Comparison of cytokine and phosphoprotein profiles in idiopathic and Crohn's disease-related perianal fistula.

BACKGROUND: Perianal fistulae are either primary (idiopathic) or secondary [commonly associated with Crohn's disease, (CD)]. It is assumed, although not proven, that the pathophysiology differs. AIM: To systematically compare the clinical phenotypes, cytokine and phosphoprotein profiles of idiopathic and CD-related perianal fistulae. METHODS: Sixty-one patients undergoing surgery for perianal fistula were prospectively recruited (48 idiopathic, 13 CD) into a cohort study. Clinical data, including the Perineal Disease Activity Index (PDAI) and EQ-5D-5L were collected. Biopsies of the fistula tract, granulation tissue, internal opening mucosa and rectal mucosa were obtained at surgery. Concentrations of 30 cytokines and 39 phosphoproteins were measured in each biopsy using a magnetic bead multiplexing instrument and a chemiluminescent antibody array respectively. Over 12000 clinical and 23500 laboratory measurements were made. RESULTS: The PDAI was significantly higher (indicating more active disease) in the CD group with a mean difference of 2.40 (95%CI: 0.52-4.28, P = 0.01). Complex pathoanatomy was more prevalent in the CD group, namely more multiple fistulae, supralevator extensions, collections and rectal thickening. The IL-12p70 concentration at the internal opening specimen site was significantly higher (median difference 19.7 pg/mL, 99%CI: 0.2-40.4, P = 0.008) and the IL-1RA/IL-1β ratio was significantly lower in the CD group at the internal opening specimen site (median difference 15.0, 99%CI = 0.4-50.5, P = 0.008). However in the remaining 27 cytokines and all 39 of the phosphoproteins across the four biopsy sites, no significant differences were found between the groups. CONCLUSION: CD-related perianal fistulae are more clinically severe and anatomically complex than idiopathic perianal fistulae. However, overall there are no major differences in cytokine and phosphoprotein profiles

Predicting hip-knee-ankle and femorotibial angles from knee radiographs with deep learning

BACKGROUND: Knee alignment affects the development and surgical treatment of knee osteoarthritis. Automating femorotibial angle (FTA) and hip-knee-ankle angle (HKA) measurement from radiographs could improve reliability and save time. Further, if HKA could be predicted from knee-only radiographs then radiation exposure could be reduced and the need for specialist equipment and personnel avoided. The aim of this research was to assess if deep learning methods could predict FTA and HKA angle from posteroanterior (PA) knee radiographs. METHODS: Convolutional neural networks with densely connected final layers were trained to analyse PA knee radiographs from the Osteoarthritis Initiative (OAI) database. The FTA dataset with 6149 radiographs and HKA dataset with 2351 radiographs were split into training, validation, and test datasets in a 70:15:15 ratio. Separate models were developed for the prediction of FTA and HKA and their accuracy was quantified using mean squared error as loss function. Heat maps were used to identify the anatomical features within each image that most contributed to the predicted angles. RESULTS: High accuracy was achieved for both FTA (mean absolute error 0.8°) and HKA (mean absolute error 1.7°). Heat maps for both models were concentrated on the knee anatomy and could prove a valuable tool for assessing prediction reliability in clinical application. CONCLUSION: Deep learning techniques enable fast, reliable and accurate predictions of both FTA and HKA from plain knee radiographs and could lead to cost savings for healthcare providers and reduced radiation exposure for patients

Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline.

PURPOSE: Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. METHODS: This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. RESULTS: Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. CONCLUSION: COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit

Public patient views of artificial intelligence in healthcare: A nominal group technique study

Objectives: The beliefs of laypeople and medical professionals often diverge with regards to disease, and technology has had a positive impact on how research is conducted. Surprisingly, given the expanding worldwide funding and research into Artificial Intelligence (AI) applications in healthcare, there is a paucity of research exploring the public patient perspective on this technology. Our study sets out to address this knowledge gap, by applying the Nominal Group Technique (NGT) to explore patient public views on AI. Methods: A Nominal Group Technique (NGT) was used involving four study groups with seven participants in each group. This started with a silent generation of ideas regarding the benefits and concerns of AI in Healthcare. This was followed by a group discussion. Then a round-robin process was conducted until no new ideas were generated. Participants then ranked their top five benefits and top five concerns regarding the use of AI in healthcare. A final group consensus was reached. Results: Twenty-Eight participants were recruited with the mean age of 47 years. The top five benefits were: Faster health services, Greater accuracy in management, AI systems available 24/7, reducing workforce burden, and equality in healthcare decision making. The top five concerns were: Data cybersecurity, bias and quality of AI data, less human interaction, algorithm errors and responsibility, and limitation in technology. Conclusion: This is the first formal qualitative study exploring patient public views on the use of AI in healthcare, and highlights that there is a clear understanding of the potential benefits delivered by this technology. Greater patient public group involvement, and a strong regulatory framework is recommended

A lower critical coracoid process angle is associated with Type-B osteoarthritis: a radiological study of normal and diseased shoulders

