Hand conditions as sequelae of infection with COVID-19: a literature review.

Patients have attended our clinics with various hand pathologies after contracting COVID-19 or receiving vaccination. We postulate the virus stimulates a systemic inflammatory response that triggers these pathologies and conducted a search of the literature for associated conditions. Twenty publications were included for this review. Three studies identified skeletal muscle inflammation, and several identified reactive arthritis post-infection. Rheumatoid arthritis post-infection was also recognized, along with crystalline arthropathy. Carpal tunnel syndrome was seen in two cases. There is a current paucity in published scientific material regarding COVID-19 sequalae in the hand. This review aims to stimulate discussion in how a virus can induce pathological processes causing common hand pathologies.

The coronavirus disease clavicle study: a predictor of future trauma trends.

Background: Clavicle fractures are a common presentation to the emergency department after falls and sporting injuries. During 2020, the coronavirus disease 2019 (COVID-19) pandemic brought with it a long period of social isolation, resulting in a change of behavior patterns and, in return, the presentation of fractures to our local hospitals. The effects of this global pandemic on the presentation and management of clavicles were noted with particular interest to the change in mechanism and its future implications. Methods: We performed a longitudinal observational study in 10 hospitals in the North West of England, reviewing all patients presenting with a clavicle fracture during 6 weeks in the first peak of COVID-19 pandemic and compared these with the same period in 2019. Collection points included the patient demographics, fracture characteristics, mechanism of injury, and management. Results: A total of 427 clavicle fractures were assessed with lower numbers of patients presenting with a clavicle fracture during the COVID-2020 period (n = 177) compared with 2019 (n = 250). Cycling-related clavicle fractures increased 3-fold during the pandemic compared with the 2019 control group. We also noted an overall increase in clavicle fractures resulting from higher energy trauma as opposed to low energy or fragility fracture. We also found a faster time to surgery in the COVID cohort by 2.7 days on average when compared with 2019. Conclusions: Government restrictions and the encouragement of social distancing led to behavioral changes with a vast increase in cyclists on the road. This created a significant rise in clavicle fractures related to this activity. This is likely to be further driven by the government pledge to double cyclists on the road by 2025 in the United Kingdom. We forecast that this increase in cyclists, a behavior change accelerated by the pandemic, is a reliable predictor for future trauma trends.

Inflammatory Arthropathy in the Elite Sports Athlete.

ABSTRACT: Elite athletes commonly present with joint pains that are attributed to overuse injuries though on occasion it can be due to an inflammatory arthropathy. The diagnostic challenge is that presenting symptoms of benign injuries are similar to inflammatory arthropathies. A holistic review of the athlete can provide clues suggestive of inflammatory arthropathy, before requesting further investigations to confirm the diagnosis. Current imaging modalities are not specific in differentiating inflammatory arthritis with other causes of joint inflammation. Prompt treatment is required to restore the athlete to an optimum level of activity and prevent career ending disability, all in adherence to the regulations of the sporting governing bodies. This review aims to highlight the importance of inflammatory arthropathy in the differentials for an athlete presenting with joint pains.

COVID-19 infection is related to differences in the use of personal protective equipment by orthopaedic specialist trainees caring for hip fracture patients during the second surge of COVID-19 in the North West of England.

INTRODUCTION: Personal protective equipment (PPE) may protect health-care workers from COVID-19 infection and limit nosocomial spread to vulnerable hip fracture patients. METHODS: We performed a cross-sectional survey amongst orthopaedic trainees to explore PPE practice in 19 hospitals caring for hip fracture patients in the North West of England. RESULTS: During the second wave of the pandemic, 14/19 (74%) hospitals experienced an outbreak of COVID-19 amongst staff or patients on the orthopaedic wards. An FFP3 respirator mask was used by doctors in only 6/19 (32%) hospitals when seeing patients with COVID-19 and a cough and in 5/19 (26%) hospitals when seeing asymptomatic patients with COVID-19. A COVID-19 outbreak was reported in 11/13 (85%) orthopaedic units where staff wore fluid resistant surgical masks compared to 3/6 (50%) units using an FFP3 respirator mask (RR 1.69, 95% CI 0.74-3.89) when caring for symptomatic patients with COVID-19. Similarly, a COVID-19 outbreak was reported in more orthopaedic units caring for asymptomatic patients with COVID-19 where staff wore fluid resistant surgical masks (12/14 (86%)) as compared to an FFP3 respirator mask (2/5 (40%)) (RR 2.14, 95% CI 0.72-6.4). CONCLUSION: Urgent re-evaluation of PPE use is required to reduce nosocomial spread of COVID-19, amongst highly vulnerable patients with hip fracture.

