Clinical variation in the treatment of trigger finger: An international survey of orthopaedic and plastic surgeons.

Trigger finger is a common condition affecting the hand. Therapeutic variability surrounds the management of trigger finger, especially in the mild cases. The aim of this study was to survey secondary care surgeons to describe the current management of trigger fingers. The steering group developed a survey for hand surgeons. Following piloting, the survey was distributed to hand surgeons in the United Kingdom and The Netherlands. A total of 713 plastic surgeons and orthopaedic surgeons were invited to participate in the online survey and 440 (62%) surgeons completed the survey. In both mild and moderate cases of trigger finger, steroid injection was the preferred treatment option. Open surgery was the treatment of choice for severe cases. However, there was variation in delivery of care, including type and dosage of steroid, site of injection, interval between injections, maximum number of injections, type of incision and treatment of patients with diabetes or rheumatoid arthritis. This highlights the need for a better evidence base for the treatment of trigger fingers.

Challenges and stresses experienced by athletes and coaches leading up to the Paralympic Games.

The demands of high-performance sport are exacerbated during the lead up to the Major Games (i.e., Paralympics). The purpose of this study was to better understand the challenges experienced and strategies utilized by Australian athletes (n = 7) and coaches (n = 5) preparing for the Tokyo Paralympic Games using semi-structured interviews. The thematic analysis highlighted challenges specific to participants' sport (e.g., budgetary constraints, decentralized experiences, athletes with various impairments), personal life (e.g., moving cities to access coaching, postponing vocational/educational developments, isolation from social circles), and associated uncertainties (e.g., COVID-19, qualifications, accreditations). Participants managed these challenges by utilizing strategies to 'anticipate and prepare' (e.g., detailed planning, effective communication, contingency plans) and 'manage expectations' (e.g., understanding specific roles and boundaries, focusing on the process [i.e., effort over results]). Trust and communication between athletes and coaches was key in coaches' better understanding of how athletes' impairments interact with their training and competition environments and tailor support to each athlete's unique needs. Last, participants reflected on the 'pressure' of the Games due to their performance having an impact on their career trajectory 'post-Tokyo' with some athletes contemplating retirement and others realizing the consequences of their performance on sport-related vocation and sponsorship. Coaches also accepted the success of their programs and job security will depend on outcomes at the Games. The findings from this study shed light on factors to consider to reduce challenges for teams preparing for major competitions but also highlight key practical implications to support athletes and coaches leading up, during, and post-major Games.

Tenosynovial giant cell tumours of the hand: A multicentre case-control study.

Many factors have been proposed to contribute to the risk of recurrent tenosynovial giant cell tumours (TSGCT); however, we remain unable to predict those at risk, which formed the rationale for this multicentre retrospective case-control study of 28 patients with recurrence. We included cases of recurrence in a 1:1 ratio matched for age and sex with controls over 10 years. Using Cox regression, we present hazard ratios (HRs) for recurrence with 95% confidence intervals (CIs). Out of 285 cases, 28 individuals developed recurrence after a median of 2.4 years. Recurrent TSGCT had a higher mitotic count/mm2 in the primary tumour (median increase of 3 [IQR 1, 7]). Mitotic count in the primary tumour was associated with the risk of recurrence (adjusted HR 1.1 [95% CI 1.1, 1.2]) meaning that for every additional mitosis, the risk of recurrence increased by 10% per annum. We recommend a prospective cohort study to validate our findings.

Controlling alcohol availability through local policy: an observational study to evaluate Cumulative Impact Zones in a London borough.

Background: Cumulative impact zones (CIZs) are a discretionary policy lever available to local government, used to restrict the availability of alcohol in areas deemed already saturated. Despite little evidence of their effect, over 200 such zones have been introduced. This study explores the impact of three CIZs on the licensing of venues in the London Borough of Southwark. Methods: Using 10 years of licensing data, we examined changes in the issuing of licences on the introduction of three CIZs within Southwark, relative to control areas. The number of licence applications made (N = 1110), the number issued, and the proportion objected to, were analysed using negative binomial regression. Results: In one area tested, CIZ implementation was associated with 119% more licence applications than control areas (incidence rate ratios (IRR) = 2.19, 95% confidence intervals (CI): 1.29-3.73, P = 0.004) and 133% more licences granted (IRR = 2.33, 95% CI: 1.31-4.16, P = 0.004). No significant effect was found for the other two areas. CIZs were found to have no discernible effect on the relative proportion of licence applications receiving objections. Conclusions: CIZs are proposed as a key lever to limit alcohol availability in areas of high outlet density. We found no evidence that CIZ establishment reduced the number of successful applications in Southwark.

