The COVID-19 Pandemic: The effect on open lower limb fractures in a London major trauma centre - a plastic surgery perspective.

BACKGROUND: COVID-19 has created huge pressures on healthcare systems. The ongoing provision of major trauma services during this time has proved challenging. We report our experience of managing open lower limb fractures (oLLFs) during the pandemic in a London major trauma centre (MTC). METHODS: This was a prospective study of all open lower limb fractures presenting to our unit over the initial 48 days of UK government lockdown - 24th March till 10th May 2020. Results were compared to the same time period in 2019 retrospectively. Epidemiological data, mechanism, Gustilo-Anderson (G-A) severity grading, time to initial debridement and definitive coverage were analysed. RESULTS: There was a 64% reduction in emergency department (ED) attendances (25,264 vs 9042). There was an 18% reduction in oLLFs (22 vs 18). Approximately three-quarters of injuries were in males across both cohorts (77% vs 78%) and tended to occur in younger patients (median age, 37 vs 35). Road-traffic-accidents (RTAs) were the most common injury mechanism in both 2019 and lockdown, but a rise in jumpers from height was seen in the latter. A similar pattern of G-A severities were seen, however only 3 injuries during lockdown required major soft tissue reconstruction. There was no significant difference in times taken for initial debridement (p = 0.72786) or definitive wound coverage (p = 0.16152). A greater proportion of independent operating was seen during lockdown between orthopaedics and plastic surgery. CONCLUSIONS: Despite government lockdown measures, oLLFs still placed significant burden on our MTC. Notwithstanding significant staffing alterations and theatre pressures, we have been able to ensure these lower limb emergencies remain a surgical priority and have managed to utilise resources appropriately.

Hand infections.

The hand is an extremely versatile organ adapted for fine tasks with various clinicoanatomical compartments. This article reviews the types of common hand infections that present to the emergency department and/or hand surgeon, with relevant investigations and strategies for diagnosis and treatment, with the emphasis on distinguishing between superficial and more serious infections.

Hand tendon injuries.

This article provides a comprehensive overview of hand tendon injuries. It has been tailored towards healthcare professionals who will be the first to assess these injuries and instigate appropriate management. It discusses the essential hand anatomy to be aware of, how to assess tendon injuries, their initial management and also the definitive surgical interventions used, if required. Rehabilitation techniques are also discussed, as this is also key to good functional outcomes. Missed injuries, or delay in their diagnosis and referral to specialist hand surgeons, can cause a large amount of morbidity for patients and therefore it is important that they are picked up in a timely manner.

Management of amputated digits.

Traumatic digit amputations account for 1% of all trauma admissions and are an important cause of morbidity in young, working people. It is essential that patients are worked up appropriately and referred promptly to a specialist unit for consideration of replantation. This review summarises the acute management of a patient presenting to the emergency department with an amputated digit. It discusses the assessment, initial management in the emergency department, how to make the decision to replant and operative steps.

Second trimester termination of pregnancy for fetal anomaly or death: comparing mifepristone/misoprostol to gemeprost.

OBJECTIVE: To assess the effect of changing the regimen for second trimester induction of labour from gemeprost to mifepristone/misoprostol. DESIGN AND SETTING: A retrospective study at a university teaching hospital over the 5-year period 1993-1997. SUBJECTS, METHODS and REGIMENS: 68 patients, 34 in the gemeprost group and 34 in the mifepristone/misoprostol group. The gemeprost group received 1mg vaginally every 3h to a maximum of five doses. The mifepristone/misoprostol group were pre-treated with 600 mg mifepristone orally followed by 800 microg misoprostol vaginally and then 400 microg orally every 3h to a maximum of four oral doses. MAIN OUTCOME MEASURES: Induction to abortion interval; delivery within 24h. RESULTS: The mifepristone/misoprostol group had a lower induction to abortion interval compared to the gemeprost group (median 8.9h versus 19.8h, respectively, p<0.01). The mifepristone/misoprostol regimen was more successful than the gemeprost regimen; 94% versus 68%, respectively, aborted without extra medical or surgical intervention, p=0.02. There were no significant differences in side effects, analgesia requirements or complications between the two groups. Three patients with previous Caesarean sections had a ruptured uterus; two from the gemeprost group and one from the mifepristone/misoprostol group. CONCLUSIONS: The new mifepristone/misoprostol regimen was more effective in second trimester induction of labour. Induction of labour with misoprostol or gemeprost should be used with care in patients with a previous Caesarean section.

Normal development of human fetal hematopoiesis between eight and seventeen weeks' gestation.

