THE RELATIONSHIP BETWEEN THE FUNCTIONALITY OF CHILDREN WITH DISABILITIES AND ITS EFFECTS ON PARENTS DURING THE COVID-19 PANDEMIC PROCESS.

Purpose: The aim of this study was to investigate the relationship between the functionality of disabled children and its effects on parents during the Covid-19 pandemic. Method(s): A total of 168 people, including 84 disabled children and 84 mothers, were included in the study. The Pediatric Disability Assessment Inventory (PEDI) and Gross Motor Function Classification System (GMFCS) were used for children with disabilities. The Zarit Burden Scale (ZBS), Fatigue Severity Scale (FSS) and The Nordic Musculoskeletal Questionnaire (NMQ) were applied to the mothers to question musculoskeletal disorders. Result(s): There was no correlation between care burden score and PEDI, total score, self-care and mobility scores (p>0.05). A moderately negative (r=-0.306;p<0.01) significant linear relationship was found between care burden score and social function score. There was no significant linear relationship between the fatigue severity score and PEDI total score, self-care, mobility and social function scores (p>0.05). No correlation was found between care burden score and fatigue severity score (p>0.05). For the last 12 months, only the pain in the lumbar region of the parents prevented them from doing their usual work. It was determined that the most aching body parts of the parents who complained of musculoskeletal pain during the last 12 months were in the waist, neck, shoulder, back, and knee regions. Conclusion(s): As a result, no relationship was found between the functionality of disabled children and their parents' influences during the Covid-19 pandemic.Copyright © 2022 Turkish Physiotherapy Association. All rights reserved.

The impact of the Covid-19 pandemic on the diabetes antenatal clinic

Aims: The Covid-19 pandemic and subsequent restrictions impacted both health outcomes and clinical practice. We explored the impact on the diabetes antenatal clinic (DANC) attendance and outcomes. Method(s): Pre and during pandemic periods were defined as January 2019 to February 2020 and March 2020 to March 2022, respectively. DANC attendance, maternal and perinatal data were analysed. Adverse neonatal outcomes included stillbirth, neonatal hypoglycaemia, jaundice, shoulder dystocia and respiratory distress. Result(s): DANC attendance increased in the pandemic compared to the pre-pandemic period (297 (Interquartile range (IQR) 269-358) vs 196 (IQR 176-211) monthly, p < 0.001) with 36.7% (IQR 33-49) virtual appointments, representing a 34% overall increase. Body mass index (BMI) increased (29.7 kg/m2 (IQR 26.4-32.2) vs 31.4 kg/ m2 (IQR 26.5-34.2)) during the pandemic (p = 0.007), but maternal age and parity remained unchanged. There was no difference in gestational age at delivery;however, induction rates reduced from 58.5% to 37.5% (p = 0.0009) and spontaneous vaginal deliveries increased from 13.7% to 34.5% during the pandemic (p = 0.0004). Instrumental deliveries reduced from 21.5% to 11.3% (p = 0.03) but there was no change in number of caesarean sections including emergency ones. There was no difference in the rates of macrosomia or neonatal admissions. There was an overall reduction in adverse neonatal outcomes (37/102 (36.2%) vs 33/142 (23.2%) p = 0.03). Conclusion(s): Clinic numbers and maternal BMI increased during the pandemic. However, delivery and perinatal outcomes improved. Out data are reassuring and align with other studies indicating maternity outcomes did not deteriorate during the pandemic, possibly explained by improved care provision and organisation culture under crisis.