Randomized feasibility trial of replacing or discarding the nail plate after nail-bed repair in children.

BACKGROUND: Nail-bed injuries are the most common hand injury in children. Surgical dogma is to replace the nail plate after repairing the nail bed. Recent evidence suggests this might increase infection rates and returns to clinic. The aim of this feasibility trial was to inform the design and conduct of a definitive trial comparing replacing or discarding the nail plate after nail-bed repair. METHODS: This study recruited participants from four hand units in the UK between April and July 2015. Participants were children under the age of 16 years with a nail-bed injury requiring surgery. They were randomized to either having the nail plate replaced or discarded after nail-bed repair. The follow-up method was also allocated randomly (postal versus clinic). Information was collected on complications at 2 weeks and 30 days, and on nail-plate appearance at 4 months using the Zook classification. Two possible approaches to follow-up were also piloted and compared. RESULTS: During the recruitment phase, there were 156 potentially eligible children. Sixty were randomized in just over 3 months using remote web-based allocation. By 2 weeks, there were two infections, both in children with replaced nail plates. The nail-replaced group also experienced more complications. There was no evidence of a difference in return rates between postal and clinic follow-up. CONCLUSION: Recruitment was rapid and nail-bed repair appeared to have low complication and infection rates in this pilot trial. The findings have led to revision of the definitive trial protocol, including the mode and timing of follow-up, and modification of the Zook classification.

Osteomyelitis of the hand.

UNLABELLED: Osteomyelitis of the hand is uncommon, but if not adequately and promptly treated the detrimental effects on hand function can be devastating. The majority of literature on osteomyelitis relates to the lower limb, but the principles of management are applicable to the hand, with good surgical debridement and culture-guided antimicrobial therapy. For osteomyelitis in general, antibiotic therapy of 4-6 weeks' duration (intravenous and/or oral) is typically recommended. In the hand, length and mode of antibiotic administration are still under study. LEVEL OF EVIDENCE: V.

Ulnar Shortening Osteotomy: Are Complications Under Reported?

Ulnar shortening osteotomy is an accepted treatment for ulnar impaction syndrome and numerous techniques for have been described in the literature. We present our single surgeon case series over 10 years of oblique ulnar shortening osteotomy using a jig technique. A review of the current literature with reference to the risk of complications is included. All patients undergoing ulnar shortening osteotomy from 2001 to 2011 were identified and case-notes were reviewed retrospectively. Risks of complications included metalwork irritation (51 %), non-union (6.3 %), refracture (1.6 %) and chronic regional pain syndrome (1.6 %). Oblique ulnar osteotomy using a jig technique is reliable and reproducible in shortening the ulna and maintaining alignment, rotation and compression at the osteotomy site. Symptoms improved in the majority of patients. However, the morbidity associated with the procedure may be underestimated as highlighted by our complication rates. Surgeons should counsel patients appropriately when offering ulnar shortening osteotomy.

Lifetime exposure to estrogens and Parkinson's disease in California teachers.

