Impact of intravenous tranexamic acid on patients undergoing shoulder arthroplasty surgery.

Background: Shoulder arthroplasty surgery carries the risk of blood loss. The antifibrinolytic tranexamic acid (TXA) is effective in reducing blood loss in lower limb arthroplasty. The purpose of this study was to assess blood loss and associated complications following shoulder arthroplasty performed with and without TXA for both elective and trauma indications. Methods: A cohort study was performed to assess blood loss, transfusion requirements and post-operative venous thromboembolic events (VTE) following shoulder arthroplasty undertaken with and without the use of intravenous TXA. Results: The study consisted of 67 patients (n = 36 with TXA; n = 31 without TXA). Type of arthroplasty included reverse-shoulder arthroplasty, total-shoulder arthroplasty and hemiarthroplasty. There was no significant difference between TXA and non-TXA groups regarding blood loss (TXA group haemoglobin drop 20.6 mg/dL; non-TXA group haemoglobin drop 20.5 mg/dL; p = 0.978). There was no significant difference in measured outcomes with or without TXA use for elective or trauma indications, nor regarding type of arthroplasty. Discussion: The use of intravenous TXA in shoulder arthroplasty was not associated with a significant reduction in blood loss or post-operative transfusion rates, nor did it impact on VTE. This result was not affected by the indication being elective or trauma nor the type of arthroplasty surgery performed.

The use of Tightrope device as the sole method of fixation in treating lateral end clavicle fractures.

BACKGROUND: Lateral end clavicle fractures can be challenging due to the small and often comminuted lateral fragment, problems with union and stability and implant morbidity. We retrospectively reviewed outcomes of Tightrope device in isolation to treat lateral end clavicle fractures. METHODS: Subjective and objective measures were assessed for 29 patients. The subjective comprised of functional clinical scores: Oxford shoulder score and EuroQoL5D. The objective measures were maintenance of fracture reduction, bone healing and complications. RESULTS: Median age was 36 years and 72% of cases were male patients. Average clinical follow up time was 21 months. Evaluation of latest radiographs showed that all reductions were maintained post-operatively. Twenty-two fractures had united and one patient had established non-union. Functional outcomes showed predominantly good results with Oxford shoulder score average of 41, EuroQoL5D index score of 0.78 and EuroQol Visual Analogue Scale 76. The overall post-operative complication rate was 10%; only one case requiring a secondary procedure. DISCUSSION: In our series, using the Tightrope as the sole device to treat displaced lateral end of clavicle fractures resulted in good radiological and functional outcomes, with minimal complications requiring secondary procedures. We believe the Tightrope device is a good method of fixing these challenging fractures and advocate its use.

The effect of the COVID-19 pandemic on mental health associated trauma, admissions and fractures at a London major trauma centre.

INTRODUCTION: Non-injury-related factors have been extensively studied in major trauma and have been shown to have a significant impact on patient outcomes. Mental illness and associated medication use has been proven to have a negative effect on bone health and fracture healing. MATERIALS AND METHODS: We collated data retrospectively from the records of orthopaedic inpatients in a non-COVID and COVID period. We analysed demographic data, referral and admission numbers, orthopaedic injuries, surgery performed and patient comorbidities, including psychiatric history. RESULTS: There were 824 orthopaedic referrals and 358 admissions (six/day) in the non-COVID period, with 38/358 (10.6%) admissions having a psychiatric diagnosis and 30/358 (8.4%) also having a fracture. This was compared with 473 referrals and 195 admissions (three/day) in the COVID period, with 73/195 (37.4%) admissions having a documented psychiatric diagnosis and 47/195 (24.1%) having a fracture. DISCUSSION: There was a reduction in the number of admissions and referrals during the pandemic, but a simultaneous three-fold rise in admissions with a psychiatric diagnosis. The proportion of patients with both a fracture and a psychiatric diagnosis more than doubled and the number of patients presenting due to a traumatic suicide attempt almost tripled. CONCLUSION: While total numbers using the orthopaedic service decreased, the impact of the pandemic and lockdown disproportionately affects those with mental health problems, a group already at higher risk of poorer functional outcomes and non-union. It is imperative that adequate support is in place for patients with vulnerable mental health during these periods, particularly as we look towards a potential 'second wave' of COVID-19.

