Bleeding complications in patients on warfarin undergoing joint injection/aspiration: systematic review and meta-analysis

Steroid injections in joints are commonly administered for the management of inflammatory or degenerative conditions. There is substantial controversy as to whether to continue warfarin when undertaking joint injection or aspiration. To assess the rate of bleeding complications in patients on warfarin undergoing joint injection/aspiration. Systematic review and meta-analysis. A literature search of 3 online databases was conducted by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study that reported bleeding complication rates in adult patients on warfarin undergoing a joint injection/aspiration whilst taking warfarin anticoagulation. Studies reporting on less than 5 patients were excluded. Meta-analysis was conducted using a random effects model. The search of databases resulted in a total of 1547 articles. After screening, 8 articles were deemed suitable for inclusion in the analysis, involving 871 injection/aspiration procedures. There were only 5 reported cases of bleeding. On meta-analysis the estimated bleeding complication rate was 1.5% (95% CI 0.5–4.5%). This meta-analysis shows that it is safe to perform joint injection and aspiration in patients on warfarin without routine prior testing of INR

COVID-19 Is Associated With a 4 Fold Increase in 30-day Mortality Risk in Hip Fracture Patients in the United Kingdom: A Systematic Review and Meta-analysis

Background: Hip fracture in elderly patients is associated with a significant mortality which may be worsened by COVID-19 infection. Objective: To undertake a systematic review and meta-analysis of studies assessing the effect of COVID-19 infection and mortality rates in hip fracture patients in the United Kingdom (UK) during the first surge of the pandemic. Design: A systematic literature search of 9 online databases was undertaken independently by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study of an adult population with a hip fracture that assessed the relationship between COVID-19 infection and 30-day mortality in the UK. Meta-analysis was conducted using a random-effects model. Results: Out of 309 identified articles, 10 studies reporting on 2448 hip fracture patients met the inclusion criteria. Meta-analysis showed that the estimated mortality rate in patients with laboratory confirmed COVID-19 infection was 32.5% (95% CI= 28.3 to 37.0) compared to 8.6% (95% CI= 6.3 to 11.6) in COVID-19 negative patients. Meta-analysis of 9 comparative studies showed a significantly higher mortality in patients with laboratory confirmed COVID-19 infection as compared to patients without (RR=3.937, 95% CI= 2.867 to 5.406, P<.001). Similar findings were obtained when comparing mortality in COVID-19 laboratory confirmed or clinically suspected infected vs non-infected patients (RR=4.576, 95% CI = 3.589 to 5.835, P <.001). Conclusions: COVID-19 infection is associated with a 4-fold increase in mortality risk in hip fracture patients. Every effort should be made to avoid COVID-19 infection and nosocomial exposure in this highly vulnerable patient group

Can the use of Proprioceptive Knee Braces have Implications in the Management of Osteoarthritic Knees: An exploratory study?

Background: Use of proprioceptive knee braces to control symptomology by altering neuromuscular control mechanisms has been shown in patellofemoral pain. Though their potential in patients with knee osteoarthritis (OA) is vast, little research has examined their efficacy. Methods: Thirteen healthy participants were asked to perform a 10cm stepdown task with and without a Proprioceptive Brace. Data was collected using a 10-camera Qualisys system. Individuals with OA completed the Knee Osteoarthritis Outcome Score (KOOS) pre- and post 4-week intervention. Results: During stepdown reductions in knee maximum internal rotation, transverse range of movement, transverse plane angular velocity and maximum internal rotation angular velocity was seen. Ankle plantar flexion and inversion angular velocity decreased while inversion and maximum supination angular velocity increased. Improvements in KOOS were noted across all parameters with brace use. Conclusions: Positive changes in kinematic variables in multiple planes can be achieved with proprioceptive bracing alongside improved patient outcome. These changes occur at the knee but analysis of other weight bearing joints should not be overlooked in future studies. This study supports the concept of neuromuscular reinforcement and re-education through proprioceptive bracing and its application in the management in knee OA

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

Wastewater reuse for irrigation and seawater intrusion: Evaluation of salinity effects on soils in Cyprus

Climate change and the continuous population growth increase the demand for water, which in arid and semiarid regions, like the Mediterranean, is considered a limited resource. Future demands will not be met by traditional water resources like surface and groundwater. In order to handle increased water demand, the treated wastewater originating from municipal wastewater treatment plants is offered to farmers for agricultural irrigation. Over pumping of fresh groundwater creates seawater intrusion that causes various problems, besides others, to the quality of recycled water used for agricultural purposes. The effects on soils irrigated with saline water are investigated. Actual investigations were carried out in land irrigated with salinity-affected wastewater and non-irrigated land nearby. Soil profile analyses are demonstrated and compared, showing very interesting results and adverse effects on soil resources. Irrigation with saline waters even at slightly above recommended values can have severe effects on soil resources. Various remediation scenarios for preventing seawater intrusion, as well for mitigation or control of soil salinity problems, are also suggested in this study. This case study was carried in the Larnaca district in Cyprus

The impact of a meta‐analysis on orthopaedic surgeons' practice with regards to vancomycin graft pre‐soaking in anterior cruciate ligament reconstruction: A paper questionnaire survey study

Abstract Background and Aims Understanding the impact of orthopaedic scientific research is vital in identifying facilitators and barriers to its implementation in clinical practice. A meta‐analysis was carried out which showed that presoaking hamstring (HT) autografts in vancomycin was associated with a 10‐fold reduction in infection rate in anterior cruciate ligament (ACL) reconstruction. Our aim was to determine the practice of orthopaedic surgeons with regards to vancomycin presoaking and explore whether they would adopt the findings of this meta‐analysis. Methods A paper questionnaire survey was administered to attendees of an annual EFORT podium presentation of the meta‐analysis findings. Descriptive statistics were used to summarize the characteristics of respondents and their responses. Results A total of 29 senior surgeons/subspecialists performing a median of 40 ACL reconstructions per year completed the survey of whom 7 (24.1%) had encountered an ACL graft infection in the previous 2 years and 14 (48.3%) in the previous 5 years. Only 3 (10.3%) presoaked the ACL graft with an antibiotic. About 1/4 of those who up to then did not pre‐soak the graft (6/26, 23.1%) would consider changing their practice to pre‐soaking with vancomycin, with similar findings (5/20, 25.0%) in those that used a HT autograft as their first choice. Conclusions Orthopaedic surgeons are receptive to the findings of a meta‐analysis reporting on the effectiveness of vancomycin graft presoaking in ACL reconstruction, which can thus have a substantial impact upon clinical care. Addressing concerns about vancomycin induced graft toxicity and comparing the pre‐soaking effect to that of specific intravenous antibiotic regimens may further enhance the uptake of this practice