Mansfield Community Hospital

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1 . A series of 166 fractures and fracture-dislocations of the dorso-lumbar spine has been reviewed. 2. A new method of classifying these injuries is suggested. 3. A type of fracture with lateral wedging, previously unidentified, which has certain distinctive clinical and anatomical features is described. 4. The factors responsible for redisplacement are discussed and it is considered that in most cases this is predictable from the outset. 5. At the present time orthodox treatment is based on the assumption that a perfect anatomical result is indispensable to a perfect functional result. Analysis of the results in the series now reported shows that there are no grounds for this assumption. 6. Treatment is discussed in the light of the foregoing conclusions. This is based on a division of cases into stable and unstable types, the recognition of which is of crucial importance.

OBJECTIVE: To assess the feasibility of conducting a randomised controlled trial of a home-based virtual reality system for rehabilitation of the arm following stroke. DESIGN: Two group feasibility randomised controlled trial of intervention versus usual care. SETTING: Patients' homes. PARTICIPANTS: Patients aged 18 or over, with residual arm dysfunction following stroke and no longer receiving any other intensive rehabilitation. INTERVENTIONS: Eight weeks' use of a low cost home-based virtual reality system employing infra-red capture to translate the position of the hand into game play or usual care. MAIN MEASURES: The primary objective was to collect information on the feasibility of a trial, including recruitment, collection of outcome measures and staff support required. Patients were assessed at three time points using the Wolf Motor Function Test, Nine-Hole Peg Test, Motor Activity Log and Nottingham Extended Activities of Daily Living. RESULTS: Over 15 months only 47 people were referred to the team. Twenty seven were randomised and 18 (67%) of those completed final outcome measures. Sample size calculation based on data from the Wolf Motor Function Test indicated a requirement for 38 per group. There was a significantly greater change from baseline in the intervention group on midpoint Wolf Grip strength and two subscales of the final Motor Activity Log. Training in the use of the equipment took a median of 230 minutes per patient. CONCLUSIONS: To achieve the required sample size, a definitive home-based trial would require additional strategies to boost recruitment rates and adequate resources for patient support.

Abstract Reforestation involves potential trade‐offs: hard choices between environmental and social benefits, individual and community benefits, and among stakeholders who bear different costs and benefits. In this manuscript, we aim to show that successful long‐term reforestation requires stakeholder engagement beyond planning stages and a recognition of the dynamism of stakeholder outlooks as stakeholders’ opportunities, relationships, interests, and roles change over time. We first summarize lessons from recent literature on stakeholder involvement within reforestation efforts. We then present findings from a multiple‐stakeholder workshop organized in west‐central Mexico, in which we illustrate their choices on how to navigate trade‐offs among different reforestation intervention strategies (agroforestry/silvopastoral, natural regeneration, native species reforestation, commercial plantations). We confirm that individual stakeholders’ circumstances, interests, and roles, as well as the contextual factors shaping them, are dynamic, continually changing the nature of the choices stakeholders face. Finally, we propose a four‐phase pathway for addressing dynamic trade‐offs and synergies in stakeholder participation in order to select, implement, and sustain successful reforestation activities. The pathway comprises four phases: (1) collaborate to devise a reforestation strategy through dialogue about dynamic trade‐offs; (2) pledge robust stakeholder commitments to mutual arrangements for implementing reforestation; (3) implement reforestation interventions; and (4) adjust strategy through continuous evaluation of outcomes. We then elucidate how components of these four phases can be operationalized so that, on one side, scientists and practitioners might better understand the dynamic trade‐offs reforestation poses for stakeholders, and on the other, stakeholders might balance their hard choices in ways that promote forest recovery.

A total of 4000 consecutive cholecystectomies performed over a period of 25 years has been analysed to determine whether routine peroperative cholangiography (PC) has influenced overall mortality. The patients have been divided into four cohorts of 1000, the first cohort before the introduction of PC, two covering the period of introduction of PC and the final cohort when PC was an established routine. A significant fall in overall mortality has been demonstrated, but when the patients are divided into simple cholecystectomy and the group undergoing additional choledochotomy there is no significant fall in the mortality rate. The mortality rate for the latter group is three or four times greater than that for the cholecystectomy alone group. The main contribution to the lower mortality is the reduced duct exploration rate following the introduction of PC. The stone recovery rate has improved from 34 to 71 per cent. The use of routine PC during cholecystectomy is recommended.