OBJECTIVE: The aim of this study was to compare the hematologic compositions of fetal blood and liver and to phenotypically quantify the hematopoietic stem and progenitor cells during early human gestation. STUDY DESIGN: Fifty fetal blood samples and 50 fetal livers were collected at 10 to 17 weeks' gestation and 8 to 17 weeks' gestation, respectively. Investigations included fetal blood cell counts, determinations of red blood cell index values, and flow cytometric analyses of mononuclear cells. RESULTS: Fetal red blood cell, white blood cell, and platelet counts all increased with gestation, reflecting hematologic development. The proportion of normoblasts decreased dramatically with gestation. Individual mature red blood cells were larger and contained more hemoglobin during early gestation. Circulating and hepatic T lymphocytes increased in number shortly before the 13th week of gestation, which reflected thymic maturation. As a proportion fetal liver contained fewer T lymphocytes than did fetal blood (2.5% vs 18.6%; P =.003) but more CD34(+) hematopoietic stem and progenitor cells (17.5% vs 4.3%; P =. 004). As a proportion, fetal liver contained more of the primitive CD34(+) and CD38(-) hematopoietic stem and progenitor cells than did fetal blood (32% vs 17%; P =.04). CONCLUSION: Both fetal blood and liver provide a rich source of hematopoietic stem and progenitor cells. Fetal liver provides a richer source of more primitive hematopoietic stem and progenitor cells than does fetal blood. For stem cell transplantation we suggest that fetal livers be collected before the 13th week of gestation, because T lymphocytes are present in much greater numbers in the fetal liver after this stage of gestation. Further, we suggest that in utero stem cell transplantations in fetuses with normal immune development should be performed before the 13th week of gestation.

What invasive procedure to use in early pregnancy?

As scientific knowledge and medicine advance so do the expectations of the general public. Advances in molecular biology, ultrasonography, access to the early gestational sac and prenatal diagnosis have helped both drive and meet these expectations. We discuss the use, advantages, potential risks and complications of invasive prenatal diagnostic procedures in early pregnancy. All invasive procedures should be performed under continuous ultrasound guidance by experienced operators. Within this context, mid-trimester amniocentesis remains the safest invasive procedure. Chorionic villus sampling (CVS) and early amniocentesis (EA) are associated with a higher risk of subsequent pregnancy loss. There is also a 10-fold increase in the risk of mosaicism with CVS compared to amniocentesis. Both CVS and EA can induce fetal structural defects and should be abandoned as routine invasive tests. Patient counselling should include an evaluation of the risk associated with each individual procedure but also the operator's personal complication rate.

Serum screening for Down syndrome and adverse pregnancy outcomes: a case-controlled study.

The relationship between adverse perinatal outcomes in women with false positive biochemical screening test for Down syndrome was investigated in a retrospective case-controlled study. A cohort of 4000 women who booked for routine antenatal care and opted for biochemical screening over a 22 month period was obtained. The pregnancy outcome data of 272 women with a false positive screening test for Down syndrome (risk >1 in 250) at 15-18 weeks of gestation (study group) were compared with data from 272 age and gestation matched controls with a negative Down syndrome screening test from the same population. The frequency of normal and adverse perinatal outcomes, including pre-eclampsia, isolated intrauterine growth restriction, spontaneous preterm labour and stillbirth was recorded. The incidence of adverse pregnancy outcomes was 11.9% in the study group and 8.6% in the control group. The estimated odds ratio of an abnormal outcome in the study group was 1.41 (95% CI-0.790, 2.55). The observed difference between proportion was 0.0324 (95% CI-0.022, 0.083; p=0.40). These data identify no evidence for a strong association between a false positive Down syndrome screening test result and subsequent adverse perinatal outcomes in the general population.

Maternal serum biochemical screening for pregnancy complications other than aneuploidy.

The link between a wide range of pregnancy complications and unexplained elevated mid-trimester levels of maternal serum alpha-fetoprotein (MSAFP) and maternal serum human chorionic gonadotrophin (MShCG), with its subunits, is becoming established. This link seems to be stronger when levels of both MSAFP and MShCG are elevated. In addition, it seems that the greater the change in levels of MSAFP or MShCG, or both, the greater the subsequent risk of pregnancy complications. By using these markers as a screening test it may be possible to identify high-risk pregnancies as early as 15 weeks' gestation and manage them more intensively.

Increased adherence of CD2 peripheral blood lymphocytes to cytomegalovirus-infected fibroblasts is blocked by anti-LFA-3 antibody.

In the accompanying manuscript (p. 405) we describe the up-regulation of the adhesion molecules LFA-3 and ICAM-1 on the surface of cytomegalovirus (CMV)-infected fibroblasts from days 1 to 5 post-infection. Peak expression was seen on day 2, when LFA-3 was twice, and ICAM-1 three times, the level on uninfected fibroblasts. The present study demonstrates a parallel increase in the adhesion of peripheral blood leucocytes to the CMV-infected fibroblasts, which was significantly greater than adhesion to uninfected fibroblasts from days 2 to 4 post-infection. This effect was seen from 2 to 24 hr of leucocyte-fibroblast co-culture. The increased binding to infected fibroblasts was accounted for by the CD2+ subset of lymphocytes. All subpopulations of CD2+ lymphocytes, namely CD3+, CD4+, and CD8+ cells, demonstrated increased adhesion to CMV-infected fibroblasts, suggesting that the CD2-LFA-3 interaction was an important component of the increased binding. This proposal was supported by the fact that the pretreatment of infected fibroblasts with monoclonal antibodies specific for LFA-3, significantly blocked the binding of CD2+ lymphocytes. Supernatants from infected fibroblasts, or co-cultures of leucocytes and infected fibroblasts, could transfer increased leucocyte binding to uninfected fibroblasts, suggesting that CMV might accentuate inflammatory responses. As lymphocytes can be activated by the CD2 pathway, CMV might also provoke nonspecific leucocyte responses to uninfected as well as infected cells, which could possibly contribute to tissue damage.