st January 2021). Primary objectives were assessed and compared according to etiology, gender, location of the mandibular fractures, and treatment provided. Quality of life (QoL) associated with the treatment outcome by closed reduction was assessed after 2 months as a secondary objective using General Oral Health Assessment Index (GOHAI) in Group B. Results: A total of 798 patients sought treatment for mandibular fractures and included 476 patients in Group A and 322 in Group B. The groups showed similar age and male: female ratio. Cases showed a steep fall during first wave of pandemic, and most of the cases occurred as result of RTA followed by fall and assault. The fractures due to fall and assault showed an obvious rise during the lockdown period. There were 718 (89.97%) patients having exclusive mandibular fractures and 80 (10.03%) patients having involvement of both mandible and maxilla. Single fractures of mandible constituted 110 (23.11%) and 58 (18.01%) in Group A and B, respectively. 324 patients (68.07%) and 226 patients (70.19%) had multiple fractures involving mandible in respective groups. Parasymphysis of mandible was most commonly involved (24.31%) followed closely by unilateral condyle (23.48%) then Angle and Ramus of mandible (20.71%) with coronoid being the least fractured. During the initial 6 months after lockdown, all the cases were treated successfully using closed reduction. GOHAI QoL assessment conducted in cases having exclusive mandibular fracture (210 Multiple, 48 Single) showed favorable results with significant (P < .05) difference between the single and multiple fractures. Conclusions: After one and half years and recovering from the second wave of pandemic that hit the country, we have come to understand COVID-19 better and embraced better management protocol. The study reveals that IMF remains the gold standard for the management of most of the facial fractures in pandemic situations. It was evident from the QoL data that most of the patients were able to carry out their day-to-day functions adequately. As the country prepares for a third wave of pandemic, management of maxillofacial trauma by closed reduction will remain the norm for most unless indicated otherwise.

Outcome Of Non-Elective Covid Positive Orthopaedic Injury Procedures In Two Tertiary Care Hospitals

Objective: To evaluate the outcome of COVID-positive orthopaedic injury patients operated as emergency cases regarding overall disease progression, laboratory parameters and fracture healing. Study Design: Prospective longitudinal study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi and Combined Military Hospital Malir Karachi Pakistan, from Apr to Nov 2020. Methodology: All the orthopaedic injury patients with no other injuries who tested positive for COVID-19 were included in the study. The demographic data, time of injury and surgery, co-morbidities and values of inflammatory markers such as Creactive protein (CRP), Total Leukocyte Count (TLC), Serum Ferritin and Neutrophil percentage were noted pre-op and on the fifth-day post-operation. The bone fracture, its severity, and the type of orthopaedic intervention were also noted. Results: A total of 17 patients were included in the study, out of which 12 were males (70.6%), and 5 were females (29.4%), with a mean age of 49.06±18.78 years. There were 9(52.9%) cases of mild COVID-19, 3(17.6%) cases of moderate and 5(29.2%) cases of severe disease among orthopaedic injury cases. The most common fracture was of the femur in 12(70.6%) patients, followed by tibia/fibula in 3(17.6%) and 2(11.8%) cases of radius and ulna. In addition, there were 2(11.8%) cases of non-union and 5(29.4%) delayed union. Only 2(5.2%) health professionals developed mild COVID. Conclusion: Orthopedic emergency operations of COVID-19-positive patients can be performed safely following strict COVID-19 protocols.

Undiagnosed Osteoporotic Vertebral Fractures in an Octogenarian During the Coronavirus Disease Pandemic.