INTRODUCTION: Parkinson's disease (PD) is consistently observed to occur less frequently in women than men, prompting investigation into whether estrogen protects against neurodegeneration of dopaminergic neurons. METHODS: We used baseline data in the California Teachers Study, a prospective cohort of women, to investigate whether reproductive factors indicating higher long-term estrogen levels are associated with PD using a nested case-control approach. We identified 228 PD cases and 3349 unaffected controls frequency matched by age and race. RESULTS: Women who reported using combined estrogen/progesterone therapy or progesterone only formulations had a 57% increase in PD risk (OR = 1.57, 95% CI = 1.06, 2.34) compared to never having used HT. Compared to women with menopause at 50-52 years, menopause at younger (<35-46 years: OR = 0.59, 95% CI = 0.37, 0.94) and older ages (≥53 years: OR = 0.54, 95% CI = 0.36, 0.83) had lower PD risk. A derived composite estrogen summary score for women's exposure to both endogenous and exogenous estrogens throughout life indicated that women with presumed higher cumulative lifetime levels of estrogen (a score of 3-5) had a significantly reduced PD risk [(OR = 0.57, 95% CI = 0.35, 0.91) relative to those with lower lifetime estrogen exposure or a composite estrogen summary score of 0-1]. CONCLUSIONS: These results provide some support for the hypothesis that lifelong high estrogen is protective in PD, suggesting that the level and persistence of exposure over the long term may be important in PD risk reduction.

Dietary fiber content influences soluble carbohydrate levels in ruminal fluids.

The soluble carbohydrate concentration of ruminal fluid, as affected by dietary forage content (DFC) and/or ruminally undegradable intake protein content (UIPC), was determined. Four ruminally cannulated steers, in a 4 × 4 Latin square design, were offered diets containing high (75 % of DM) or low (25 % of DM) DFC and high (6 % of DM) or low (5 % of DM) UIPC, in a 2 × 2 factorial arrangement. Zinc-treated SBM was the primary UIP source. Soluble hexose concentration (145.1 µM) in ruminal fluid (RF) of steers fed low DFC diets exhibited a higher trend (P = 0.08) than that (124.5 µM) of steers fed high DFC diets. UIPC did not modulate (P = 0.54) ruminal soluble hexose concentrations. Regardless of diet, soluble hexose concentration declined immediately after feeding and did not rise until 3 h after feeding (P < 0.0001). Cellobiose (≈90 %) and glucose (≈10 %) were the major soluble hexoses present in RF. Maltose was not detected. Soluble glucose concentration (13.0 µM) was not modified by either UIPC (P = 0.40) nor DFC (P = 0.61). However, a DFC by post-prandial time interaction was detected (P = 0.02). Pentose concentrations were greater (P = 0.02) in RF of steers fed high DFC (100.2 µM) than steers fed low DFC (177.0 µM). UIPC did not influence (P = 0.35) soluble pentose concentration. The identity of soluble pentoses in ruminal fluid could not be determined. However, unsubstituted xylose and arabinose were excluded. These data indicate that: (i) soluble carbohydrate concentrations remain in ruminal fluid during digestion and fermentation; (ii) slight diurnal changes began after feeding; (iii) DFC influences the soluble carbohydrate concentration in RF; and (iv) UIPC of these diets does not affect the soluble carbohydrate concentration of RF.

Sugar phosphorylation activity in ruminal acetogens.

Acetogenic bacteria Acetitomaculum ruminis, Acetobacterium woodii, and Eubacterium limosum were compared for phosphoenolpyruvate (PEP) and ATP-dependent phosphorylation of glucose and 2-deoxy-glucose. Rate of phosphorylation activity was measured in toluene-treated acetogenic cells using PEP and ATP and radiolabled glucose or 2-deoxy glucose. Eubacterium limosum, most likely has a glucose phosphotransferase system (PTS). In contrast, A. ruminis, and A. woodii had PEP-dependent glucose phosphorylation rates very similar to control rates, suggesting the lack of PTS activity. These results were confirmed by PEP dependent 2-deoxyglucose phosphorylation data. The rates of ATP-dependent glucose phosphorylation were higher than PEP-dependent glucose dependent in all organisms surveyed. Only E. limosum appeared to have PTS. The presence of PTS in E. limosum could explain why it is not capable of utilizing sugars and H(2)/CO(2) simultaneously and why acetogenesis is not as prominant in the rumen because of the availability of carbohydrates as alternative energy substrates.

Accuracy in skin lesion diagnosis and the exclusion of malignancy.

