Oral contraceptives, hormone replacement therapy, thrombophilias and risk of venous thromboembolism: a systematic review The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) Study

Combined oral contraceptives,oral hormone replacement therapy and thrombophilias are recognised risk factors for venous thromboembolism in women.The objective of this study was to assess the risk of thromboembolism among women with thrombophilia who are taking oral contraceptives or hormone replacement therapy, conducting a systematic review and metaanalysis. Of 201 studies identified, only nine met the inclusion criteria. Seven studies included pre-menopausal women on oral contraceptives and two studies included peri-menopausal women on hormone replacement therapy. For oral contraceptive use, significant associations of the risk of venous thromboembolism were found in women with factor V Leiden (OR 15.62; 95%CI 8.66 to 28.15); deficiencies of antithrombin (OR 12.60; 95%CI 1.37 to 115.79), protein C (OR 6.33; 95%CI 1.68 to 23.87), or protein S (OR 4.88; 95%CI 1.39 to 17.10), elevated levels of factor VIIIc (OR 8.80; 95%CI 4.13 to 18.75); and factor V Leiden and prothrombin G20210A (OR 7.85; 95%CI 1.65 to 37.41). For hormone replacement therapy, a significant association was found in women with factor V Leiden (OR 13.16; 95%CI 4.28 to 40.47).Although limited by the small number of studies, the findings of this study support the presence of interaction between thrombophilia and venous thromboembolism among women taking oral contraceptives. However, further studies are required to establish with greater confidence the associations of these, and other, thrombophilias with venous thromboembolism among hormone users

Hair regrowth treatment efficacy and resistance in androgenetic alopecia: A systematic review and continuous Bayesian network meta-analysis

BackgroundAndrogenetic alopecia (AGA) affects almost half the population, and several treatments intending to regenerate a normal scalp hair phenotype are used. This is the first study comparing treatment efficacy response and resistance using standardized continuous outcomes.ObjectiveTo systematically compare the relative efficacy of treatments used for terminal hair (TH) regrowth in women and men with AGA.MethodsA systematic literature review was conducted (from inception to August 11, 2021) to identify randomized, Placebo-controlled trials with ≥ 20 patients and reporting changes in TH density after 24 weeks. Efficacy was analyzed by sex at 12 and 24 weeks using Bayesian network meta-analysis (B-NMA) and compared to frequentist and continuous outcomes profiles.ResultsThe search identified 2,314 unique articles. Ninety-eight were included for full-text review, and 17 articles met the inclusion criteria for data extraction and analyses. Eligible treatments included ALRV5XR, Dutasteride 0.5 mg/day, Finasteride 1 mg/day, low-level laser comb treatment (LLLT), Minoxidil 2% and 5%, Nutrafol, and Viviscal. At 24 weeks, the B-NMA regrowth efficacy in TH/cm2 and significance (**) in women were ALRV5XR: 30.09**, LLLT: 16.62**, Minoxidil 2%: 12.13**, Minoxidil 5%: 10.82**, and Nutrafol: 7.32**, and in men; ALRV5XR: 21.03**, LLLT: 18.75**, Dutasteride: 18.37**, Viviscal: 13.23, Minoxidil 5%: 13.13**, Finasteride: 12.38, and Minoxidil 2%: 10.54. Two distinct TH regrowth response profiles were found; Continuous: ALRV5XR regrowth rates were linear in men and accelerated in women; Resistant: after 12 weeks, LLLT, Nutrafol, and Viviscal regrowth rates attenuated while Dutasteride and Finasteride plateaued; Minoxidil 2% and 5% lost some regrowth. There were no statistical differences for the same treatment between women and men. B-NMA provided more accurate, statistically relevant, and conservative results than the frequentist-NMA.ConclusionSome TH regrowth can be expected from most AGA treatments with less variability in women than men. Responses to drug treatments were rapid, showing strong early efficacy followed by the greatest resistance effects from flatlining to loss of regrowth after 12–16 weeks. Finasteride, Minoxidil 2% and Viviscal in men were not statistically different from Placebo. LLLT appeared more efficacious than pharmaceuticals. The natural product formulation ALRV5XR showed better efficacy in all tested parameters without signs of treatment resistance (see Graphical abstract).Systematic review registrationwww.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021268040, identifier CRD42021268040