GDM diagnosis criteria: Standard and Covid-19 criteria

Aim: Standard diagnosis of gestational diabetes (GDM) is based on the Oral Glucose Tolerance test (OGTT). During the Covid-19 outbreak, due to Covid restrictions, criteria were modified i.e Fasting Blood Glucose >=5.3 and/ or HbA1c >= 39 for diagnosis of GDM. After the lifting of the Covid restrictions, the standard criteria were reimplemented and on analyzing the data, it was highlighted that some of the patients could have tested negative for GDM based on Covid Criteria. Method(s): We analyzed the data of 43 patients based on standard criteria (OGTT and HbA1c) after Covid restrictions, with the following results. Result(s): 11/43(28%) patients who were diagnosed on the basis of standard criteria could have been missed based on Covid criteria. Out of 11 deliveries, 2 babies with weight above 4 kg. There were no admissions to NICU. One patient had postpartum hemorrhage with 670 mL of blood loss. Conclusion(s): This was a retrospective study in which we analyzed the data of 45 pregnant females diagnosed with GDM based on testing using the Covid criteria and compared this to 43 pregnant females who were diagnosed with GDM on the basis of OGTT based on GOLD standard NICE criteria. In addition, we also examined maternal and obstetric outcomes in both groups such as the mode of delivery, the baby's birth weight, the incidence of shoulder dystocia, mean blood loss (MBL), and NICU admission. We understand that Covid GDM diagnosis was a necessity of time. In this study, we want to learn what could have been missed with that diagnostic criteria. For future pandemics, we need to revise our diagnostic criteria to avoid the risk of underdiagnosing GDM and associated complications.

Isometric thumb extension exercise as part of a multimodal intervention for de Quervain's syndrome: A randomised feasibility trial

Introduction: de Quervain's syndrome is a painful condition commonly presented to hand therapists. Exercise is utilised as an intervention, but isometric exercise has not been investigated. We aimed to assess the feasibility and safety of isometric thumb extension exercise for de Quervain's syndrome and to explore differences between high-load and low-load isometric exercise. Method(s): This parallel-group randomised clinical feasibility trial included individuals with de Quervain's syndrome. All participants underwent a 2 week washout period where they received an orthosis, education, and range of motion exercises. Eligible participants were then randomised to receive high or low-load isometric thumb extension exercises, performed daily for 4 weeks. Feasibility and safety were assessed by recruitment and drop-out rates, adherence, adverse events, and participant feedback via semi-structured interviews. Secondary outcomes included patient-reported outcomes for pain and function, and blinded assessment of range of motion and strength. Result(s): Twenty-eight participants were randomised. There were no drop-outs after randomisation, and no serious adverse events. Adherence to exercise was 86.7%, with 84% of participants stating they would choose to participate again. There were clinically and statistically significant improvements in pain and function over time (p < 0.001) but not in range of motion or strength. There were no statistically significant between-group differences. Conclusion(s): Isometric thumb extension exercise within a multimodal approach appears a safe and feasible intervention for people with de Quervain's syndrome. A large multi-centre trial would be required to compare high- and low-load isometric exercises. Further research investigating exercise and multimodal interventions in this population is warranted.Copyright © The Author(s) 2023.

A breath of fresh air

Submission content Introduction: This is a story about the day I wheeled a patient outside. I know, it sounds somewhat underwhelming. But little did I know that this short trip down a hospital corridor and beyond the entrance foyer would mark a profound shift in perspective both for me and my patient, which I hope will influence me for the rest of my career. Main Body: "Paul" was in his 50s and severely afflicted by COVID-19, resulting in a protracted ICU admission with a slow and arduous ventilator wean. Throughout his time on the unit, Paul had seen no daylight;no view of the outside world. He was struggling to make progress and was becoming exasperated. His deteriorating mood in turn affected his sleep, which further undermined his progress. Due to COVID-19, visiting was not permitted and Paul's cuffed tracheostomy meant that he couldn't speak to his family. One day, witnessing Paul's psychological decline, I asked him if he fancied a trip outside. Despite initial reluctance, he eventually gave in to some gentle persuasion from the staff nurse, with whom he had developed a close bond. So there we went;Paul, his nurse and me. And as we wheeled his bed through the door into open air, Paul's whole demeanour suddenly changed. He appeared as though the weight of the world had been lifted from his shoulders and his face lit up with awe, a tear emerging in the corner of his eye. In that moment he rediscovered life. Not as a hospital patient, but as a person. Watching the world go by, he remembered what it was like to be a member of the human race, not the subject of endless tests and treatments. He tasted freedom. Conclusion(s): Awakened by his experience of the forgotten outside world, when we eventually returned to the ICU Paul was an entirely different man. To Paul, the trip outside symbolised progress. After weeks of frustration and despair, he finally had a purpose;a motivation to get better. Meanwhile, I was having my own quiet realisation. I now understood what it truly meant to deliver holistic care. It can become all too easy to focus on the clinical aspects;to obsess about the numbers. But in fact, often what matter most to patients are the 'little things', to which no amount of medication is the solution. I now try to consider during my daily review: what matters to this patient? How are they feeling? What are they thinking? What else can I do to help their psychological recovery? And as for me personally? Having witnessed Paul's reaction to the outside world, I suddenly became aware of how little attention I normally pay to the world around me. How little I appreciate the simple ability to walk outside, and the fundamental things we take for granted. Now, when I'm feeling annoyed or frustrated about something trivial, I stop and think of Paul. I then thank my lucky stars for what I have to be grateful for. Ultrasound Ninja.

