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Monday 25 April 2022

WUTH publication: Alterations of mucosa-attached microbiome and epithelial cell numbers in the cystic fibrosis small intestine with implications for intestinal disease

Citation: Scientific Reports. 2022, 12(1), 6593
Author: Jennifer Kelly, Miran Al-Rammahi, Kristian Daly, Paul K Flanagan, Arun Urs, Marta C Cohen, Gabriella di Stefano, Marcel J C Bijvelds, David N Sheppard, Hugo R de Jonge, Ursula E Seidler, Soraya P Shirazi-Beechey
Abstract: Cystic fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Defective CFTR leads to accumulation of dehydrated viscous mucus within the small intestine, luminal acidification and altered intestinal motility, resulting in blockage. These changes promote gut microbial dysbiosis, adversely influencing the normal proliferation and differentiation of intestinal epithelial cells. Using Illumina 16S rRNA gene sequencing and immunohistochemistry, we assessed changes in mucosa-attached microbiome and epithelial cell profile in the small intestine of CF mice and a CF patient compared to wild-type mice and non-CF humans. We found increased abundance of pro-inflammatory Escherichia and depletion of beneficial secondary bile-acid producing bacteria in the ileal mucosa-attached microbiome of CFTR-null mice. The ileal mucosa in a CF patient was dominated by a non-aeruginosa Pseudomonas species and lacked numerous beneficial anti-inflammatory and short-chain fatty acid-producing bacteria. In the ileum of both CF mice and a CF patient, the number of absorptive enterocytes, Paneth and glucagon-like peptide 1 and 2 secreting L-type enteroendocrine cells were decreased, whereas stem and goblet cell numbers were increased. These changes in mucosa-attached microbiome and epithelial cell profile suggest that microbiota-host interactions may contribute to intestinal CF disease development with implications for therapy.

Thursday 14 April 2022

WUTH publication: An Uncommon Presentation of Fracture-dislocation of the 4th and 5th Carpometacarpal Joints with Volar Displacement and its Management

Citation: Journal of Orthopaedic Case Reports. 2021, 11(9), 24-28
Author: Nikhil Jawaharlal, Vasanthakumar Ramsingh, Vijaya Bhalaik 
Abstract: Introduction: Carpo-metacarpal joint fracture-dislocations are rare injuries. They constitute less than 1% of all hand injuries [1]. They often go unnoticed [2]. Of these, dorsal fracture-dislocations on the ulnar side are more commonly seen [3] because of the greater stabilizing dorsal structures. Volar fracture-dislocations are very rare and difficult to diagnose for which, one should have a keen eye on.
Case report: This is a case of a 51-year-old female with a closed injury to her wrist. With clinical suspicion and appropriate radiographs fracture-dislocation of the 4th and 5th carpometacarpal joints with volar displacement was diagnosed. She underwent closed reduction and percutaneous Kirschner wire fixation, followed by 6 weeks of immobilization. At the final follow-up in 4 months, the patient was noted to have a satisfactory outcome following intense physiotherapy.
Conclusion: Fourth and fifth carpometacarpal joint fracture-dislocations of the fingers are unique; their diagnosis can be challenging and often overlooked [4], which if missed can have very poor outcomes. The functional prognosis depends on the precocity of diagnosis and appropriate reduction and vigorous rehabilitation.
Keywords: Carpometacarpal joint; fracture-dislocation; volar displacement; wrist injury.

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Tuesday 12 April 2022

WUTH publication: Subspecialist abdominal wall reconstruction services in Canada

Citation: Canadian Journal of Surgery. 2022, 65(2), E264-E265
Author: Simon T Adams, Michael Harington 
Abstract: SummaryRecent years have seen considerable increases in both the demand for, and complexity of, ventral hernia repairs. This has led to calls for abdominal wall surgery to become a recognized subspecialty in the United States and Europe, with some centres responding by forming specialized, multidisciplinary teams for abdominal wall reconstruction. At present, however, no Canadian city has followed suit. In this article, we outline the major arguments underlying the drive toward the centralization of complex abdominal wall services. 

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Thursday 7 April 2022

WUTH publication: The British Orthopaedic Surgery Surveillance study: Perthes' disease: the epidemiology and two-year outcomes from a prospective cohort in Great Britain

Citation: The bone & joint journal. 2022, 104-B(4), 510-18 
Author: Daniel C Perry, Barbara Arch, Duncan Appelbe, Priya Francis, Joanna Craven, Fergal P Monsell, Paula Williamson, Marian Knight, BOSS collaborators 
Abstract: Aims: The aim of this study was to evaluate the epidemiology and treatment of Perthes' disease of the hip.
Methods: This was an anonymized comprehensive cohort study of Perthes' disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children's hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.
Results: Overall, 371 children (396 hips) were newly affected by Perthes' disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years.
Conclusion: Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510-518.
Keywords: Avascular necrosis; BOSS; Cohort; Epidemiology; Incidence; Legg-CalvĂ©-Perthes; Legg-calve-perthes disease; Osteonecrosis; Patient-reported outcome measures (PROMs); Perthes; clinicians; cohort studies; epidemiology; hip disease; hips; orthopaedic surgery; radiological outcomes; randomized controlled trials. 

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Tuesday 5 April 2022

WUTH publication: The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain

Citation: The bone & joint journal. 2022, 104-B(4), 519-28 
Author: Daniel C Perry, Barbara Arch, Duncan Appelbe, Priya Francis, Joanna Craven, Fergal P Monsell, Paula Williamson, Marian Knight, BOSS collaborators 
Abstract: Aims: The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE).
Methods: This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.
Results: A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define 'at risk'. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE.
Conclusion: The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519-528.
Keywords: Avascular necrosis; BOSS; Cohort study; Epidemiology; Incidence; Patient-reported outcome measures (PROMs); SCFE; SUFE; Slipped capital femoral epiphysis; Slipped capital femoral epiphysis (SCFE); Slipped upper femoral epiphysis; avascular necrosis; clinicians; deformity; hip(s); open reduction and internal fixation; orthopaedic surgery; prophylactic fixation; randomized controlled trials. 

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