We describe a previously unreported test to confirm accurate needle placement in caudal epidurals. Of 26 patients undergoing caudal epidural, 19 (73%) had correct needle placement as determined by epidurography. All of these had a positive 'whoosh' test. There were no false positives.

INTRODUCTION: Symptoms may persist after the initial phases of COVID-19 infection, a phenomenon termed long COVID. Current knowledge on long COVID has been mostly derived from test-confirmed and hospitalized COVID-19 patients. Data are required on the burden and predictors of long COVID in a broader patient group, which includes both tested and untested COVID-19 patients in primary care. METHODS: This is an observational study using data from Platform C19, a quality improvement program-derived research database linking primary care electronic health record data (EHR) with patient-reported questionnaire information. Participating general practices invited consenting patients aged 18-85 to complete an online questionnaire since 7th August 2020. COVID-19 self-diagnosis, clinician-diagnosis, testing, and the presence and duration of symptoms were assessed via the questionnaire. Patients were considered present with long COVID if they reported symptoms lasting ≥4 weeks. EHR and questionnaire data up till 22nd January 2021 were extracted for analysis. Multivariable regression analyses were conducted comparing demographics, clinical characteristics, and presence of symptoms between patients with long COVID and patients with shorter symptom duration. RESULTS: Long COVID was present in 310/3151 (9.8%) patients with self-diagnosed, clinician-diagnosed, or test-confirmed COVID-19. Only 106/310 (34.2%) long COVID patients had test-confirmed COVID-19. Risk predictors of long COVID were age ≥40 years (adjusted Odds Ratio [AdjOR]=1.49 [1.05-2.17]), female sex (adjOR=1.37 [1.02-1.85]), frailty (adjOR=2.39 [1.29-4.27]), visit to A&E (adjOR=4.28 [2.31-7.78]), and hospital admission for COVID-19 symptoms (adjOR=3.22 [1.77-5.79]). Aches and pain (adjOR=1.70 [1.21-2.39]), appetite loss (adjOR=3.15 [1.78-5.92]), confusion and disorientation (adjOR=2.17 [1.57-2.99]), diarrhea (adjOR=1.4 [1.03-1.89]), and persistent dry cough (adjOR=2.77 [1.94-3.98]) were symptom features statistically more common in long COVID. CONCLUSION: This study reports the factors and symptom features predicting long COVID in a broad primary care population, including both test-confirmed and the previously missed group of COVID-19 patients.

Synaptosomal associated protein 25 kDa (SNAP25) is an essential component of the SNARE complex regulating synaptic vesicle fusion. SNAP25 deficiency has been implicated in a variety of cognitive disorders. We ablated SNAP25 from selected neuronal populations by generating a transgenic mouse (B6-Snap25tm3mcw (Snap25-flox)) with LoxP sites flanking exon5a/5b. In the presence of Cre-recombinase, Snap25-flox is recombined to a truncated transcript. Evoked synaptic vesicle release is severely reduced in Snap25 conditional knockout (cKO) neurons as shown by live cell imaging of synaptic vesicle fusion and whole cell patch clamp recordings in cultured hippocampal neurons. We studied Snap25 cKO in subsets of cortical projection neurons in vivo (L5-Rbp4-Cre; L6-Ntsr1-Cre; L6b-Drd1a-Cre). cKO neurons develop normal axonal projections, but axons are not maintained appropriately, showing signs of swelling, fragmentation and eventually complete absence. Onset and progression of degeneration are dependent on the neuron type, with L5 cells showing the earliest and most severe axonal loss. Ultrastructural examination revealed that cKO neurites contain autophagosome/lysosome-like structures. Markers of inflammation such as Iba1 and lipofuscin are increased only in adult cKO cortex. Snap25 cKO can provide a model to study genetic interactions with environmental influences in several disorders.