No time to waste, the impact of the COVID-19 pandemic on hip, knee, and shoulder arthroplasty surgeries in the Netherlands and Denmark

AimsThis study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID- 19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists.MethodsAll hip, knee, and shoulder arthroplasties (2014 to 2020) from the Dutch Arthroplasty Reg-ister, and hip and knee arthroplasties from the Danish Hip and Knee Arthroplasty Registries, were included. The expected number of arthroplasties per month in 2020 was estimated using Poisson regression, taking into account changes in age and sex distribution of the general Dutch/Danish population over time, calculating observed/expected (O/E) ratios. Country-specific proportions of patient characteristics and hospital type were calculated per indication category (osteoarthritis/other elective/acute). Waiting list outcomes including QALYs were estimated by modelling virtual waiting lists including 0%, 5% and 10% extra capacity.ResultsDuring COVID-period, fewer arthroplasties were performed than expected (Netherlands: 20%;Denmark: 5%), with the lowest O/E in April. In the Netherlands, more acute indica-tions were prioritized, resulting in more American Society of Anesthesiologists grade III to IV patients receiving surgery. In both countries, no other patient prioritization was present. Relatively more arthroplasties were performed in private hospitals. There were no clinically relevant differences in revision arthroplasties between pre- COVID and COVID-period. Esti-mated total health loss depending on extra capacity ranged from: 19,800 to 29,400 QALYs (Netherlands): 1,700 to 2,400 QALYs (Denmark). With no extra capacity it will take > 30 years to deplete the waiting lists.ConclusionThe COVID- 19 pandemic had an enormous negative effect on arthroplasty rates, but more in the Netherlands than Denmark. In the Netherlands, hip and shoulder patients with acute indications were prioritized. Private hospitals filled in part of the capacity gap. QALY loss due to postponed arthroplasty surgeries is considerable.

Orthopedic surgical scoring in asymptomatic COVID-19 patients

Aim: The purpose of this study is to create a scoring system to decide which patient will take maximum precautions while the covid 19 disease continues. Taking maximum precautions is not always possible in all surgical procedures. Therefore, surgical scoring in asymptomatic patients, selecting patients who need maximum precautions, and taking the necessary precautions for these patients will prevent unnecessary use of the equipment. Material(s) and Method(s): A total of 347 who were surgically treated for emergency or elective procedures between March 11 and November 11, 2020 were included in the study. Of these patients, 277 patients whose data could be accessed were included in the study. A scoring system has been created. Patients were divided into 2 groups: bearing low and high risk. Patients with a score above 10 were identified as having a high surgical risk, and those with a score below 10 were identified as having a low surgical risk. Result(s): There were 132 patients in Group 1 and 145 patients in Group 2. It was observed that 29 of 277 patients became positive within the first month. Two of these patients were in Group 1 and 27 of them were in Group 2. It was observed that COVID-19 antibody or PCR tests gave more positive results in patients in Group 2 in the first month compared to two patients in Group 1. The highest positivity rate in Group 2 was observed in the arthroscopy group. Discussion(s): Advanced precautions should be taken in patients with high surgical risk scores. In patients with low surgical risk scores, less strict precautions can be taken.Copyright © 2023, Derman Medical Publishing. All rights reserved.

The COVID-19 pandemic and follow-up for shoulder surgery: The impact of a shift toward telemedicine on validated patient-reported outcomes.

