Poole Hospital

Combat-related traumatic injury (CRTI) has been linked to reduced myocardial blood-flow- reserve (MBFR), measured using the subendocardial viability ratio (SEVR). We aimed to assess the mediating role of known cardiovascular risk factors on SEVR. We examined 1018 UK servicemen (prospective ADVANCE Cohort Study) comprising 504 with CRTI (140 amputees) and 514 uninjured men, frequency-matched at sampling, by age, rank and deployment (Afghanistan 2003-2014). We examined the mediating role of cardiovascular risk factors, shown to significantly greater with CRTI at study baseline (~8 years post-injury/deployment), on SEVR, measured three-years later (FU1). The cardiovascular risk measures were heart-rate variability (HRV, root-mean-square-of-successive-differences [RMSSD]), visceral-fat-mass (VFM, using DEXA), venous-blood high-sensitivity C-reactive protein (Hs-CRP, inflammation), six-minute walk distance (6MWD, physical function) and weekly leisure-time moderate-to-vigorous physical activity (LT-MVPA, physical activity). At baseline, VFM was significantly greater and RMSSD, 6MWD and LT-MVPA lower with CRTI compared to the uninjured. VFM and Hs-CRP were significantly greater and RMSSD, 6MWD and LT-MVPA lower in the injured amputees versus the injured non-amputees and uninjured. The SEVR at FU1 was significantly lower in the injured (mean ± standard deviation; 187.2 ± 39.7) compared to the uninjured (194.1 ± 31.5) and lowest in the amputee sub-group (181.9 ± 30.0). The association between CRTI and SEVR was mediated by VFM (natural indirect effect -1.80: 95%CI: -2.90, -0.67), RMSSD (-1.82: -3.45, -0.19) and 6MWD (-1.79: -3.16, -0.41) but not Hs-CRP and LT-MVPA. The association between traumatic amputation and SEVR was mediated by VFM, HRV and LT-MVPA. VFM, HRV and physical function/activity were significant mediators of the link between CRTI and SEVR. Interventions on physical activity/function could mitigate the association between CRTI and SEVR. Data from longer-term follow up are required to robustly determine the temporal effects of this relationship.

Barn-integrated operating rooms represent an emerging model in surgical education, offering open-plan layouts designed to enhance efficiency and learning. Despite growing use across United Kingdom centres, limited data exist on their impact on surgical training. This primary aim of this study is to explore the perceived benefits and challenges of barn-integrated operating rooms among orthopaedic surgeons in the context of the multidisciplinary team. A prospective mixed-methods study was conducted using a pilot-tested questionnaire distributed to 93 orthopaedic theatre personnel, including consultant and trainee orthopaedic surgeons, operating department practitioners, and scrub nurses, assessing satisfaction, supervision, and educational value. Of 54 respondents (58% response rate), 81.5% preferred barn-integrated operating rooms to conventional theatres. Of the total, 78.3% of surgeons reported visiting adjacent barn-integrated operating rooms theatres for learning, and 67.4% agreed supervision was superior. Thematic analysis revealed improved accountability, communication, and support. Concerns included potential infection risk (33%), radiation exposure (33%), and noise disturbance (46%). Barn-integrated operating rooms provide a promising environment for surgical training, promoting supervision, learning frequency, and teamwork. Addressing perceived risks through structured safety protocols will be essential as adoption expands. Further multicentre research is warranted to evaluate long-term outcomes. Findings should be interpreted within the constraint that perspectives were limited predominantly to surgeons.