The virtual knee clinic - A tool to streamline new outpatient referrals

INTRODUCTION: Traditionally it has been the case for orthopaedic consultants to review GP referrals for the orthopaedic outpatient clinic where possible in amongst other clinical commitments. This could sometimes lead to unsuitable patients being reviewed and both patients and clinicians becoming frustrated. Building on the virtual fracture clinic, a new screening tool was implemented to streamline new referrals. The aim of this study is to investigate the change in patients given outpatient appointments following the introduction of a new streamlining protocol.METHODS: Referrals had to meet the criteria of BMI under 40 or evidence of weight loss effort, recent radiographs and appropriate clinical details in keeping with Getting It Right First Time (GIRFT). Consultant were given dedicated clinical time to review and either triage the patient to the most appropriate clinic type, or return the referral with advice to the GP. 10 months of data was collected prior to the protocol and 10 months after implementation.RESULTS: 1781 patients were referred pre-protocol with an average of 14.2% of these being returned. Post protocol there were 2110 patients referred with 31.2% returned. There was an increase in 195% of referrals returned to the GP (p &lt; 0.0001). The highest proportion of these was for mild to moderate osteoarthritis on the radiograph which has been proven to be unsuitable for intervention. At 12 month analysis there was no significant increase in patients re-referred to the service (p = 0.53) DISCUSSION: The new screening tool allows more appropriate referrals to be seen in clinic allowing less frustration to clinicians and patients by reducing therapeutic inertia. Furthermore it allows new referrals to be seen by the most appropriate sub-specialist. It allows advice to be given to GPs on further management for the patient. 619 appointments were saved. At a cost of £120 per appointment, this leads to a real terms cost saving of £74,280, with further savings in time and travel.</p

The practice of bilateral, simultaneous total knee replacement in Scotland over the last decade. Data from the Scottish Arthroplasty Project

The issue of the safety of performing simultaneous, bilateral total knee replacement (SBTKR) for patients with bilateral knee osteoarthritis remains controversial. Several small series have reported inconclusive findings and the few large series published are contradictory. We present data retrieved from the Scottish Arthroplasty Project on over 19,000 total knee replacements (TKR) performed in Scotland between 1989 and 1999. The trends in the practice of SBTKR are shown together with the associated mortality from the procedure compared with unilateral or staged, bilateral TKR. The data shows that there was no statistically significant difference in the 90-day mortality between unilateral TKR, staged TKR or SBTKR. In addition, the length of stay for SBTKR has reduced, equaling that of unilateral TKR since 1993. Despite an initial increase in the percentage of consultants performing SBTKR early in the decade, since 1993, only approximately 25% of knee arthroplasty surgeons in Scotland per year ever performed a SBTKR.</p

Outcome of hip arthroplasty in octogenarians compared with younger patients

This prospective study aimed to ascertain if octogenarians undergoing primary hip arthroplasty experienced a similar clinical outcome and complication rate as younger patients. Significantly better (p=0.019) improvement in mean Harris hip score (SD) was seen 18 months after surgery in the younger cohort: 43.4 (SD 13.8) compared with 39.8 (SD 10.6). Length of hospital stay was longer (p&lt;0.001) in the octogenarians: 12.9 days (SD 7.0) days versus 10.1 (SD 4.7) with a higher blood transfusion rate of 40% compared with 28% (p = 0.009). No significant differences in infection, dislocation, thromboembolism or 90-day mortality rates were found. Conclusions: octogenarians are more likely to require blood transfusions and a longer hospital stay, with less improvement in clinical outcome at 18 months after primary hip arthroplasty.</p

Does body mass index affect the early outcome of primary total hip arthroplasty?