INTRODUCTION: The emergence of COVID-19 and its ensuing restrictions on in-person healthcare has resulted in a sudden shift towards the utilization of telemedicine. The purpose of this study is to assess patient satisfaction and patient-reported outcome measures (PROMs) for individuals who underwent follow-up for shoulder surgery using telemedicine compared to those who received traditional in-person clinic follow-up. METHODS: Patients who underwent either rotator cuff repair or total shoulder arthroplasty during a designated pre-COVID-19 (traditional clinic follow-up) or peri-COVID-19 (telemedicine follow-up) span of time were identified. PROMs including the American Shoulder and Elbow Surgeons standardized assessment form, the three-level version of the EQ-5D form, the 12-Item Short Form survey, and a modified version of a published telemedicine survey were administered to participants six months post-operatively via phone call. RESULTS: Sixty patients agreed to participate. There was no significant difference between the pre-COVID-19 and peri-COVID-19 groups in patient satisfaction with their follow-up visit (p = 0.289), nor was there a significant difference in PROMs between the two groups. In total, 83.33% of the telemedicine group and 70.37% of the in-person clinic group preferred traditional in-person follow-up over telemedicine. DISCUSSION: In a cohort of patients who underwent telemedicine follow-up for shoulder surgery during the COVID-19 pandemic, there was no difference in patient satisfaction and PROMs compared to traditional in-person clinic follow-up. This study indicates that while the majority of participants preferred face-to-face visits, patients were relatively satisfied with their care and had similar functional outcome scores in both groups, despite the large disruption in healthcare logistics caused by COVID-19.

Calcific Tendinitis of the Shoulder Induced by an mRNA Vaccine for COVID-19: A Case Report.

Coronavirus disease 2019 (COVID-19) vaccines have been widely used and have been shown to be effective in combating the pandemic. However, various side effects have been reported following vaccination. For instance, a condition called "shoulder injury related to vaccine administration" (SIRVA) is characterized by shoulder pain and limited range of motion after intramuscular injection of a vaccine into the deltoid muscle of the shoulder. Despite an increase in SIRVA cases, the exact incidence of the disease is unclear, and there are a few reports of SIRVA about the COVID-19 vaccine. Here, we report a rare case of an 83-year-old woman who was diagnosed with calcification in her left shoulder one year ago and developed calcific tendinitis after receiving an mRNA vaccine for COVID-19 (Pfizer-BioNTech). Radiographs showed calcification of the supraspinatus tendon, and magnetic resonance images showed continuous inflammatory findings from the subdeltoid bursa to the subacromial bursa. We treated the patient with celecoxib and acetaminophen, and she recovered after about two months. In order to prevent SIRVA, the presence of shoulder joint disease should be carefully asked during a pre-vaccination assessment. The puncture point should be chosen with the median point of the deltoid muscle or the anterior-posterior axillary line as landmarks, because the more cephalad the puncture position, the greater the chance of causing SIRVA.

Acute myopericarditis and left shoulder capsulitis following second dose of mRNA SARS-CoV-2 Moderna vaccination.

Vaccination against mRNA SARS-CoV-2 has been administered on a very large scale and various side effects have been described. The increased risk of myopericarditis is known, and only a few cases of shoulder capsulitis have been reported after vaccination. These two pathologies have never been reported in the same patient after vaccination. Our article presents the history of a man in his 40s who presented with myopericarditis a few days after vaccination against SARS-CoV-2 with mRNA(Messenger RNA) Moderna® vaccine and who at the same time developed shoulder capsulitis. His cardiovascular symptoms resolved rapidly, and his shoulder symptoms improved/resolved within 1 year. This case should make physicians aware of the possibility of several concomitant side effects following vaccination against SARS-CoV-2.

Partial infraspinatus tear with bursitis following an mRNA vaccination: a case report.

We report a case of a shoulder injury related to vaccine administration (SIRVA) that developed symptoms 2 weeks following a coronavirus disease 2019 (COVID-19) vaccination and improved after receiving both intraarticular and subacromial corticosteroid injections. Presentation of case: A 52-year-old Thai female without preexisting shoulder pathology and symptom had developed left shoulder pain for 3 days. Two weeks prior to shoulder pain, she received an mRNA COVID-19 vaccination. She positioned her arm in combined internal rotation with 60° of arm abduction. Her symptoms were pain in all directions of shoulder motion and tenderness at the bicipital groove and over the deltoid area. The testing of the rotator cuff power of the infraspinatus tendon showed pain. Intervention and outcome: An MRI showed infraspinatus tendinosis with a low-grade (almost 50%) bursal-surface tear at the footprint of the superior fiber with associated overlying subacromial-subdeltoid bursitis. She was treated with both intraarticular and subacromial corticosteroid injections (triamcinolone acetate (40 mg/ml) 1 ml+1% lidocaine with adrenaline 9 ml). She did not respond to oral naproxen but responded well to intraarticular and subacromial corticosteroid injections. Relevance and impact: The best way to deal with SIRVA is to prevent this condition by using the correct injection technique. First, the injection site should be two or three fingerbreadths below the mid-acromion process. Second, the needle's direction should be perpendicular to the skin. Third, using the correct needle penetration depth.