Osteoporotic vertebral fractures are frequently misdiagnosed or under-recognized in the older population, leading to disease progression and reduced quality of life. This case of an 87-year-old woman with acute back pain highlights the importance of early diagnosis and management of fragility fractures. During the coronavirus disease (COVID-19) pandemic, patients with a history of well-managed osteoporosis experienced worsening symptoms of vertebral collapse due to activity limitations and prolonged immobilization. The initial diagnosis of spinal stenosis delayed appropriate treatment for four months. Serial magnetic resonance imaging revealed compression fractures at L1 and L3, and a dual-energy x-ray absorptiometry scan showed osteoporosis with a T-score of -3.2. Pharmacological therapy, including bisphosphonates, was initiated. A comprehensive rehabilitation program with a multidisciplinary approach, with bracing, and lifestyle changes helped stabilize the spine, reduce pain, and maximized function. Her condition improved with close monitoring and guidance during home exercises. This case exemplifies the necessity of a precise and timely diagnosis of osteoporotic vertebral fractures to initiate management and mitigate disease progression.

Early mobilisation after pain relief for conservative management for intertrochanteric fractures: a pandemic enforced innovation and its results.

BACKGROUND: The COVID pandemic challenged the orthopaedic mind on several fronts. 1 of them was in the management of intertrochanteric fractures. A subset of these patients refused surgical intervention during the pandemic for related reasons. Faced with the goal of early verticalisation, the senior author used pain relief as a method to facilitate early mobilisation in 23 patients with peritrochanteric fractures. METHODS: 23 patients with stable intertrochanteric fractures received a ß 6 distal sodium channel block (DSCB) and were allowed to walk from day 1 without surgery, traction or spica. The goal was to prevent complications of recumbency in this subset of patients. The basic idea of immediate mobilisation from the time of fracture was based on Sarmiento's sausage theory. RESULTS: All the fractures united. There were no major complications. No shortening was seen in more than 50% cases and the shortening did not exceed 2 cm in any case. All patients were satisfied with the outcome and had good to excellent Harris Hip Scores. CONCLUSIONS: The block and walk method is a surprisingly satisfactory method of treatment for stable intertrochanteric fractures. It circumvents the risks of surgery whilst allowing immediate mobilisation preventing complications associated with the other modalities of fracture management.

A tale of three pandemics: Shining a light on a hidden problem

An "epidemic" is an event in which a disease, infectious or non-infectious, is actively spreading within a population and designated area. The term "pandemic" is defined as "an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people".The global response to the COVID-19 pandemic has not been seen since the outbreak of Human Immunodeficiency Virus in the early eighties. But there is another unseen pandemic running alongside the current COVID-19 pandemic, which affects a vast number of people, crossing international boundaries and occurring in every single country world-wide. The pandemic of traumatic injuries. Traumatic injuries account for 11% of the current Global Burden of Disease, resulting in nearly 5 million deaths annually and is the third-leading cause of death worldwide. For every trauma-related death, it is estimated that up to 50 people sustain permanent or temporary disabilities. Furthermore, traumatic injuries occur at disproportionately higher rates in low-and middle-income countries, with approximately 90% of injuries and more than 90% of global deaths from injury occurring these countries.Injuries are increasing worldwide, crossing international boundaries and affecting a large number of people, in the same manner Human Immunodeficiency Virus did in the 1980's and COVID-19 is today. The tremendous global effort to tackle the COVID-19 and Human Immunodeficiency Virus pandemics has occurred whilst ignoring the comparable pandemic of injury. Without change and future engagement with policy makers and in-ternational donors this disparity is likely to continue.(c) 2021 Published by Elsevier Ltd on behalf of Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.

Proton pump inhibitors: Understanding the associated risks and benefits of long-term use.