The accuracy of clinical diagnosis of skin lesions has important ramifications for treatment selection and importantly prioritisation for treatment. The objective of this study was to assess the accuracy of diagnosis of skin lesions within our department with an emphasis placed on whether there were any negative consequences of a missed malignant diagnosis. The study was conducted retrospectively. Accuracy of diagnosis was judged on 2 criteria. The first, if the clinical diagnosis matched the histological diagnosis. The second, if the malignancy was diagnosed correctly. 1186 lesions were excised. 57% of patients were female and the mean age was 56 (range 6-94). 25% were invasive malignancies. Clinical diagnosis was correct in 700 (66%) cases. 89% BCCs and 33% of SCCs excised were correctly diagnosed preoperatively. Misdiagnosis of BCCs or SCCs as benign was associated with a stastically significant delay in treatment (BCC 6.2 vs 10.7 weeks, p=0.02) (SCC 3.7 vs 9.5 weeks p=0.004). 100% of correctly diagnosed vs 79% of misdiagnosed SCCs were completely excised. The sensitivity and specificity of the diagnosis of MM were 87% and 97.7% respectively. The mean waiting time for patients correctly diagnosed preoperatively was 2.4 weeks vs 3 weeks (p=0.39). For malignant diagnoses sensitivity was 91%, specificity 84%, PPV 65% and NPV 96%. Misdiagnosis of skin lesions results in delays in treatment and may increase the rate of incomplete excision. The high NPV rate suggests that few malignancies are missed but those that are may have serious consequences if discharged untreated.

Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion.

The loss of elbow flexion is an uncommon, but devastating consequence of injury to the upper limb and a complex problem to manage. This paper describes our experience with free functioning gracilis muscle transfer (FFGMT) to the upper limb for elbow flexion. 33 patients were followed up after FFGMT for elbow flexion. 26 patients were male, and 20 were children. Indications for FFGMT included obstetric brachial palsy (n=13) and adult brachial plexus injury (n=12), arthrogryposis (n=4), sarcoma, polio and radial dysplasia. Seventy percent (n=23) of patients had a successful outcome. Power comparable to the other side (M5) was recorded in two patients, 19 patients scored M4, and three scored M3. FFGMT in the OBP group alone (n=13) was the most successful; all had a pre-operative score of M2 or less and post-operatively 12 (92%) achieved a score of M4 or greater. A greater increase in Medical Research Council (MRC) grade for elbow flexion was achieved when intercostal nerves (ICN) were transferred to innervate the gracilis flap (mean gain three points, SD1.3), than ulnar fascicles (mean gain 1.75 points, SD2.3), P=0.05. With a multidisciplinary team approach involving experienced surgeons, theatre staff and therapists, a significant, reproducible and measurable improvement in elbow flexion can be achieved by FFGMT.

Long term study into surgical re-exploration of the 'free flap in difficulty'.

BACKGROUND: Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote. MATERIAL AND METHODS: We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome. RESULTS: Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. CONCLUSION: We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.

Free tissue transfers in the first 2 years of life--a successful cost effective and humane option.

Experience shows that young children are favourable candidates for microsurgical reconstruction, having few of the established risk factors for flap failure. In children's reconstructive surgery free tissue transfer (FTT) permits reconstruction whilst retaining growth potential, and reduces the overall number and duration of care episodes, and their related distress to the child and family. We present one centre's experience of free tissue transfer in children less than 2 years of age, over a 15-year period, demonstrating that free tissue transfer can be successfully employed in children under 2 years old. Salient aspects of patient selection, pre-operative counselling, and per-operative management are presented. Data from all free flaps in children under 2 years of age at the time of surgery were collected prospectively. Forty-seven flaps were performed as 37 separate procedures, in 32 children under 2 years of age. In ten patients, double transfers were performed in single procedures. Free tissue transfers were performed for reconstruction of congenital defects, following trauma and meningococcal septicaemia. All but one flap survived. In our series operative and ischaemia times, re-exploration, complication and flap failure rates were not higher than in comparable adult or older paediatric series from this unit, suggesting that there is no microvascular, or other, factor inherent to the infant that should preclude the use of free tissue transfer. Individual microsurgeons with appropriate facilities should not be inhibited from performing free tissue transfers which are humane and cost effective when compared with alternatives for very young children.

Multidisciplinary research in public health: a case study of research on access to green space.