Bilateral Divergent Fracture Dislocations in a COVID-19 Patient Following a Hyponatremia-Induced Seizure

Bilateral divergent fracture dislocations of the shoulder are very rare. Caution with regards to seizure development in COVID-19 patients must be taken to avoid such injuries. This is the case of a male COVID-19 patient who sustained hyponatremia-induced seizure that resulted in bilateral divergent shoulder fracture dislocations. The patient suffered a lesser tuberosity fracture on his left shoulder which was posteriorly dislocated, and a greater tuberosity fracture on his right, which was anteriorly dislocated. The patient underwent bilateral open reduction and internal fixation, with suture anchor fixation for the lesser tuberosity fracture on the left side, and a proximal humerus locking plate for the greater tuberosity fracture on the right side. Education on postoperative complications and expectations were provided to the patient.

A Review of Intra-Articular Corticosteroid Injection Safety and Clinical Effectiveness during Covid-19

Background/Aims Intraarticular corticosteroid injections (CSI) are used as a short-term treatment for inflammatory arthritis and osteoarthritis. At the outset of the COVID-19 pandemic there was concern regarding the immunosuppressive effect of steroids and the potential risk of COVID-19 infection in patients treated with CSI. There is no universal evidencebased consensus on the optimum dosing of CSI. Nationally there was a mixed response to CSI use during the COVID- 19 pandemic. Early during the pandemic, our Trust advised using only the lowest BNF indicated steroid dose to minimize any potential side effects. Large joints (knees and shoulders) were injected with 40mg of Kenalog compared to 80mg pre pandemic. No previous survey has reported the incidence of covid infection post CSI. The primary aim of this project was to address this gap. A secondary aim was to review the clinical effectiveness of a 'larger' versus 'smaller' steroid dose in CSI. Methods Retrospective data collection was carried out for 107 patients who received CSI during the pandemic. All patients who received CSI within the Trust rheumatology department were followed up with a sixweek phone call. During this consultation the effectiveness of the CSI was considered by asking them to score the effectiveness of the CSI out of 10 (10 being maximum improvement). The incidence of COVID- 19 infection was also recorded. This data was compared to the same data from a group of patients injected with a larger dose of CSI pre-pandemic (n=114). Results The patient reported incidence of COVID-19 infection within 6 weeks of CSI was 1.87%. Patient reported outcomes showed a mean improvement in joint symptoms of 6.97 using 80mg of kenalog, versus 5.02 improvement using the smaller 40mg dose at six week follow up. Interestingly 56% of people injected with a larger dose reported a minimum 8/10 improvement compared to 22% of patients injected with a smaller dose. Conclusion The low incidence of COVID-19 infections following CSI indicates that there is no significant correlation with increased in risk of contracting COVID-19. This study did not collect any data on outcomes of infection but at the time of the phone calls no patients had been hospitalized or died. The incidence of COVID-19 infection was below the national average. Some of the Rheumatology patients injected may have been advised to shield which may have contributed to the lower-than-expected figure. The significantly increased benefit consistently reported by patients supports the use of a higher dose steroid (Kenalog 80mg) versus lower dose (40mg) when injecting large joints in patients with arthritis. It is important to weight up the risks and benefits of CSI but this suggests that we should use the higher dose in clinical practice.