Higher degrees in nursing: traditional research PhD or professional doctorate?

Doctoral-level study is increasingly popular for clinicians who wish to advance their clinical, research and academic career pathways. A range of alternatives to the traditional PhD are now well-established. This article aims to outline the different approaches and discuss some advantages and drawbacks of doctoral-level postgraduate study. By comparing the various doctoral programmes, the authors seek to clarify the issues for clinicians who may wish to embark on a future doctorate. Primary clinical or medical degrees are not discussed.

The progression of hallux valgus in the oriental Chinese population in Hong Kong.

BACKGROUND: Hallux valgus is the lateral deviation of the great toe at the MTPJ that has many attributing aetiologies. This study will aim to identify whether hallux valgus progresses over time in the oriental Chinese population in Hong Kong. METHODS: Patients with acquired symptomatic hallux valgus who presented to clinic between 2008 and 2013 were included. The deformities were analysed radiologically at presentation and pre-operative and angles were measured. These angles were analysed in relation to the waiting time from presentation to surgery. RESULTS: A sample of 43 cases from 38 patients (Mean age 63 years, range 48-80 years) were included. Forty-one cases had a hallux valgus angle (HVA) >24° at presentation (Mean 40.4°) and all had an intermetatarsal angle (IMA) >9°. A significant difference is seen with HVA (p=0.040, t=-2.128) at presentation and pre-op but not IMA (p=0.281, t=-1.095). The average wait for surgery was 705.7days which had shown significant correlation with progression in HVA (p=0.031). No significant difference was seen between IMA and waiting time to surgery (p=0.195). DISCUSSION: The findings suggests severe hallux valgus deformity does progress over time in Hong Kong. Shorter waiting times for surgery could be beneficial to this population. Level III, retrospective comparative series.

Clinic and ambulatory heart rates in patients with ischaemic heart disease and/or chronic heart failure taking rate-limiting medications: are they interchangeable?

BACKGROUND: The prognostic benefit from heart rate (HR) reduction in patients with ischaemic heart disease (IHD) and/or chronic heart failure (CHF) is now firmly established. Most decisions regarding initiation and/or dose adjustment of HR-limiting medications in such patients are based on clinic HR. Yet, this is a highly variable parameter that may not necessarily reflect HR control over the 24 h period. OBJECTIVE: To examine the level of agreement between mean clinic and mean ambulatory HRs in patients with IHD and/or CHF taking rate-limiting medications. METHODS: Prospective, observational study. Fifty patients with IHD and/or CHF who attended cardiology outpatient clinics at the Manchester Heart Centre and underwent same-day 24 h continuous ECG recording between March and October 2013 were included in the study. Mean clinic HR was compared with mean 24 h, daytime and night-time HRs. Limits-of-agreement plots were constructed to examine the relationship between the two HR measures in more detail. RESULTS: The mean clinic HR was numerically similar to the mean HRs of all ambulatory time periods examined. However, on Bland-Altman plots, the limits of agreement between clinic and ambulatory HR means were quite wide, with the mean clinic HR ranging between 10.93 and 13.58 bpm below and 8.4 and 18.15 bpm above the mean ambulatory HR. CONCLUSIONS: Although numerically similar, the means of clinic and ambulatory HRs in patients with IHD and/or CHF display wide limits of agreement. As such, the two measures cannot be regarded as interchangeable.

Prognostic significance of CEBPA mutations in a large cohort of younger adult patients with acute myeloid leukemia: impact of double CEBPA mutations and the interaction with FLT3 and NPM1 mutations.