Oblique "Scotty dog" versus antero-posterior (AP) views in performing x-ray guided facet joint injections.

BACKGROUND: Facet joint pain contributes significantly to lower back pain. Image intensifier x-ray guidance is used to locate the facet joints. This can either be in the oblique "Scotty dog" or antero-posterior views. The aim is to investigate whether improved visualisation of facet joints using the oblique method would increase the accuracy of the injection and hence lead to enhanced pain relief effect when compared to AP views in Lumbar facet joints. METHODS: Single centre, single blinded. A total of 42 consecutive patients were recruited between December 2014 and March 2015 at Colchester General Hospital. Patients randomly allocated into facet joint injections using the oblique or AP projection. Pre-operatively the patients were asked to rate their back pain using a numerical 11 point pain rating scale in the questionnaire. Post-operatively patients were seen at 6 weeks and once again were asked to fill out the afore mentioned questionnaire. The results were collated and statistical analysis performed using Microsoft Excel. RESULTS: 29 patients returned their post-op questionnaire at approximately 6 weeks post-op. 12 patients had oblique view and 17 patients had AP view. There was a statistically significant difference in the pain scores comparing pre and post op scores for both the Oblique and AP groups. However, there was no significant difference when comparing the post-op pain scores or the absolute changes in pain scores between the two groups. DISCUSSION: Spinal facet joint injections provide significant relief at the 6 week post-op follow up with no difference between the oblique and AP techniques.

Second generation cephalosporin antibiotic prophylaxis and Clostridium difficile infection in hip and knee arthroplasty.

Introduction The use of broad spectrum cephalosporin antibiotics has been discouraged by the Department of Health in England because of the link to increased Clostridium difficile infection rates. The aim of this study was to evaluate whether a local protocol that included the use of second generation cephalosporin (cefuroxime) antibiotics as a prophylactic agent was associated with increased risk of C difficile in elective hip and knee arthroplasty patients. Methods A retrospective intention-to-treat study was conducted. An infection control database of all cases of C difficile infection both in hospital and in the community was reviewed and cross-referenced against surgical records. A positive correlation was identified when a C difficile positive sample was documented within eight weeks of arthroplasty surgery. Results Only 1 case (0.02%) of C difficile positive diarrhoea was identified that correlated to the 8-week postoperative period following 4,488 arthroplasty procedures. Conclusions The use of cephalosporin antibiotic prophylaxis in the elective hip and knee arthroplasty setting does not appear to be associated with increased C difficile infection rates, achieving surgical site infection rates that are comparable with the national average.

Risk factors, characteristics and outcomes of necrotizing enterocolitis in late preterm and term infants.

OBJECTIVE: To identify the risk factors, characteristics and outcomes of necrotizing enterocolitis (NEC) at our institution. STUDY DESIGN: A retrospective case-control analysis of the charts of all late preterm and term infants, who had NEC of Bell's stage ≥ II from 1995 to 2009, along with infants of the same gestational age. Thirty-two late preterm infants had NEC meeting criteria and 128 late preterm and term infants were chosen as matched controls. RESULTS: The 32 NEC infants were more likely to have the following characteristics: a culture-proven sepsis (p = 0.0001), be small for their gestational age (p = 0.003), have a congenital heart disease (p = 0.007), and suffer from hypoxic- ischemic encephalopathy (p = 0.04). The presence of hypotension, metabolic acidosis, thrombocytopenia, and pneumoperitoneum was associated with a poor prognosis. Twelve of the 13 (92%) NEC infants who died had a surgical intervention. CONCLUSION: In this study, late preterm and term infants who developed NEC had other underlying clinical diagnoses and had culture-proven sepsis. Mortality rate was high in infants who required surgical intervention, indicating that they were gravely ill from the onset. Thrombocytopenia, hypotension and metabolic acidosis in late preterm and term infant with NEC were associated with poor prognosis.

Inducible Clindamycin Resistance among Staphylococci Isolated from Burn Patients.