PURPOSE: Proton pump inhibitors (PPIs) are widely prescribed medications. Various adverse clinical effects of PPIs have been reported in the literature, particularly over the past decade. The purpose of this article is to review published data primarily describing adverse effects associated with PPI use and to help clinicians determine which patients may still benefit from therapy despite safety concerns. SUMMARY: Associations between PPIs and the following have been described: bone fracture, acute and chronic kidney disease, gastrointestinal infections, deficiencies in vitamin B12 and magnesium, and coronavirus disease 2019 and respiratory infections. For inclusion in this review, studies must have evaluated potential adverse events associated with PPIs as a primary or secondary objective. Increased risks of bone fracture, acute and chronic kidney disease, gastrointestinal infections, and magnesium deficiency were consistently reported, albeit mostly in studies involving low-quality data (case-control and/or observational studies) and subject to bias. In the only pertinent randomized controlled trial to date, chronic pantoprazole use was associated with a greater risk of enteric infections relative to placebo use; there was no significant between-group difference in any other adverse event evaluated. PPIs continue to be recommended by the American College of Gastroenterology as a first-line treatment for management of gastroesophageal reflux disease and in the acute period following upper gastrointestinal and ulcer bleeding. CONCLUSION: Higher-quality data is needed to better understand PPI-associated risks of the adverse effects listed above. Until then, clinicians may consider greater vigilance with PPI use; however, the data does not demonstrate a need for wide adoption of de-escalation strategies solely out of safety concerns.

Outpatient management of facial fractures in France: Current state.

Maxillofacial trauma is still very common in France with possible involvement of all face bones. Outpatient surgery is an axis strongly put forward by the public authorities. The aim of this study is to establish a current state in the outpatient management of facial fractures in France in 2019 before COVID infection. A closed and semi-open-ended questionnaire was sent to French hospitals treating facial fractures in order to evaluate current and possible future practices in terms of outpatient and perioperative management. Data extracted from the Program for giving Medical significance to Information Systems (PMSI) thanks to the Agency for Information on Hospital Care (ATIH) were also studied to obtain proportions of outpatient care by department. About the questionnaire 43 replies were received. Nasal fractures were the only type of fracture having a minimum average length of stay below 24hours (12.00±16.65) as well as an actual average length of stay (14.22±24.24). Concerning data extracted from the PMSI, 14510 stays were found. Currently only nasal fractures and zygomatic arch fractures requiring simple reduction without osteosynthesis are performed on an outpatient basis. Mandibular fractures could be performed as an outpatient procedure. Access to the operating room and organizational problems specific to each center are factors that limit the development of outpatient management of these facial fractures. Some incompressible parameters such as the monitoring required following the management of these fractures as well as the patients' comorbidities must be taken into account.

The effect of COVID-19 on 30-day mortality rates amongst fragility hip fracture patients

Aim: Fragility hip fracture patients have always been vulnerable to high rates of short term mortality, an issue that may have been exacerbated by the ongoing COVID-19 pandemic. To date, published data regarding Irish hip fracture patients in the era of COVID-19 is limited. This study aims to assess the effect of COVID-19 on 30-day mortality rates amongst a group of Irish hip fracture patients. Additionally, patient demographics, length of stay, admission haematological parameters, fracture type and surgical procedure will be assessed. Methods: A multicentre, observational, retrospective study of hip fracture patients (n = 1,017) admitted to six Dublin teaching hospitals during the COVID-19 pandemic (4th February to 9th July 2020) was performed. For comparative purposes, equivalent data was retrospectively collected relating to hip fracture patients admitted to the same six teaching hospitals during the same time period in 2019. Results: 481 patients were admitted during the specified timeframe in 2020, compared with 536 in 2019. The mean patient age was 77.6 years and 65.9% of patients were female. There was no statistically significant overall difference in 30-day mortality rates between the study and control groups, at 5.4% in 2020 and 4.3% in 2019 (p=0.338). There was an insignificant decrease in mean length of stay (17.85 days in 2020 vs. 18.82 days in 2019;p=0.106). Advancing age (p=0.021), male gender (p=0.019), low admission haemoglobin (p=0.024) and high admission white cell count (p=0.019) were all associated with increased 30-day mortality. Conclusion: We found no significant difference in 30-day mortality rates amongst our cohort of hip fracture patients at the height of the COVID-19 pandemic in Ireland. Advancing age, male gender, anaemia at admission and leucocytosis at admission were associated with increased 30-day mortality. The continuation of COVID-19 related safety protocols in the treatment of hip fracture patients is essential in maintaining a safe hip fracture service.