PURPOSE: To determine the clinical relevance of mutations in the CCAAT/enhancer binding protein alpha (CEBPA) gene in acute myeloid leukemia (AML) and to examine factors that might modify prognostic impact. PATIENTS AND METHODS: The entire CEBPA coding sequence was screened in 1,427 young adult patients with AML, excluding acute promyelocytic leukemia, using denaturing high-performance liquid chromatography and direct sequencing. RESULTS: Of 107 patients (7%) with CEBPA mutations, 48 patients (45%) had one mutation (CEBPA-single), and 59 patients (55%) had two mutations (CEBPA-double). The incidence of CEBPA-double patients was similar in intermediate cytogenetic risk patients with and without a normal karyotype (6% and 5%, respectively). CEBPA-double patients had evidence of a lower coincidence with FLT3/ITDs (P = .04) and were highly unlikely to have an NPM1 mutation (P < .0001). CEBPA-double but not CEBPA-single patients had a significantly better overall survival (OS) at 8 years (34%, 31%, and 54% for CEBPA-wild-type [WT], CEBPA-single, and CEBPA-double, respectively, P = .004). This benefit was lost in the presence of a FLT3/ITD (OS for CEBPA-WT, CEBPA-single, and CEBPA-double FLT3/ITD-negative patients: 36%, 35%, 59%, respectively, P = .002; OS for CEBPA-WT, CEBPA-single, and CEBPA-double FLT3/ITD-positive patients: 26%, 21%, 14%, respectively, P = .05). There was no evidence of any additional favorable benefit for a CEBPA-single mutation in the presence of an NPM1 mutation (OS, 45%, 44%, and 56%, P = .2, for NPM1-positive/CEBPA-WT, NPM1-positive/CEBPA-single, and NPM1-negative/CEBPA-double patients, respectively). CONCLUSION: Screening for CEBPA mutations can be restricted to patients with intermediate-risk cytogenetics lacking an FLT3/ITD or NPM1 mutation. Only the presence of a CEBPA-double mutation should be used for therapy risk stratification.

The impact on outcome of the addition of all-trans retinoic acid to intensive chemotherapy in younger patients with nonacute promyelocytic acute myeloid leukemia: overall results and results in genotypic subgroups defined by mutations in NPM1, FLT3, and CEBPA.

We investigated the benefit of adding all-trans retinoic acid (ATRA) to chemotherapy for younger patients with nonacute promyelocytic acute myeloid leukemia and high-risk myelodysplastic syndrome, and considered interactions between treatment and molecular markers. Overall, 1075 patients less than 60 years of age were randomized to receive or not receive ATRA in addition to daunorubicin/Ara-C/thioguanine chemotherapy with Ara-C at standard or double standard dose. There were data on FLT3 internal tandem duplications and NPM1 mutations (n = 592), CEBPA mutations (n = 423), and MN1 expression (n = 195). The complete remission rate was 68% with complete remission with incomplete count recovery in an additional 16%; 8-year overall survival was 32%. There was no significant treatment effect for any outcome, with no significant interactions between treatment and demographics, or cytarabine randomization. Importantly, there were no interactions by FLT3/internal tandem duplications, NPM1, or CEBPA mutation. There was a suggestion that ATRA reduced relapse in patients with lower MN1 levels, but no significant effect on overall survival. Results were consistent when restricted to patients with normal karyotype. ATRA has no overall effect on treatment outcomes in this group of patients. The study did not identify any subgroup of patients likely to derive a significant survival benefit from the addition of ATRA to chemotherapy.

Prognostic implications of NOTCH1 and FBXW7 mutations in adults with T-cell acute lymphoblastic leukemia treated on the MRC UKALLXII/ECOG E2993 protocol.

PURPOSE: Notch pathway activation by mutations in either NOTCH1 and/or FBXW7 is one of the most common molecular events in T-cell acute lymphoblastic leukemia (T-ALL) and, in pediatric disease, predicts for favorable outcome. Their prognostic significance in adult T-ALL is unclear. We sought to evaluate the outcome according to mutation status of patients with adult T-ALL treated on the United Kingdom Acute Lymphoblastic Leukaemia XII (UKALLXII)/Eastern Cooperative Oncology Group (ECOG) E2993 protocol. METHODS: NOTCH1 and FBXW7 were screened by a combination of denaturing high-performance liquid chromatography and sequencing in 88 adult patients with T-ALL treated on the UKALLXII/ECOG E2993 protocol and compared with clinical characteristics and outcome. RESULTS: NOTCH1 and FBXW7 mutations were common (60% and 18%, respectively) and were not associated with age or WBC count. NOTCH1 heterodimerization domain mutations were associated with FBXW7 mutations (P = .02), and NOTCH1 proline, glutamic acid, serine, threonine (PEST) rich domain and FBXW7 mutations were mutually exclusive. There were an equal number of high- and standard-risk patients in the NOTCH1 and FBXW7 mutated (MUT) groups. Patients wild type (WT) for both markers trended toward poorer event-free survival (EFS; MUT v WT, 51% v 27%, P = .10; hazard ratio, 0.6). Analysis by each marker individually was not significantly predictive of outcome (NOTCH1 MUT v WT, EFS 49% v 34%, P = .20; FBXW7 MUT v WT, EFS 53% v 41%, P.72). CONCLUSION: NOTCH1 and FBXW7 mutant-positive patients do not fare sufficiently well to warrant an individualized treatment approach in future studies.