Clindamycin has been used successfully to treat pneumonia and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. However, inducible clindamycin resistance has been described as a cause of treatment failure of such infections. A total of 159 staphylococcal isolates from different clinical specimens from burn patients in Tripoli Burn Center were tested for inducible clindamycin resistance by the disk-diffusion induction test. Inducible clindamycin resistance was detected in 66.2% of 65 methicillin-resistant S. aureus isolates and in none of 55 methicillin-sensitive S. aureus, 10 methicillin-resistant coagulase negative staphylococci and 29 methicllin-sensitive coagulase negative staphylococci isolates. In our setting, clindamycin can be used for the treatment of infections due to staphylococci, but we recommend that staphylococci isolates, particularly methicillin-resistant S. aureus, are tested by the D-test before treatment.

Ursodeoxycholic acid therapy for intractable total parenteral nutrition-associated cholestasis in surgical very low birth weight infants.

INTRODUCTION: Cholestasis associated with long-term total parenteral nutrition (TPN) occurs commonly in very low birth weight (VLBW) infants. Indeed, the majority of infants with TPN-associated cholestasis (TPNAC) respond very well to TPN withdrawal and full enteral feeding, yet some of them do not respond and have the potential for development of intractable cholestasis. It has been demonstrated that ursodeoxycholic acid (UDCA) has beneficial effects in treating TPNAC in various age groups. Nevertheless, the clinical data of UDCA use in VLBW infants, the most vulnerable group, are limited. We report the results of administration of UDCA therapy to VLBW infants with intractable TPNAC. METHODS: Medical records of VLBW infants who were treated with oral UDCA, at dose of 15-20 mg/kg/day, for intractable TPNAC were reviewed from 1999-2001. Treatment effectiveness was evaluated by monitoring the biochemical hepatic markers, including total bilirubin, direct bilirubin, alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transferase (GGT). RESULTS: A total of 13 infants were identified with the diagnosis of intractable TPNAC and they were treated with UDCA therapy. There was a significant reduction in serum levels of direct bilirubin, total bilirubin (p-value equals 0.0001) and AST (p-value equals 0.001). However, the serum levels of ALP, ALT and GGT showed a trend of improvement, yet none of them was statistically significant. Serum direct bilirubin was noted as the first marker to respond to UDCA therapy. It declined steadily during the course of therapy except in two intervals at the sixth and twelfth week of therapy that apparently associated with severe sepsis. There were no serious side effects noted. CONCLUSION: Our series data suggest that UDCA is safe and may be a potential treatment for intractable TPNAC if used within two weeks after TPN withdrawal and full enteral feeding. Sepsis may alter the effectiveness of UDCA therapy.

Sporadic neonatal schizencephaly associated with brain calcification.

Schizencephaly rarely presents in the neonatal period. We present the case of a baby girl born with growth retardation and microcephaly who developed seizures on the 3rd day of life. There was no clinical or laboratory evidence of a congenital viral infection but brain imaging revealed widespread calcification and bilateral schizencephaly clefts. By the age of 11 months, she had developed gross psychomotor retardation.

Congenital chylothorax.

The objective of this paper is a retrospective study of all infants treated for congenital chylothorax at the Royal Children's Hospital (RCH), Melbourne, Australia and King Fahad National Guard Hospital (KFNGH), Riyadh, Kingdom of Saudi Arabia. The charts of all infants with congenital chylothorax admitted to RCH over a period of 13 years, June 1982-August 1994, and admissions to KFNGH over a 7-year period, June 1992-August 1998 inclusive, were reviewed including management outcome and complications. There were 19 infants, 13 from RCH and 6 from KFNGH; 11 females and 8 males. Three infants were managed antenatally. Fifteen infants presented immediately after birth. Seven were born with hydrops fetalis, 6 infants had syndromes and 10 infants were born prematurely. Regular infant feeding formula and/or breast milk were used successfully in 12 infants, while in 7 infants medium chain triglycerides (MCT) rich formula was used. Sixteen infants were mechanically ventilated with 75% of them ventilated for < or = 28 days. Fifteen infants received total parenteral nutrition (TPN), and in 80% for < or = 32 days. Hydropic infants had longer duration of mechanical ventilation and hospital stay with mean (range) of 33.9 (3-120) and 115 (23-225) days, respectively, compared with 18 (1-62) and 34.3 (14-88) days for nonhydropic infants. Five infants underwent surgery with failure in four. Sepsis and bronchopulmonary dysplasia were the main complications. The survival rate was 100% regardless of the mode of therapy. The prognosis of Isolated congenital chylothorax in term, and preterm infants is good even in the presence of hydrops. Breast milk and/or regular infant feeding formula should be used initially before proceeding to MCT-rich formula, which may be necessary in some cases. Surgery should be considered if conservative management of congenital chylothorax fails after 4-5 weeks.