OBJECTIVES: Quantitative analysis of the physical and demographic parameters of access to Thames Chase Community Forest (TCCF), and how these have changed between 1990 and 2003; and qualitative exploration of our understanding of the links between health and the natural environment (TCCF), with a focus on the issue of 'access' to green space. STUDY DESIGN: Multimethod design involving both quantitative (analysis of physical access to green space) and qualitative (ethnography) components. METHODS: Quantitative analysis, using geographical information systems, of physical access to the community forest; and ethnographic research including participant observation, non-participant observation, in-depth interviews and attendance at meetings and conferences. RESULTS: The quantitative analysis showed that public access to green space improved between 1990 and 2003 as a result of the regeneration and acquisition of new areas, and the average reduction in distance to green space was 162 m. However, such improvements were distributed differentially between population groups. In both 1990 and 2003, people from deprived areas and in poorer health had better access to green space than people from less deprived areas, but the greatest improvement in access to green space over this interval occurred in areas of below average deprivation (i.e. in the more affluent areas). The ethnographic research showed different interpretations of the notion of access. Use of TCCF was determined by a variety of factors including whether a person could 'imagine themselves' using such a space, different perceptions of what is actually being accessed (e.g. a place to exercise or a place to socialise), and ideas about using the countryside 'properly'. CONCLUSIONS: The health benefits of using a green space, such as TCCF, for walking or exercising are well recognized. However, whether people choose to use local green space may be determined by a variety of factors. These are likely to include physical distance to access of green space, as well as perceptions and understandings of what is being accessed and how it should be used. This study has also illustrated the ways in which multiple methods can be integrated in public health research, and the merits of different approaches to undertaking multidisciplinary work of this type.

Alcohol, wine and mental health: focus on dementia and stroke.

The relative risks of coronary heart disease (CHD) and overall mortality are reduced by moderate consumption of alcoholic beverages, particularly wine, which has major implications for public health. It appears likely that this beneficial effect of alcohol will soon be extended to some mental disorders. Although data on psychosis and mood and anxiety disorders are currently lacking, it appears that the relative risks of developing ischaemic stroke and Alzheimer's or vascular dementia are also lowered by moderate alcohol consumption. Such findings are still tentative because of the inherent methodological problems involved in population-based epidemiological studies, and it is unclear whether the benefit can be ascribed to alcohol itself or to other constituents specific to wine such as polyphenols. Plausible biological mechanisms have been advanced for the protective effect of alcohol and wine against CHD, many of which will also play roles in their protective actions against cerebrovascular disease and dementia. The specific antioxidant properties of wine polyphenols may be particularly important in preventing Alzheimer's disease. Because of the substantially unpredictable risk of progression to problem drinking and alcohol abuse, the most sensible advice to the general public is that heavy drinkers should drink less or not at all, that abstainers should not be indiscriminately encouraged to begin drinking for health reasons, and that light to moderate drinkers need not change their drinking habits for health reasons, except in exceptional circumstances.

Correlates of vitamin supplement use in the United States: data from the California Teachers Study cohort.

OBJECTIVE: To describe factors associated with vitamin supplement use in a large cohort of adult women. METHODS: California teachers and administrators (n = 133,479) completed a questionnaire on lifestyle factors and medical history. Specific supplement users regularly used at least one specific vitamin supplement in the past year; multivitamin users regularly used a multivitamin; and multivitamin and specific supplement users took a multivitamin and one or more specific supplements. Associations between supplement use and other variables were quantified using means, cross-tabulations, and age-adjusted prevalence odds ratios. RESULTS: Multivitamin and specific supplement users tended to be older and Caucasian. Compared to non-users, they were also leaner (odds ratio [OR] for BMI > or = 30 kg/m2 = 0.6 for specific supplement users with or without multivitamins, and OR = 0.7 for multivitamin only users), and were less likely to be current smokers (OR for current smoking = 0.8 for multivitamin plus specific supplement users, OR = 0.9 for specific supplement only users, and OR = 0.7 for multivitamin only users). Specific supplement users (with or without multivitamins) were more likely to use cancer screening tests, eat fruits and vegetables, and exercise than were multivitamin only users or non-users. CONCLUSIONS: A variety of demographic, dietary, and health-related factors were associated with different categories of supplement use.