Prevention: can we stop problems before they arise?

It is estimated that 50% of diabetic ulcerations and amputations can be prevented by identifying the at-risk foot and implementing preventative strategies. Patients with diabetes mellitus (DM) should be screened and placed in the appropriate risk category. Risk factors for the development of ulcer in several prospective studies include neuropathy, deformity, limited joint mobility, vascular disease, and history of previous ulceration or amputation. Early identification of the at-risk foot and placing the patient in the appropriate risk category is essential to prevention. Once the at-risk foot is identified, abnormal foot pressures should be reduced or eliminated using several treatment options. Repetitive, moderate mechanical stress (the pressure time integral) is often the initial mechanism of injury in the formation and/or recurrence of diabetic foot ulcers. Once conservative treatment options to off load the foot have failed, surgery should be considered. There are patients with diabetic foot ulcers for whom a combination of surgery (intrinsic off loading) and extrinsic off loading is better than either method alone. These difficult wounds are characterized by a combination of variables acting singularly or together, such as neuropathy, rigid deformity, limited joint mobility, and activity level. Our experience dictates, patients with rigid deformity and limited joint mobility get caught in the cycle of repetitive stress and cannot break the cycle until the etiology of the structural deformity is addressed surgically and preventative strategies for off loading, temperature monitoring, and activity level are implemented. If a structural deformity exists, the deformity will delay or prevent healing of the ulcer. Once the ulcer is healed, the likelihood for recurrence is high unless the deformity is corrected. When a structural deformity exists, the patient should be referred for evaluation and possible prophylactic surgery.     

Dynamic live imaging of bone: opening a new era with ‘bone histodynametry’

Recent advances in optical imaging with two-photon excitation microscopy have enabled visualization of the inside of intact bone tissues in living animals. Using these advanced techniques, the dynamic behaviors of live bone cells and static histological information on bone tissue structures can be elucidated. The migration and positioning of osteoclast precursor monocytes, the bone-resorbing function of mature osteoclasts, and its functional coupling with bone-replenishing osteoblasts have been evaluated, including their dynamic properties in intact live bones. This novel ‘bone histodynametric’ methodology, combined with conventional histomorphometric analyses, will surely contribute to opening of a new era in bone and mineral research.     

Data from national media reports of ‘Acid attacks’ in England: A new piece in the Jigsaw

IntroductionThere has been considerable concern in the UK with what seems to have been an increase in so-called ‘Acid Attacks’. The key data sources (Police data, Hospital admissions and Burns unit data) have limitations in capturing the acid attacks comprehensively. Incidents not reported to the police are missed in the Police data. The more serious injuries are included in the hospital admissions data, with no information on people with less severe injuries, not accessing health care. Burns unit data reveals detailed information on the burns treatment but represents only a small percent of all the acid attacks. Our aim was to explore the role of media reports as an additional data source.MethodsData was obtained from the public domain using generic online search engines along with a formal medical literature review. Search parameters included any news articles on ‘Acid Attacks’ printed between 01/01/2016 and 31/12/2017 in England and Articles in National Press only. We compared the data from media reports to the only other data sources available on these crimes which were (a) Crime statistics from police (b) the proportion treated in hospital (c) the subgroup treated in the burns service in the highest incidence location in the UK.ResultsTwo hundred and Thirty media articles in total were found in the preliminary search. Following the application of the exclusion criteria, sixty attacks were analysed. The demographic data, the geographic data were obtained from the articles and the results were analysed using Microsoft Excel. There were a total of 118 survivors with an average age of 29.5 years and a male to female ratio of 5.1:1. There were no reported deaths. In the assailants group, the average age was 21.6 years with a male to female ratio of 15.7:1.All the data sources revealed higher male survivor predominance. The average age of the survivors was similar in the media reports, police data and the Burns centre data and was higher in the hospital data. Information on assailants and motives, available only on media reports and police data, corroborated well with each other. Media reports gave further information on the circumstances of the incident, the location and the number of survivors per assault, which was not available on any other data source.Though there was a rise in chemical assaults reported in media reports and MPS data in 2017 compared to the previous year, there was no rise in chemical assault related hospital admissions.ConclusionThe majority of the survivors were males, which is consistent between all UK data sources. Media reports revealed that the South east of England had the majority of chemical assaults in England. Data from this source provides a further piece in the jigsaw especially in relation to the circumstances, the geographic location of the chemical assault and number of survivors per incident. We acknowledge the limitations of media reporting. In the absence of a formal database for such injuries and incomplete data from various sources, we have to consider all possible data sources to provide new information. We have discussed the utility, pros & cons of media reports as one of the additional sources of information to better understand these injuries.     