Megacystis-microcolon-intestinal hypoperistalsis syndrome associated with megaesophagus.

Megacystis-microcolon-intestinal hypoperistalsis syndrome is a rare congenital disorder characterized by megacystis and hypoperistalsis of the gastrointestinal tract. About 80 cases have been reported, predominantly in females. We present a female newborn with typical features of the syndrome associated with megaesophagus.

Congenital diaphragmatic hernia: experience with preoperative stabilization and delayed surgery without ECMO and inhaled nitric oxide.

Despite many advances in the management of congenital diaphragmatic hernia (CDH), the condition carries a mortality rate of 40-50% usually consequent to pulmonary hypoplasia and/or persistent pulmonary hypertension. Several centers have reported improved survival with preoperative stabilization and delayed surgery, which is now an accepted method of management. This is a retrospective analysis of all neonates with respiratory distress at birth due to CDH who were treated at our institution with neither extracorporeal membrane oxygenation nor nitric oxide being used. The medical records of all neonates with CDH and respiratory distress at birth who were treated at this institution from August 1, 1992 through March 1, 1997 were reviewed. There were 21 patients, 11 male and 10 female. There were 17 full-term and 4 premature infants; two premature infants at 30 and 34 weeks' gestation were not resuscitated because of severe associated congenital anomalies. Surgery was performed from 5 to 144 hr (mean 45 hr) in 18 infants. One infant died during preoperative stabilization from severe pulmonary hypoplasia and pulmonary hypertension and one infant died postoperatively from the same conditions. Seventeen of 19 infants (89.5%) survived and were discharged home. Three infants (17.6%) who failed to thrive due to severe gastroesophageal reflux (GER) required fundoplication. Eleven infants (64.7%) who had sepsis proven by blood culture responded satisfactorily to appropriate antibiotics. Preoperative stabilization and delayed surgery has been a satisfactory form of management in our series. The significant complication was sepsis, which must be addressed.

Sporadic congenital infantile cortical hyperostosis (Caffey's disease).

Prognosis of congenital infantile cortical hyperostosis (Caffey's disease) is poor particularly in premature babies. Two cases are presented of congenital Caffey's disease in premature babies. The first baby was hydropic at birth and had cortical hyperostosis involving the mandible and long bones of right upper limb and both lower limbs. The second baby had cortical hyperostosis of the nasal bones causing severe nasal nonchoanal stenosis that needed surgery, in addition to involvement of long bones of the four extremities. Both babies recovered from the disease and were discharged home well. These cases suggest that the improved outcome of congenital of infantile cortical hyperostosis may reflect improvement of neonatal mechanical ventilation and availability of neonatal total parenteral nutrition.

Sexual dimorphism in plasma leptin concentration.

Leptin, the obese (ob) gene product, is thought to be a lipostatic hormone that contributes to body weight regulation through modulating feeding behavior and/or energy expenditure. The determinants of plasma leptin concentration were evaluated in 267 subjects (106 with normal glucose tolerance, 102 with impaired glucose tolerance, and 59 with noninsulin-dependent diabetes). Fasting plasma leptin levels ranged from 1.8-79.6 ng/mL (geometric mean, 12.4), were higher in the obese subjects, and were not related to glucose tolerance. Women had approximately 40% higher leptin levels than men at any level of adiposity. After controlling for body fat, postmenopausal women had still higher leptin levels than men of similar age, and their levels were not different from those in younger women. Multiple regression analysis showed that adiposity, gender, and insulinemia were significant determinants of leptin concentration, explaining 42%, 28%, and 2% of its variance, respectively. Neither age nor the waist/hip ratio was significantly related to leptin concentration. Thus, our data indicate that gender is a major determinant of the plasma leptin concentration. This sex difference is not apparently explained by sex hormones or body fat distribution. Leptin's sexual dimorphism suggests that women may be resistant to its putative lipostatic actions and that it may have a reproductive function.

Accuracy of pulse oximetry in hypothermic neonates and infants undergoing cardiac surgery.

OBJECTIVES: To assess the accuracy of pulse oximetry under hypothermic conditions in neonates and infants undergoing cardiac surgery, and to assess the effect of probe site as well as probe site skin temperature on the reliability of pulse oximetry. DESIGN: Prospective Study. SETTING: Cardiac operating room and intensive care unit of children's hospital. PATIENTS: Twenty-five infants <3 months of age undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Pulse oximeter readings (Sp O2) from probes placed on the hand and foot were recorded at various skin temperatures and compared with hemoximeter oxygen saturations (Sa O2) obtained on simultaneously drawn arterial blood samples. Core temperature, arterial pressure and vasodilator use were recorded simultaneously. MEASUREMENTS AND MAIN RESULTS: Pulse oximetry bias (Sp O2 - Sa O2) increased to an unacceptable range (>+3% or <-3%) in 45.5% of the readings at foot probe site temperatures of <27 degrees. Pulse oximetry bias was within an acceptable range in 94.7% of the readings at temperatures >29 degrees. There was no significant difference between oximeter readings obtained from two probe sites (hand and foot). Administration of phenoxybenzamine improved the accuracy of pulse oximetry in ten infants at skin temperature of <27 degrees. CONCLUSIONS: Pulse oximetry readings in small infants are likely to be unreliable at skin temperatures of <27 degrees, irrespective of probe site. Intravenous phenoxybenzamine appeared to improve the accuracy of pulse oximetry at low temperatures.

Gastroschisis: 13 years' experience at RCH Melbourne.

OBJECTIVE: To review recent experience of gastroschisis at the Royal Children's Hospital, Melbourne. METHODOLOGY: Retrospective review of admissions over a 13 year period, June 1980-June 1993 inclusive, including an analysis of those factors influencing mortality, morbidity and complications. RESULTS: There were 49 infants, of whom two died (4%), both having an associated bowel atresia. Mode of delivery, age at operative repair, birthweight centile and silo repair had no significant effect on the duration of total parenteral nutrition (TPN) or hospital stay. The presence of short gut and/or gut resection and localized bowel narrowing or bowel atresia resulted in a significant increase in the duration of TPN and hospital stay. The presence of a central venous line was a highly significant risk factor for the development of systemic sepsis. CONCLUSION: Currently gastroschisis has a good outlook with a low mortality. Infants with short gut/resection and bowel atresia have a long duration of TPN and hospitalization, with significant morbidity and complications.

Breast feeding practices in Qatar.

PIP: Medical staff at the neonatal outpatient clinic of the Women's Hospital in Doha, Qatar randomly distributed a questionnaire about breast feeding and socioeconomic characteristics to 340 women (53.5% Qataris and 46.5% other Arabic speaking women) from February-August 1988. Only 32% of the mothers exclusively breast fed at birth. This low incidence could be due to excessive advertising by formula manufacturers and the increasing purchasing power of the Qataris. 5l5% used both breast milk and formula. 13% only bottle fed their infants. 50% of the mothers from the below average income group (5000 Qatar Riyals) breast fed their infants, while only 12% of those from the high income group (10,000 Qatar Riyals) did. Further, 55% of the mothers with less than secondary school education exclusively breast fed whereas 25% of those with secondary school and above breast fed. This result confirmed the downward trend for breast feeding in Qatar as identified in the early 1980s. Even though most mothers decided themselves not to breast feed, 31% reported that their physician suggested feeding formula to their infants. The longer infants stayed in the neonatal intensive care unit the less likely their mothers would breast feed them. For example, 72% were breast fed if discharged 1 week after admission while none were breast fed if discharged 3 weeks after admission. The leading reasons for bottle feeding included that the infant was still hungry (634%), night feeding (12%), mother worked (11%), and maternal diseases (5%). Regardless of the reasons for the downward trend in breast feeding in Qatar, public health professionals and health practitioners must begin direct and specific health education efforts about the benefits of breast feeding.^ieng