Abstract Introduction Calcium pyrophosphate disease (CPPD) can present both acutely with hot, swollen and painful joints, often with an underlying trigger, or with chronic forms of arthritis resulting in slower joint destruction. A rare and often misdiagnosed presentation is crowned dens syndrome (CDS). Classically, these patients present with neck pain, possible fever and raised inflammatory markers. Peripheral joints may also flare with CPPD simultaneously and there may be a precipitating event. We describe two cases of CDS recently encountered at Poole Hospital in Dorset. Case description Case 1: A 74-year-old male presented with acute onset foot pain, neck pain, fever, elevated CRP (192 mg/l) and normal urate (226micromol/l). He had hypomagnesaemia (0.22mmol/l) and hypocalcaemia (1.99mmol/l). He reported three months of diarrhoea and took omeprazole 20 mg twice daily. He had a negative infection screen with normal vitamin D and parathyroid hormone levels. CT C-spine showed soft tissue calcification around the odontoid peg and down to C2. However, initially the radiology reporting did not clearly identify CDS as a possible differential; an input from the rheumatologist was required for re-reporting of the scan with CDS in mind. He was successfully treated with a weaning course of oral prednisolone starting at 15 mg daily, weaning by 5 mg weekly and switching his omeprazole to famotidine. Case 2: An 85-year-old lady presented to the community team with 10 months of intractable cervical pain, headaches and difficulty sleeping. An MRI of the C-spine showed erosive and hypertrophic changes at the C1/2 articulation; a CT showed calcification of the ligaments posterior to the odontoid PEG. Following a spinal MDT discussion, a more chronic form of CDS was thought to be the most likely diagnosis. She was treated with non-steroidal anti-inflammatory drugs (lack of response), colchicine (intolerance) and targeted injection. Discussion We describe two patients with CDS - one presenting acutely and the other with a more chronic history. This highlights the challenge in diagnosing CPPD as the clinical picture can be highly variable. A high index of suspicion is required, especially in elderly patients presenting with neck pain; in such situations, a CT scan of the cervical spine allows rapid exclusion of fractures, identification degenerative disease and diagnosis of CDS. Another interesting observation was that one of our patients had hypocalcaemia and hypomagnesaemia, both of which could potentially be involved in the pathogenesis of CPPD/CDS. Although hyperparathyroidism and resulting hypercalcaemia can cause CPPD in its more chronic form, hypocalcaemia may result in the mobilisation of calcium pyrophosphate crystals, triggering an inflammatory response and acute CPPD. Magnesium is a cofactor for alkaline phosphatase which is involved in breakdown of pyrophosphate; a deficiency in magnesium can result in pyrophosphate build up, which can trigger pseudogout attacks. Furthermore, magnesium is involved in parathyroid hormone and thereby calcium regulation; a significant deficiency in magnesium can cause a hypocalcaemia which can precipitate acute pseudogout as well. Common causes for low magnesium include the use of proton pump inhibitors and chronic diarrhoea, which can be addressed to reduce the risk of future attacks of CPPD. This case highlights the importance of investigating for an underlying cause for CDS. We suggest that all patients with CDS and acute CPPD have a bone profile and magnesium performed, both of which are easily available; identifying and addressing these electrolyte abnormalities and their causes can help treat the CDS and prevent future attacks. From our cases, a weaning course of prednisolone over weeks appears to be successful in treating CDS. Shorter courses may risk a relapse and treatment-resistant cases may benefit from the addition of colchicine. Key learning points Our cases highlight four key learning points: • Elderly patients presenting with acute neck pain without any history of trauma and raised inflammatory markers, a high index of suspicion for CDS and an early investigation with CT of the cervical spine allows rapid diagnosis of this condition and exclusion of other differentials. • CDS can often have an underlying trigger precipitating the CPPD. Two important causes we highlight here are low calcium and low magnesium, both of which can play a role in the pathogenesis of acute CDS presentations. • Despite having had reported CT scans on the cervical spine, CRS was not initially reported by the reporting radiologist suggesting under-recognition of this condition. • We suggest the use of a weaning regime of prednisolone initially as a successful treatment option with lower chance of relapse. Colchicine and targeted injections can be alternatives.