In with the new, out with the old? Comparison of two approaches for psoas compartment block

We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy. Sixty patients underwent PCB (0.4 mL/kg levobupivacaine 0.5%) and subsequent spinal anesthesia for primary joint arthroplasty (hip or knee) in a prospective, double-blind study. Patients were randomly allocated to undergo PCB by using the Capdevila (group C; n = 30) or a modified Winnie (group W; n = 30) approach. Contralateral spread and lumbar plexus blockade were assessed 15, 30, and 45 min after PCB. Contralateral spread (bilateral from T4 to S5) and femoral and lateral cutaneous nerve block were evaluated by sensory testing, and obturator motor block was assessed. Bilateral anesthesia occurred in 10 patients in group C and 12 patients in group W (P = 0.8). Blockade of the femoral, lateral cutaneous, and obturator nerves was 90%, 93%, and 80%, respectively, for group C and 93%, 97%, and 90%, respectively, for group W (P > 0.05). No differences were found in PCB procedure time, pain scores, 24-h morphine consumption, or time to first morphine analgesia.     

Tibial hemimelia with ‘mirror foot’

Mirror foot anomalies are extremely rare forms of duplications of toes. They can be associated with several other anomalies such as mirror hands, fibular dimelia, tibial hypoplasia/aplasia or facial deformities. A case of a mirror foot anomaly in association with an extremely rare variant of tibial hemimelia is presented. Other similar cases in the literature and modern theories regarding the aetiology are also presented.     

‘POSTE’ study (Patients OSTeopathic Experience): A UK national survey of patients: Part III

BackgroundPatient satisfaction is a complex process, which is not solely based on the patient outcome, but also patient's perception and expectation as well as communication and information from the healthcare practitioner. Patients who are satisfied are known to have greater treatment compliance, better outcomes and result in fewer malpractice cases.MethodsAdverts were placed in a number of national newspapers; posters were placed in osteopathic clinics, Osteopathic Educational Institutes and GP surgeries directing patients who had undergone osteopathic treatment to an online or postal questionnaire. Not all questions needed to be completed. Respondents could answer for good and/or bad experiences. Local ethical approval was granted.ResultsThere were 764 responses: 547 responses reported a good experience, 68 reported a bad experience and 149 reported both good and bad experiences. There was no significant difference in gender (p = 0.14) or age for reported experience. There was no difference in health status and reported experiences (p = 0.7). Those who reported good experiences were significantly more likely to have been referred to an osteopath (p = 0.01), though referral was from a number of sources. There was no statistical significance between the expectation of recovery or outcome between good and bad experiences. Visual analogue scale after treatment was significantly lower in those who reported a good experience compared to those who had a bad experience (p < 0.001). Participants who described a bad experience were significantly less likely to have their treatment explained in full compared to those who described a good experience (p ≤ 0.01) and the osteopaths were significantly less likely to have performed a risk assessment with respondents who described a bad experience (p < 0.01). Further those who reported a bad experience more often reported a treatment reaction. Those who described a bad experience were significantly less likely to complete their course than those who described a good experience (p < 0.001); however, they would still recommend osteopathy to friends and family.ConclusionsOsteopathic patients report a high level of satisfaction in both this current study and in other published studies. However, those patients who did report a bad experience one of the issues was a failure of the osteopath to explain to the patient the treatment method, the risks and to perform a risk assessment. Explaining treatment effects and risks more effectively could further improve patient satisfaction in osteopathy.