Although well described in the orthopaedic literature and some orthopaedic textbooks, postoperative discitis is regularly missed or diagnosed late. Six cases of discitis were studied in detail with special reference to the clinical presentation. All patients with discitis had an erythrocyte sedimentation rate (ESR) greater than 50 at 2 or more weeks after surgery. A prospective study of 26 patients undergoing uncomplicated discectomy or fusion was made. ESRs were measured preoperatively and at 1,2, and 6 weeks after operation. Any patient with increasing back pain and an ESR greater than 52 or more weeks after surgery should be considered to have discitis until proven otherwise. If the ESR is measured routinely preoperatively and at 2 weeks postoperatively, this condition should not be missed.

Spondylolysis of more than one lumbar vertebra occurring in the same individual is rare. The incidence of multiple lumbar spondylolyses appears to vary between 1.2% and 5.6%. Most cases respond to conservative treatment. When surgery is indicated, it must be radical, and the fusion should include all the defects and the intervening normal vertebrae and the sacrum. The condition is more common among men, and trauma plays a major role in its initial appearance.

Respiratory function was assessed in 20 patients with idiopathic scoliosis undergoing spinal surgery (median age, 15 years; range, 11-34 years; median preoperative vital capacity, 67%; range, 28-109% predicted). Ten patients underwent anterior spinal surgery through a thoracotomy incision, seven of whom had posterior spinal surgery as a second-stage procedure. The other ten had posterior spinal surgery as their initial operation. Postoperatively, three patients had clinical evidence of respiratory complications. Daytime oxygen saturation was reduced throughout the first postoperative week, with no significant difference between anterior and posterior spinal surgery. Hypercapnia was unusual and generally mild. Vital capacity was reduced significantly 1 week after both anterior and posterior spinal surgery (P less than 0.05). The median vital capacity 1 week after anterior spinal surgery was 45% of preoperative values compared with 78% after posterior surgery (P less than 0.05). Inspiratory muscle strength, as assessed by sniff mouth pressure, was 56% of preoperative values 1 week after anterior spinal surgery (P less than 0.05) and 85% after posterior spinal surgery (not significant). Vital capacity, but not sniff mouth pressure, remained significantly reduced 6 weeks after surgery. Oxygen saturation should be monitored noninvasively during the first week after both anterior and posterior spinal surgery even in patients at low risk of developing respiratory complications.

Immunoscintigraphy using radioisotope-labelled monoclonal antibody prepared against osteosarcoma 791T cells was used to detect a primary osteosarcoma. The eight-centimetre tumour was detected using rectilinear scintigraphy of 131I-labelled antibodies. Image enhancement was achieved by subtraction of blood-pool radioactivity labelled with technetium-99m. The ratio of tumour to non-tumour uptake of radioactivity (5:1) suggested that antibody targeting of therapeutic agents is feasible.

We present the results of 38 children with leg inequality treated by circumferential periosteal release. Leg-length discrepancy was expressed as a percentage of the longer limb. All patients showed a decrease in percentage difference at one year after operation, the mean difference dropping from 7.24% to 5.45%. The size of the response was directly related to the age of the patient at operation, being more pronounced in the younger patients. The response was not related to sex, diagnosis, or rate of growth of the patient immediately preceding operation.

FORSTER, I. W. F.R.C.S; CRAWFORD, R. M.B.B.S.Editor(s): URIST, MARSHALL R. M.D., Editor-in-Chief Author Information

Tricho-rhino-phalangeal syndrome is probably not so much uncommon as unrecognised. Its significance to orthopaedic surgeons, apart from the functionally unimportant minor finger deformities, lies in its mimicking both Perthes' disease and diaphyseal aclasis. The 14 cases analysed in this paper illustrate the wide range of clinical variation.