Degenerative rotator cuff tears (RCT) and osteoarthritis (OA) are associated with differences in coronal plane scapular morphology, with particular focus on the effect of the Critical Shoulder Angle (CSA) on shoulder biomechanics. The effect, if any, of axial plane scapular morphology is less well established. We have noticed wide disparity of axial coracoid tip position in relation to the face of the glenoid, and sought to investigate the significance of this through measurement of the Critical Coracoid Process Angle (CCPA), which incorporates coracoid tip position and glenoid version. Methods: CCPA, CSA and glenoid retroversion were measured by three independent reviewers from the cross-sectional imaging of 160 patients in four equal and matched case-control groups: 1) a control group of patients with a radiologically normal shoulder and no history of shoulder symptoms who had a CT thorax for another reason; 2) patients with primary OA with Walch Type-A glenoid wear pattern on CT scan; 3) patients with Type-B glenoid primary OA; 4) patients with MRI proven atraumatic tears of the posterosuperior rotator cuff. Results: Interobserver agreement was excellent for all measured parameters. Median CCPA was significantly lower in the Type-B OA group (9.3˚) when compared to controls (18.7˚), but not significantly different in the other study groups. There was a trend towards greater glenoid retroversion in the Type-B OA group, but Receiver Operating Characteristic curve analysis demonstrated CCPA to be by far the most powerful discriminator for Type-B OA. Optimal cut-off value was calculated for CCPA at 14.3˚ with a sensitivity of 93% and specificity of 90% for Type-B OA. Compared to controls, CSA was significantly higher than controls in the RCT group, and lower in both OA groups, but did not differentiate between Type-A and Type-B OA. Conclusion: Combined with a lower CSA, a lower CCPA (<14.3˚) is strongly predictive of Type-B glenoid OA. The authors propose a simple model of Pectoralis Major biomechanics to explain the effect of this axial plane anatomical variation, which requires further investigation

The effect of obesity on revision rate in unicompartmental knee arthroplasty: a systematic review and meta-analysis

The number of patients with knee osteoarthritis, the proportion that is obese and the number undergoing unicompartmental knee arthroplasty (UKA) are all increasing. The primary aim of this systematic review was to determine the effects of obesity on outcomes in UKA. A systematic review was performed using PRISMA guidelines and the primary outcome was revision rate per 100 observed component years, with a BMI of ≥ 30 used to define obesity. The MINORS criteria and OCEBM criteria were used to assess risk of bias and level of evidence, respectively. 9 studies were included in the analysis. In total there were 4621 knees that underwent UKA. The mean age in included studies was reported to be 63 years (mean range 59.5–72 years old)) and range of follow up was 2–18 years. Four studies were OCEBM level 2b and the average MINORS score was 13. The mean revision rate in obese patients (BMI > 30) was 0.33% pa (95% CI − 3.16 to 2.5) higher than in non-obese patients, however this was not statistically significant (p = 0.82). This meta-analysis concludes that there is no significant difference in outcomes between obese and non-obese patients undergoing UKA. There is currently no evidence that obesity should be considered a definite contraindication to UKA. Further studies are needed to increase the numbers in meta-analysis to explore activity levels, surgeon’s operative data, implant design and perioperative complications and revision in more depth

Increased perioperative mortality for femoral neck fractures in patients with coronavirus disease 2019 (COVID-19): experience from the United Kingdom during the first wave of the pandemic

The coronavirus disease 19 (COVID-19) pandemic has presented modern healthcare with an unprecedented challenge. At the peak of the pandemic, Trauma and Orthopaedic services at our institutions undertook internal restructuring, diverting resources to frontline medical care. Consequently, we sought to assess the impact on the elderly and comorbid patients presenting with femoral neck fractures, with a particular focus on 30-day mortality, length of stay, multidisciplinary team involvement and departmental structuring. Method A retrospective analysis of patients presenting with femoral neck fractures at three separate West London NHS Trusts was undertaken between March 11, 2020, to April 30, 2020. Length of stay, mortality and adherence to parameters constituting the best care evidence-based practice tariffs were compared between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and negative patients. A similar comparison was also conducted between our cohort and the equivalent period in 2018 using data from the National Hip Fracture Database. Results A total of 68 patients presenting with femoral neck fractures were identified, mean age 81 (range 38-98), 73% female. There were 10 confirmed/suspected cases of COVID-19 on admission and a further seven confirmed as inpatients. The 30-day mortality within our cohort was 11.76% compared to 6% nationally in 2018 (p=0.045). Orthogeriatric reviews occurred within 72 hours in 71% of cases compared to 88% in the equivalent 2018 period. Within our cohort, mean length of stay was 17.13 days (SD 5.6, range 8-27days) for SARS-CoV-2 positive patients compared to 10 days (SD 8.7, range 1-53 days) for negative patients (p<0.05). Thirty-two patients (47%) required increased packages of care on discharge or rehabilitation. Conclusions The increase in 30-day mortality for SARS-CoV-2 positive patients presenting with femoral neck fractures is multifactorial, resulting from a combination of the direct effects of COVID-19 pneumonia as well as changes to the delivery of orthopaedic services. The provision of multidisciplinary care was directly affected by staff redeployment, particularly reorganisation of orthogeriatric services and lack of continuity of ward based clinical care. Our experiences have re-directed our efforts towards the management of theatre teams, patient services and staffing, should we be faced with either a resurgence of COVID-19 or a future pandemic

A nutrient combination designed to enhance synapse formation and function improves outcome in experimental spinal cord injury

We gratefully acknowledge support from Nutricia Research (NSCP1B7R)