Remember to Screen the Spleen: A Case Study of Spontaneous Splenic Rupture

Introduction: Splenic rupture is a potentially life-threatening condition often associated with trauma or viral infection. Most cases of splenic rupture are due to trauma, viral infection, lymphoproliferative disease, malaria, tick borne illness, splenic neoplasms, connective tissue disease, or in one case, sneezing. Spontaneous splenic rupture (SSR) is a rare condition with less than five cases reported. In this case, we present a 20-year-old male who was seen with abdominal pain who was found to have an SSR with no clear etiology. Case Description/Methods: A 20-year-old male with no relevant past medical history presented with abdominal pain that radiated to the left shoulder. The patient reported the pain began after an episode of emesis which occurred 12 hours prior to arrival. He reported experiencing shortness of breath and pain on inspiration. He denied any fall or trauma, recent travel or sick contacts, fevers, weight loss, or night sweats. His social history was significant for occasional marijuana use. Upon physical exam, the patient had diffuse abdominal tenderness most pronounced in the left upper quadrant without any palpable masses. Relevant labs included a hemoglobin of 12.2, WBC count within normal limits and unremarkable manual differential, and an INR of 1. Blood parasite, heterophile antibodies, COVID, influenza, CMV, and HIV were negative. Computed tomography angiography (CTA) revealed hematoma at the splenic hilum. Interventional radiology was consulted and did not recommend intervention at time of initial presentation. Patient was admitted;his hemoglobin remained stable and he was monitored with serial abdominal exam then discharged the following day. Imaging was repeated one month later which revealed near complete resolution of hematoma. (Figure) Discussion: SSR should be considered on the differential diagnosis of physicians when encountering patients who present with LUQ pain with unclear etiology. The patient presented with the characteristic Kehr's sign (left diaphragmatic irritation resulting in referred pain to the left shoulder) but not the Ballance sign (palpable tender mass in the left upper quadrant). The incidence of SSR is estimated to be around 1 to 7% with a mortality rate of 12.2% so a broad differential for young patients presenting with abdominal pain must be entertained and should include splenic rupture as it is a potentially life-threatening condition.

Bupivacaine-Induced Hepatotoxicity in a Healthy Patient Without Chronic Liver Disease After Shoulder Arthroscopy

Introduction: Bupivacaine is a local anesthetic which has been increasingly used in the post-operative state for pain control. Hepatotoxicity is a rare complication, and few cases are reported in patients with chronic liver disease. We present a case of acute liver injury from bupivacaine use in a healthy patient without prior history of liver disease. Case Description/Methods: A 68-year-old female with a past medical history of primary hypertension and recent nontraumatic complete tear of the right rotator cuff, presents to the hospital with fatigue, loss of appetite, and nausea. She recently underwent an arthroscopy of the right shoulder with repair of the rotator cuff two weeks prior. Her surgery was uncomplicated, and patient was started on bupivacaine ONQ pump infusion at 5 ml/hr for three days for post-operative pain. Further history reveals patient is non-alcoholic without prior liver disease, including cirrhosis. Review of systems is concerning for associated generalized abdominal discomfort. Physical exam demonstrated jaundice with scleral icterus with mild periumbilical tenderness to palpation without hepatosplenomegaly or ascites. Labs demonstrated elevated total bilirubin of 10.2 mg/dL with Alkaline phosphatase, ALT, and AST being 924 U/L, 429 U/L, and 279 U/L, respectively. Imaging studies including CT abdomen and pelvis with contrast, abdominal ultrasound, MRCP, and portal vein doppler were negative. Additional work up for underlying liver disease including acetaminophen and ethanol levels, SARS-CoV2, Hepatitis panel, EBV antigen, and urine toxicology were negative. It was determined patient had bupivacaine induced hepatotoxicity. Patient's health improved with conservative management and she was discharged with instructions for close monitoring of her LFTs. Discussion(s): Bupivacaine is an amino-amide anesthetic which binds to the intracellular portion of voltage-gated sodium channels and prevents depolarization of pain signals. It is metabolized by the liver and thus reports of hepatotoxicity, although rare, occur in patients with underlying liver pathology. Our patient became symptomatic with acute rise in LFTs. An extensive workup for other etiologies of acute liver toxicity was negative. Rapid vascular uptake of the drug is the most common reason for bupivacaine toxicity;and this remains a possibility for the mechanism of toxicity in our patient. A prior case report of bupivacaine hepatotoxicity demonstrated a cholestatic pattern, which is consistent with our findings.

Shoulder Weakness Following Intramuscular COVID- 19 Vaccine

History: Transient and generalized adverse effects are common following COVID-19 vaccination;among other adverse effects, shoulder injuries related to vaccine administration (SIRVA) have been known to occur. In this case, a previously healthy right-hand dominant 62-year-old male presented with left shoulder pain and weakness 3 months after receiving a COVID-19 intramuscular vaccine in the left deltoid. Approximately 2 weeks after the injection, he started experiencing pain and numbness around the injection site along with ipsilateral shoulder weakness. Despite conservative management with Motrin, Medrol Dosepak, gabapentin and physical therapy (PT), the pain and weakness persisted. Physical Exam: Left Shoulder-No calor or erythema;significant atrophy of the anterior and middle deltoid muscle relative to right side;abduction 4/5;external rotation with shoulder adducted 4/5;range of motion for active forward flexion was 150 degrees and passive was 170 degrees;passive range of motion for external rotation was 70 degrees;internal rotation to the level of L5;sensation to light touch was intact. Right Shoulder-Range of motion, strength, and sensation were intact. Cervical Spine-Full ROM;no cervical paraspinal tenderness noted. Negative Spurling's and Lhermitte's tests. Differential Diagnosis: 161. Axillary Nerve Palsy 2/2 Chemical Neurotoxicity 162. Brachial Neuritis 163. Mechanical Axillary Nerve Palsy 2/2 Vaccination 164. Partial-Tear of Left Supraspinatus Tendon 165. Acromioclavicular Osteoarthritis Test Results: Left Shoulder-XR:Mild pseudo-subluxation;MRI w/o contrast: 8x9mmpartial-thickness articular surface tear of the distal supraspinatus tendon (<50%fiber thickness). Minimal subacromial bursitis. Mild acromioclavicular joint osteoarthritis. EMG/NCV: Left and Right Axillary Motor Nerves: prolonged distal onset latency;Left Deltoid: increased insertion activity, moderately increased spontaneous activity, reduced recruitment;Remaining LUE muscles without evidence of electrical instability Final Diagnosis: Axillary Nerve Palsy Secondary To Chemical Neurotoxicity from Intramuscular COVID-19 Vaccine. Discussion(s): We postulate that the neurologic deficits presented in our case may be attributed to chemical neurotoxicity to the axillary nerve following vaccination as the delayed onset of pain and weakness are most consistent with this differential. There are several cases of brachial neuritis following vaccination for the prevention of COVID- 19, however, EMG/NCV results in our patient were not consistent with brachial plexopathy. Additionally, while there have been a handful of reported cases of bursitis following COVID-19 vaccines falling under the SIRVA classification of injuries, this is the first case of reported axillary nerve neurapraxia. Outcome(s): The patient's left shoulder numbness and pain improved with PT and medical management. While mild improvement in strength was noted, weakness and atrophy persisted even on the third follow up visit 6 months after the initial appointment. He was counseled on his injury and was recommended to undergo repeat EMG testing to document recovery after his 6-month follow-up appointment. Follow-Up: The patient did not follow-up for a repeatEMG after his 6-month follow-up appointment. At that time, the patient was clinically stable, tolerating PT, and expecting recovery of his deltoid function.

Covid-19 Vaccine-Induced Myositis

Background/Aims Through the COVID pandemic there have emerged reports of autoimmunity or new rheumatic diseases presenting in patients after they had COVID-19. This is thought to be caused by cross-reactivity of the COVID-19 spike protein to human antigens. Given the use of mRNA COVID-19 vaccinations which express the spike protein we might expect to see presentation of new rheumatic diseases following their use. We discuss a case where this appears to have occurred. Methods Our patient is a 24-year-old male with mixed phenotype acute leukaemia who had been treated with allogenic stem cell transplant and was currently in remission. He presented with fevers, palpitations, myalgia and bilateral arm and leg swelling. Symptoms began the day after receiving the first dose of an mRNA COVID-19 vaccination (Pfizer/BioNTech.) There were no other symptoms or recent change in medications. Physical examination revealed tender oedema in his forearms, biceps and thighs bilaterally with sparring of the hands. He had reduced power with shoulder (MRC 3/5), elbow (4), wrist (4+) and hip (4) movements. Observations revealed tachycardia and fevers up to 40C. Results Laboratory studies showed markedly elevated C-reactive protein (202), creatinine kinase (6697) and troponin (593) whilst investigations for infection were negative. An autoimmune panel was positive for anti- PM-SCL-75-Ab. An electrocardiogram showed sinus tachycardia. Echocardiogram was normal. Bilateral upper limb dopplers revealed no deep vein thrombus. An MRI of his thighs showed diffuse symmetrical oedema within the muscles, in keeping with an inflammatory myositis. A quadricep muscle biopsy showed evidence of MHC class 1 up-regulation, suggesting an inflammatory process. In addition, there were numerous macrophages evident in the endomysium. While this can be seen in graft-versus-host disease (GVHD), they would usually be found in the perimysium. After discussion between haematology, rheumatology and neurology, this was felt to be a case of vaccine induced myositis and myocarditis. Autoimmune myositis was thought to be less likely due to the relative sparing of the hands and the absence of Raynaud's phenomenon. 1 gram of intravenous methylprednisolone was then given for 3 days. The patient had a marked response with defervescence, improving laboratory markers, improved myalgia and decreased limb swelling. The patient was stepped down to a reducing regime of prednisolone and discharged. Due to relapse whilst weaning he has started on mycophenalate mofetil and rituximab and now continues to improve. Conclusion There are case reports of myositis following COVID-19 vaccination but our patient's case is complicated by the differential diagnosis of GVHD and concurrent myocarditis. Ongoing work is needed to clarify the exact link between vaccination and the presentation of a new inflammatory myositis, but it is important to recognise and start treatment early in order to preserve muscle bulk and ensure recovery.

Comparison of Survivorship and Failure Modes Between Anatomic and Reverse Total Shoulder Arthroplasty Across Multiple Government Joint Registries for a Single Platform Shoulder System

[...]recent years have seen a dramatic shift in utilization of rTSA in which rTSA is increasingly used to treat OA in patients with an intact rotator cuff, with a corresponding decline in use of aTSA.1-5 The reasons for this shift in usage are multi-factorial but may be due to the perceived lower risk of revision surgery with rTSA relative to aTSA, as the quality of the rotator cuff muscles and tendon are not necessary for a functional rTSA but are pre-requisite for a functional aTSA. Furthermore, these registries have high rates of government-mandated compliance such that all patients are enrolled and very few patients are lost to follow-up, thus minimizing the potential for selection bias that is inherently present in nearly all nongovernment registry clinical outcome studies. [...]to better understand the relative differences in primary aTSA and primary rTSA usage and performance, we analyzed two different government joint registries for survivorship and for reasons for revision associated with one platform shoulder system and compared trends in usage of aTSA and rTSA over a period of over 10 years to elucidate reasons for any market trends. Additionally, reasons for revision and the cumulative revision rate were assessed across the government joint registries to quantify and compare the performance of this platform shoulder prosthesis for primary aTSA and primary rTSA in each country over the study period. Over the period of analysis, use of primary aTSA and primary rTSA with the particular platform system has increased year to year in both Australia and the UK, with the exception of a decline in 2020 and 2021 due to COVID-19.

Establishment of prediction equations for subcutaneous tissue thickness in two representative intramuscular deltoid injections.

This study clarifies the predicted subcutaneous shoulder depth and investigates the safety of the conventional (three-finger breadth method) and new (axillary method) intramuscular injection methods. The anatomical features of 245 volunteers who received the COVID-19 vaccination via the conventional method were investigated at the injection site (T point) and the hypothetical injection site using the new method (A point) via ultrasonography. The body mass index (BMI) and subcutaneous thickness at the T point (men: r = 0.75; women: r = 0.45) and the A point (men: r = 0.81; women: r = 0.55) were positively correlated. The upper arm circumference and subcutaneous thickness at the T point (r = 0.51) and the A point (r = 0.58) were correlated in women. Formulas to predict subcutaneous thickness using BMI and upper arm circumference were established: predicted subcutaneous thickness at the A point = 0.62 × BMI - 7.7 mm (R2 = 0.66) in men and 0.658 × BMI - 5.5 mm (R2 = 0.31) in women. This study demonstrates safe intramuscular injection sites and their depth.