Clinical research of pre-hospital emergency care, nursing, infection prevention and control for senile osteoporotic vertebral compression fracture during epidemic period

Background: Novel coronavirus pneumonia (NCP) and osteoporotic vertebral compression fractures (OVCF) are the high incidences of diseases in the elderly. During the epidemic period, if not treated in time, the complications are high and the mortality is high. If we do not pay attention to infection prevention and control in pre-hospital emergency care, it will lead to the first time infection of medical staff and in-hospital cross infection in emergency outpatient receiving area. The correct consideration of both and the establishment of perfect pre-hospital emergency treatment and infection prevention and control synchronous strategy is an important premise to ensure the stable, orderly and safe medical treatment. Background: To explore the effect of synchronous implementation of pre-hospital emergency care, nursing and infection pre-vention and control for senile OVCF during the epidemic. In order to improve the efficiency of pre-hospital emergency care and prevent the spread of infection. Method: A total of 92 elderly patients with OVCF who received pre-hospital treatment in 18 hospitals in Zhangjiakou City during the epidemic prevention and control period from January 2020 to November 2022 and met the inclusion criteria were selected as research objects, including 24 males and 68 females, aged 65 - 82 (74.2 +or- 2.2) years. All patients were associated with concomitant injuries and underlying diseases. All patients in this group underwent predictive pre-hospital rescue and infection prevention and control procedures. Results: All the 92 elderly patients with OVCF received timely pre-hospital treatment during the epidemic period, and no aggravation occurred of the 92 patients, 35 were in the high risk area, 10 were in the medium risk area, and 47 were in the low risk area. Exclude OVCF for NCP Patients were treated according to the conventional diagnosis and treatment principles. Suspected and confirmed cases are transferred to designated surgical hospitals for treatment. All patients were followed up 3 months, 6 months and 12 months after treatment. There was no death rate, high satisfaction of pre-hospital first aid, high diagnostic accuracy, and good curative effect. None of the rescue personnel had any infection rate, and no hospital infection transmission and nosocomial cross infection occurred. Conclusion: It is the first step to safely treat patients and prevent cross infection to establish a perfect synchronous strategy of pre-hospital first aid and infection prevention and control.

A fractured system: have existing problems in health and social care for visually impaired people been exacerbated by COVID-19?

Visually impaired people in the UK have been adversely impacted during the COVID-19 pandemic due to an inconsistent approach between agencies and a failure to effectively manage key data. In this paper, fractures in the system already evident, particularly around the transition between health and social care, and the ways in which the COVID-19 pandemic has further starkly highlighted them, are presented. Key recommendations are proposed to improve the system and prevent such failings being repeated.

Outcomes of AstraZeneca vaccine for relapse and COVID-19 infection in people with multiple sclerosis

Background: People with chronic diseases of the immune system, such as multiple sclerosis (MS), are at risk for Covid-19 disease. However, more research is needed with long-term follow-up. The aim of the study was to follow up people with MS (PwMS) for up to three months after AstraZeneca vaccination for the recurrence of MS and Covid-19 infection. Methods: This study was a case study (descriptive-analytical) of follow-up type. The study population was PwMS over 18 years of age in Kermanshah province who received both doses of the AstraZeneca vaccine. This study was conducted from August to November 2021. Sampling was done with existing methods based on the National MS Registry of Iran (NMSRI). Demographic information of patients was extracted from NMSRI. A researcher-made form was used to collect information by telephone three months after vaccination about clinical characteristics, Covid-19 infection, and recurrence of MS. Data were analyzed using SPSS-25 software. Results: Study participants were 40 MS patients with a mean (SD) age of 39.27 (8.8) years, including 32 (80.0%) women. A mean of 9.39 (4.6) years had passed since The patients were diagnosed with MS, and 29 (76.4%) had RR type MS. Four patients (10%) relapsed between the second dose and three months later, of whom two (50%) had sensory symptoms, one (25%) had optic nerve involvement, and one (25%) had motor symptoms and pyramidal pathway involvement. The symptoms of Covid-19 were mild in three patients (10%), while severe symptoms developed in one patient (10%) who received rituximab. Among the patients, no cases of thrombosis were observed. Infusion therapy, a leg fracture, and kidney stones were the only hospitalized cases. Conclusion: Covid-19 and MS relapse prevalence did not differ significantly in the three months before and after vaccination. There is a need for further studies with a longer follow-up period.