Abstract Introduction We present a series of cases of atypical stress fractures in patients on methotrexate (MTX) who did not have other predisposing risk factors for stress fractures. These are characteristic of methotrexate osteopathy. MTX osteopathy is characterised by a pathognomonic type of stress fracture with a band- or meander-shaped appearance along the growth plate. They typically occur in older patients on long-term oral MTX, often with established osteoporosis. Case description Case 1: This is a 73-year-old lady with seropositive rheumatoid arthritis diagnosed in May 2007 who was on methotrexate and continually presented with severe ankle pain in May 2024. MRI performed in November 2024 showed a nondisplaced horizontal fracture of the distal tibia. Her DEXA showed the lowest femoral neck T score is -1.7. Case 2: This is an 86-year-old lady, diagnosed with seropositive rheumatoid arthritis in December 2014 and treated with oral methotrexate. Despite a sedentary lifestyle, she developed on three different occasions different stress fractures, including in September 2020 developing hindfoot pain and struggling to walk, and an MRI showed a stress fracture of the calcaneum. In February 2022 she developed left-side pain in her upper tibia, struggling to walk, and an MRI confirmed a medial tibial stress fracture. DEXA showed her mean total femoral neck DEXA was a T score of –1.8. Case 3: This is a 79-year-old sedentary female diagnosed with seropositive rheumatoid arthritis in 2006 on methotrexate. She had a series of atraumatic fractures, including fourth metatarsal stress fracture. Previous insufficiency fractures include the right distal tibia, first metatarsal, and left non-displaced fracture just above the lateral malleolus in the fibula. Only after her fourth fracture was methotrexate osteopathy considered, and methotrexate stopped. Case 4: This is a 74-year-old sedentary female who presented in January 2025 with atraumatic bilateral distal tibial and fibular fractures that have not healed with conservative measures. She had been on methotrexate since the diagnosis of seropositive rheumatoid arthritis in 2017. She had a diagnosis of treated osteoporosis. Case 5: This is a 76-year-old female diagnosed with rheumatoid arthritis in 2004 and treated with methotrexate throughout. Over this time, she has had multiple atypical and atraumatic fractures, including previous stress fractures in both feet (2017 & 2019) and an additional insufficiency fracture in the right distal femur in 2023. Discussion All of these cases were elderly postmenopausal females on long-term methotrexate for several years for seropositive rheumatoid arthritis. The fractures all presented with pain on weight-bearing and were atraumatic and resembled stress fractures rather than classical osteoporotic fractures in distribution. X-rays were most often initially normal. Flares of inflammatory arthritis were often initially considered, and the diagnosis of fractures was most commonly detected on subsequent MRI scans. At least three of these fractures had very delayed healing. Methotrexate osteopathy was not considered on first fracture, leading to further fractures. In vitro studies demonstrating toxicity of MTX mainly showed a decrease in the number of osteoblasts, osteocytes, and chondrocytes in the growth plate, and an increase in the number and activity of osteoclasts. MTX osteopathy has previously been described as a clinical triad of pain, osteoporosis, and atypical stress fractures; while rare, it needs to be considered in people with atypical or atraumatic fractures on long-term methotrexate. Like a previously published series, not all of our cases had osteoporosis on DEXA. Key learning points 1. Refractory localised pain in long-standing rheumatoid arthritis on MTX may represent atypical fractures that may be best identified on MRI. 2. Atypical low or atraumatic fractures in people on long-term methotrexate need to be considered to be MTX osteopathy. 3. In MTX osteopathy, if the drug is not stopped, there is a very high risk of future atypical fractures.