The indications for anterior surgery are well defined in the upper and lower cervical spine if one accepts the importance of early restoration of stability for improved patient rehabilitation. Cannulated screw fixation of Type II fractures of the odontoid peg is a highly specialized procedure that requires technical expertise still only available at a limited number of orthopaedic centers. The engineering improvements in internal fixation for the anterior cervical spine, allied with an increasing expertise in instrumentation, have increased the tendency toward anterior stabilization for all unstable lower cervical fractures, except irreducible dislocations, irrespective of the mechanism of injury. Most thoracolumbar fractures with less than 50% to 60% canal compromise can be adequately dealt with by posterior surgery, largely because of the powerful correction inherent in the short segment, pedicle crew systems available. Anterior surgery continues to have a role in the correction of severe disruption, late deformity, and chronic anterior cord compression. No ideal anterior internal fixation system exists, but the Kaneda device is undoubtedly the strongest. The timing and indications for intervention for acute cord compression remain controversial in the absence of neurologic deterioration, although the route is undisputedly anterior in view of the usual site of compression.

A series of fifty one lesions arising in the hand is reviewed. Fifty nine per cent of the lesions arose from the joints of the hand which are also frequently the site of degenerative changes. Twenty five per cent of available radiographs also showed such changes. The aetiology and diagnosis of this condition, the treatment and the results are discussed.

A new ultrasound method was used to measure femoral anteversion (torsion) of both hips in children with unilateral Perthes' disease, children with previous irritable hips, and healthy children of a similar age. In children with Perthes' disease, the mean femoral anteversion of affected hips is significantly higher compared with normal controls. In the opposite hips, femoral anteversion for right and left hips separately is not significantly different from that of controls. The affected hips show a significantly greater scatter of anteversion than do normal hips, which could be secondary to the disease; but the opposite hips also show a significantly wider scatter of anteversion than do normal hips, which suggests a developmental abnormality of femoral torsion in the femur of the unaffected limb. In children with Perthes' disease, femoral anteversion asymmetry is characteristic, marked, and significantly different from that of normal hips, with the affected hips usually being the more anteverted (with two exceptions). Irritable hips show significantly greater femoral anteversion asymmetry than do normal hips, with the affected femur usually being less anteverted than the opposite femur. These observations may have relevance in Perthes' disease with respect to both etiology, femoral osteotomy, and prognosis.

Research is underway to examine how a wide range of animal species have responded to reduced levels of human activity during the COVID-19 pandemic. In this perspective article, we argue that raptors (i.e., the orders Accipitriformes, Cariamiformes, Cathartiformes, Falconiformes, and Strigiformes) are particularly well-suited for investigating potential 'anthropause' effects: they are sensitive to environmental perturbation, affected by various human activities, and include many locally and globally threatened species. Lockdowns likely alter extrinsic factors that normally limit raptor populations. These environmental changes are in turn expected to influence - mediated by behavioral and physiological responses - the intrinsic (demographic) factors that ultimately determine raptor population levels and distributions. Using this population-limitation framework, we identify a range of research opportunities and conservation challenges that have arisen during the pandemic, related to changes in human disturbance, light and noise pollution, collision risk, road-kill availability, supplementary feeding, and persecution levels. Importantly, raptors attract intense research interest, with many professional and amateur researchers running long-term monitoring programs, often incorporating community-science components, advanced tracking technology and field-methodological approaches that allow flexible timing, enabling continued data collection before, during, and after COVID-19 lockdowns. To facilitate and coordinate global collaboration, we are hereby launching the 'Global Anthropause Raptor Research Network' (GARRN). We invite the international raptor research community to join this inclusive and diverse group, to tackle ambitious analyses across geographic regions, ecosystems, species, and gradients of lockdown perturbation. Under the most tragic of circumstances, the COVID-19 anthropause has afforded an invaluable opportunity to significantly boost global raptor conservation.

The duration of sleep following intravenous administration of three doses of disoprofol (1.2 and 3 mg/kg) was compared with that following methohexione 1 or 2 mg/kg. Disoprofol and methohexitone were shown to be approximately equipotent. Side-effects were dose-related for both drugs, but the incidence was significantly less following disoprofol than methohexitone 2 mg/kg. The most frequent side-effects were pain on injection, myoclonia and hiccup. Studies of blood concentrations of disoprofol show that the profile is dose-independent and conforms to a two-compartment model with a very short distribution phase (about 2 minutes) and short elimination phase (about 70 minutes). Waking blood levels gave no indication of acute tolerance. Disoprofol would appear to be particularly useful for induction of a short period of sleep using a small dose given quickly, or for maintenance of sleep by continuous infusion.