Fracture incidence and fracture-related mortality decreased with decreases in population mobility during the early days of the COVID-19 pandemic: an epidemiological study.

INTRODUCTION: We investigated the impact of coronavirus disease 2019 (COVID-19) social distancing measures on fracture incidence and fracture-related mortality, as well as associations with population mobility. METHODS: In total, 47 186 fractures were analysed across 43 public hospitals from 22 November 2016 to 26 March 2020. Considering the smartphone penetration of 91.5% in the study population, population mobility was quantified using Apple Inc's Mobility Trends Report, an index of internet location services usage volume. Fracture incidences were compared between the first 62 days of social distancing measures and corresponding preceding epochs. Primary outcomes were associations between fracture incidence and population mobility, quantified by incidence rate ratios (IRRs). Secondary outcomes included fracture-related mortality rate (death within 30 days of fracture) and associations between emergency orthopaedic healthcare demand and population mobility. RESULTS: Overall, 1748 fewer fractures than projected were observed during the first 62 days of COVID-19 social distancing (fracture incidence: 321.9 vs 459.1 per 100 000 person-years, P<0.001); the relative risk was 0.690, compared with mean incidences during the same period in the previous 3 years. Population mobility exhibited significant associations with fracture incidence (IRR=1.0055, P<0.001), fracture-related emergency department attendances (IRR=1.0076, P<0.001), hospital admissions (IRR=1.0054, P<0.001), and subsequent surgery (IRR=1.0041, P<0.001). Fracture-related mortality decreased from 4.70 (in prior years) to 3.22 deaths per 100 000 person-years during the COVID-19 social distancing period (P<0.001). CONCLUSION: Fracture incidence and fracture-related mortality decreased during the early days of the COVID-19 pandemic; they demonstrated significant temporal associations with daily population mobility, presumably as a collateral effect of social distancing measures.

Bilateral Atypical Femoral Fractures after Bisphosphonate Treatment for Osteoporosis: A Literature Review.

INTRODUCTION: This literature review aimed to investigate the incidence, anatomical concerns, etiology, symptoms, diagnostic tools, management, and prognosis of bisphosphonate (BP)-associated bilateral atypical femoral fractures (AFFs). METHODS: The PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to 20 March 2022. All cases of bilateral AFFs were included, excluding those without any bisphosphonate treatment information and those in which the femoral fracture did not precisely fit into the diagnostic criteria for AFF. RESULTS: We identified 43 patients with bilateral AFFs associated with BP use and conducted a comprehensive analysis. Among 43 patients, 29 (67%) had prodromal symptoms. Regarding the simultaneity of fracture, 21 cases (49%) occurred simultaneously, and 22 cases (51%) occurred sequentially. Alendronate was the most commonly used BP treatment (59%). Regardless of the medication type, BP intake duration was more than 5 years in 77%. The initial diagnosis was performed using X-rays in all cases. A total of 53% of patients had complete fractures, and all patients underwent surgical treatment. Among the remaining patients with incomplete fractures, 18% and 29% received surgical and medical treatments, respectively. After BP discontinuation, teriparatide was most commonly used (63%). CONCLUSIONS: The careful evaluation of relevant imaging findings in patients with thigh/groin pain allows the identification of early incomplete fractures and timely management. Since the rate of contralateral side fractures is also high, imaging studies should be performed on the asymptomatic contralateral side.

Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates-Functional Results before and during the SARS-COVID-19 Pandemics.

Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life-being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer's three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck-shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant-Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant-Murley score (p = 0.0048; Student's t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic.