Delayed Diagnosis of a Ligamentous Lisfranc Injury on a Bomber Task Force Member.

The tarsometatarsal joint, or Lisfranc joint, is an extremely important anatomical structure and injury to it has been shown to cause long-term disabling ramifications. With a wide spectrum of injury involvement, from fracture dislocations to sprains, it is important to establish a diagnosis early to guide management. Although the more extreme higher energy fracture dislocations are more widely studied, there remains a paucity of literature on lower energy purely ligamentous injuries, especially among military service members.1 The deployed setting provides an extra layer of complexity in determining a musculoskeletal injury etiology for the provider, especially in resource-limited areas. When a high level of suspicion for Lisfranc injury exists based upon clinical presentation and in the setting of negative X-rays, more prudence should be placed on additional workup. This will guide decision-making for possible expedited stateside return for the patient and better odds of follow-up care. The following case demonstrates a unique scenario of an undiagnosed, purely ligamentous Lisfranc tear in a 23-year-old woman in a deployed environment with late presentation to an orthopedic surgeon stateside. Furthermore, emphasis is placed on factors that led to her delayed diagnosis and how advocating for advanced imaging modalities up-front can expedite care.

New paradigms for BRCA1/BRCA2 testing in women with ovarian cancer: results of the Genetic Testing in Epithelial Ovarian Cancer (GTEOC) study.

BACKGROUND: Over recent years genetic testing for germline mutations in BRCA1/BRCA2 has become more readily available because of technological advances and reducing costs. OBJECTIVE: To explore the feasibility and acceptability of offering genetic testing to all women recently diagnosed with epithelial ovarian cancer (EOC). METHODS: Between 1 July 2013 and 30 June 2015 women newly diagnosed with EOC were recruited through six sites in East Anglia, UK into the Genetic Testing in Epithelial Ovarian Cancer (GTEOC) study. Eligibility was irrespective of patient age and family history of cancer. The psychosocial arm of the study used self-report, psychometrically validated questionnaires (Depression Anxiety and Stress Scale (DASS-21); Impact of Event Scale (IES)) and cost analysis was performed. RESULTS: 232 women were recruited and 18 mutations were detected (12 in BRCA1, 6 in BRCA2), giving a mutation yield of 8%, which increased to 12% in unselected women aged <70 years (17/146) but was only 1% in unselected women aged ≥70 years (1/86). IES and DASS-21 scores in response to genetic testing were significantly lower than equivalent scores in response to cancer diagnosis (p<0.001). Correlation tests indicated that although older age is a protective factor against any traumatic impacts of genetic testing, no significant correlation exists between age and distress outcomes. CONCLUSIONS: The mutation yield in unselected women diagnosed with EOC from a heterogeneous population with no founder mutations was 8% in all ages and 12% in women under 70. Unselected genetic testing in women with EOC was acceptable to patients and is potentially less resource-intensive than current standard practice.

"Payment by Results"--financial incentives and motivational interviewing, adherence interventions in young adults with perinatally acquired HIV-1 infection: a pilot program.

Emerging evidence suggests financial incentives (FIs) improve medication adherence in select populations. A small proportion of adolescents with perinatal HIV (PaHIV) transfer to adult services with established poor adherence and advanced disease. We describe a single center adherence intervention combining FIs with motivational interviewing (MI). Eligible patients (PaHIV,16-25 years, CD4 count ≤ 200, off ART despite multiple attempts) received MI, and FI dependent on viral load (VL) reduction for 1 year. Outcome measures compared CD4 gain from baseline at 1 year and 12 months post cessation of FI/MI. Eleven young people enrolled; median age 19 years, 8 female. Baseline median CD4 count 30 cells/µL (IQR 10-160), VL 12,870 c/mL. Outcomes at 12 months: 9/11 ever achieved VL < 50, 5 sustained undetectable VL, median CD4 140, mean CD4 gain 90 cells/µL at 1 year. Twelve months post cessation of MI/FI; six VL < 50, median CD4 75, mean CD4 gain 122 cells/µL. Total FI expenditure £1,350: £68 per 50 CD4 cells at 1 year, £55 at 24 months. To prevent death, adolescents with PaHIV require novel interventions to reverse poor patterns of adherence established since childhood. FI/MI improved virological and immunological outcomes with minimal expenditure. Extension of this pilot work for vulnerable individuals is now indicated.

Effect on survey response rate of hand written versus printed signature on a covering letter: randomised controlled trial [ISRCTN67566265].

BACKGROUND: It is important that response rates to postal surveys are as high as possible to ensure that the results are representative and to maximise statistical power. Previous research has suggested that any personalisation of approach helps to improve the response rate. This experiment tested whether personalising questionnaires by hand signing the covering letter improved the response rate compared with a non-personalised group where the investigator's signature on the covering letter was scanned into the document and printed. METHODS: Randomised controlled trial. Questionnaires about surgical techniques of caesarean section were mailed to 3,799 Members and Fellows of the Royal College of Obstetricians and Gynaecologists resident in the UK. Individuals were randomly allocated to receive a covering letter with either a computer printed signature or a hand written signature. Two reminders were sent to non-respondents. The outcome measures were the proportion of questionnaires returned and their time to return. RESULTS: The response rate was 79.1% (1506/1905) in the hand-signed group and 78.4% (1484/1894) in the scanned and printed signature group. There was no detectable difference between the groups in response rate or time taken to respond. CONCLUSION: No advantage was detected to hand signing the covering letter accompanying a postal questionnaire to health professionals.

Thromboprophylaxis and pregnancy: two randomized controlled pilot trials that used low-molecular-weight heparin.

OBJECTIVE: The purpose of this study was to conduct pilot studies for large randomized controlled trials to compare low-molecular-weight heparin with placebo for antenatal thromboprophylaxis (trial 1), and for thromboprophylaxis after cesarean delivery (trial 2). STUDY DESIGN: Multicenter randomized controlled trials (trial 1, 23 units; trial 2, 8 units) were conducted. Pregnant women at increased risk for thromboembolic disease were eligible for trial 1; women who underwent cesarean delivery were eligible for trial 2. The interventions were once daily injections of low-molecular-weight heparin or placebo. Primary outcomes were as follows: trial 1, confirmed symptomatic thromboembolic events and symptomatic osteoporotic fractures; trial 2, confirmed symptomatic thromboembolic events and wound complications. RESULTS: Sixteen women were recruited for trial 1; 1 woman in the placebo group had a symptomatic thromboembolic event. One hundred forty-one women were recruited for trial 2; 1 woman in the low molecular weight heparin group had a symptomatic thromboembolic event. CONCLUSION: Poor recruitment indicates that large-scale trials using these designs would be difficult. Collection of data on the number of women that are eligible and the reasons for nonrecruitment in future trials of these interventions would allow a better understanding of the reasons for poor recruitment.

Surgical techniques used during caesarean section operations: results of a national survey of practice in the UK.

OBJECTIVE: To determine what surgical techniques are used by obstetricians in the UK for elective and emergency caesarean section operations. STUDY DESIGN: A postal questionnaire to all members and fellows of the Royal College of Obstetricians and Gynaecologists (RCOG) resident in the UK, requesting information about the use of surgical techniques and antibiotic and anticoagulant prophylaxis for elective and emergency caesarean sections. RESULTS: The response rate was 78.7%. A range of techniques was used for all procedures in caesarean section operations. Only a few techniques were used by more than 80% of obstetricians, including double layer closure of the uterus, use of prophylactic antibiotics and Pfannenstiel abdominal entry (for elective caesarean sections). There were few large differences in practice between elective and emergency caesarean sections. In emergency operations, more obstetricians use the Joel-Cohen method of abdominal entry (32.7 versus 16%) and more usually use prophylactic antibiotics and heparin (93.2 versus 85.4% and 45.8 versus 32.9%, respectively). CONCLUSIONS: There was wide variation in the surgical techniques used by obstetricians for caesarean section operations. There is an urgent need for future research to evaluate many aspects of caesarean section operations on substantive short- and long-term outcomes.