There is little evidence describing the influence of body mass index on the outcome of total hip arthroplasty (THA). Eight hundred patients undergoing primary cemented THA were followed for a minimum of 18 months. The Harris Hip Score (HHS) and Short Form 36 were recorded preoperatively and at 6 and 18 months postoperatively. In addition, other significant events were noted, namely death, dislocation, reoperation, superficial and deep infection, and blood loss. Multiple regression analysis was performed to identify whether body mass index (BMI) was an independently significant predictor of the outcome of THA. No relationship was seen between the BMI of an individual and the development of any of the complications noted. The HHS was seen to increase dramatically postoperatively in all patients. Body mass index did predict for a lower HHS at 6 and 18 months. This effect was small when compared with the overall improvements in these scores. There was no influence on the Short Form 36 component scores. On the basis of this study, we can find no justification for withholding THA solely on the grounds of BMI.</p

Press fit condylar cobalt chrome sigma total knee arthroplasty:no difference to original design at five year point

Background: Total knee arthroplasty (TKA) is an established procedure for relieving pain and improving function. The Press Fit Condylar Cobalt Chrome Sigma (PFCSCC) Total Knee System was introduced by Depuy, Johnson &amp; Johnson in 2006, as an update of their existing PFC Sigma design intended to reduce backside wear.Methods: To identify any significant early failures following the introduction of this knee system, we prospectively identified all patients undergoing TKA with the PFCSCC over a one-year period. Clinical and demographic patient data, American Knee Society scores, Oxford Knee scores, SF-12 scores and radiographic data were recorded pre-operatively and at three and five years post-operatively.Results: 233 patients underwent 249 primary TKA's with the PFCSCC. Seventeen patients (19 TKAs) died before the last review and 29 patients (30 knees) were lost to follow up. The mean age was 66.6 (range 34-80) with 47.6% male. Mean five year follow-up was 1836. days (range 1530-2307). Five knees (2.2%) were revised for infection with three revised for pain. The 5-year survival rate was 96.6% and 98.6% for aseptic failure. American Knee Society Score (AKSS) was 32.6 (0-86.6) preoperatively and 80.7 (29-95) 5 years post-operatively P. &lt;. 0.001. OKS was 20.9 (7-38) preoperatively and 36.4 (10-48) at 5 years P. &lt;. 0.001.Conclusion: We report the first five year outcome of this design change, which demonstrates a good early survivorship when compared to the previous PFC Sigma design.</p

Predictors of mortality after total knee replacement:a ten-year survivorship analysis

We report the general mortality rate after total knee replacement and identify independent predictors of survival. We studied 2428 patients: there were 1127 men (46%) and 1301 (54%) women with a mean age of 69.3 years (28 to 94). Patients were allocated a predicted life expectancy based on their age and gender. There were 223 deaths during the study period. This represented an overall survivorship of 99% (95% confidence interval (CI) 98 to 99) at one year, 90% (95% CI 89 to 92) at five years, and 84% (95% CI 82 to 86) at ten years. There was no difference in survival by gender. A greater mortality rate was associated with increasing age (p &lt; 0.001), American Society of Anesthesiologists (ASA) grade (p &lt; 0.001), smoking (p &lt; 0.001), body mass index (BMI) &lt; 20 kg/m(2) (p &lt; 0.001) and rheumatoid arthritis (p &lt; 0.001). Multivariate modelling confirmed the independent effect of age, ASA grade, BMI, and rheumatoid disease on mortality. Based on the predicted average mortality, 114 patients were predicted to have died, whereas 217 actually died. This resulted in an overall excess standardised mortality ratio of 1.90. Patient mortality after TKR is predicted by their demographics: these could be used to assign an individual mortality risk after surgery.</p