<h3>Introduction</h3> Decompensated cirrhosis (DC) is associated with frequent hospital admissions and prolonged inpatient stays, contributing to significant healthcare resource utilisation. The British Society of Gastroenterology (BSG) has emphasised the importance of structured outpatient care pathways, including multidisciplinary team (MDT) approaches, to improve patient outcomes and reduce hospital dependency in this population. This study evaluates the practicality and impact of a dedicated MDT clinic on healthcare utilisation among patients with decompensated cirrhosis. <h3>Methods</h3> A dedicated MDT clinic was established at a district general hospital (DGH), comprising a consultant hepatologist, advanced nurse practitioner (ANP), dietician, physiotherapist, palliative care specialist, and assertive alcohol outreach worker. All patients were discussed in an MDT immediately prior to clinic and were then reviewed by the appropriate members of the team. Patients were referred to the clinic for comprehensive outpatient management following an admission with decompensated cirrhosis, or if they had decompensated as an outpatient, aligning with BSG recommendations. A retrospective analysis of 79 patients who had attended clinic compared total bed days, number of admissions (excluding day case admissions), and mean length of hospital stay during the 90 days before and after the initial clinic attendance. <h3>Results</h3> In the 90 days preceding clinic attendance, 79 patients accounted for 743 hospital bed days, which decreased to 220 bed days in the 90 days following clinic attendance—a reduction of 523 bed days (70.4%). The number of admissions longer than one day decreased from 71 to 37 (47.9% reduction). The mean length of hospital stay per admission reduced from 10.5 days to 6 days (43.1% reduction). Elective day case activities, such as paracentesis, continued to be supported through outpatient services. <h3>Discussion</h3> The implementation of a multidisciplinary clinic for patients with decompensated cirrhosis, in line with BSG outpatient care guidelines, resulted in significant reductions in hospital bed days, admission frequency, and length of stay. The integration of hepatology, nursing, allied health, palliative care, and addiction services facilitated proactive management of complications and reduced hospital dependency. These findings support the efficacy of structured MDT outpatient models in improving care quality and reducing healthcare burden in advanced liver disease and demonstrate its practicality in a DGH setting. <h3>References</h3> Williams R, Aspinall R, Bellis MA, Camps-Walsh G, Cramp ME, Dhawan A, Ferguson J, Forton D, Foster GR, Gilmore I, Hudson M, Kelly D, Langford A, McDougall N, McPherson S, O’Grady J, Pryke R, Rutter H, Ryder S, Sheron N, Storey K, Verne J, Wright T, Newsome PN. Outpatient care of people with alcohol-related liver disease and decompensated cirrhosis: a multidisciplinary ‘day-case’ model from the British association for the study of the liver (BASL) decompensated cirrhosis working group. <i>Frontline Gastroenterology</i> 2023;<b>14</b>(6):462–470. [online] Available at: https://fg.bmj.com/content/14/6/462 [Accessed 13 May 2025]. British Society of Gastroenterology and British Association for the Study of the Liver, 2020. <i>Cirrhosis discharge bundle – long version v1.1</i>. [online] Available at: https://www.bsg.org.uk/getattachment/eeecefff-8776–4da8–9257-fc1cd330f4c5/Cirrhosis-discharge-bundle-long-V1–1-BSG-BASL-25–08-2020.pdf?lang=en-US [Accessed 13 May 2025]. Cox L, Ballesteros K, Sharma V. Impact of a joint clinical specialist nurse and dietitian clinic on health-related quality of life outcome in patients with decompensated liver disease. <i>Gut</i> 2024;<b>73</b>(Suppl 3):A3. [online] Available at: https://doi.org/10.1136/gutjnl-2024-BASL.3 [Accessed 13 May 2025]

Abstract The Amaravella collective, also known as the Cosmists, belongs to the period of the Russian avant-garde. There were seven members: Petr Fateev (1891–1971), Aleksandr Baranov (1901–1974), Vera Pshesetskaia (1879–1945/46), Sergei Shigolev (1895–1942), Boris Smirnoff-Rusetsky (1905–1993), Victor Chernovolenko (1900–1972), and Vladimir Yatskevich (?–late 1930s). Until now, very little was known about the work of Yatskevich. The article looks at the Petr Fateev archive in Moscow, which contains some 750 items, the majority by Fateev, and hundreds of drawings by Yatskevich; they show that he was a central member of the group, and that a reassessment needs to be made. The paper looks at the occult background of cosmism, the influence of Nikolai and Elena Roerich, the philosophy of Nikolai Fedorov, and the science of Konstantin Tsiolkovsky. An examination of Yatskevich’s hitherto unknown Maro album, posits the theory that it is a visual and textual manifesto of Amaravella. A critical look at the cosmist landscapes by Fateev, shows how the cosmists’ spiritual quest elided into space flight, how Amaravella was intended to be the guide on that journey.