Princess Royal Hospital

Background and objectivePlacenta accreta spectrum (PAS) is a severe obstetric complication associated with significant maternal morbidity and mortality. As cesarean delivery rates continue to rise, the prevalence of PAS is increasing, creating a growing challenge for healthcare systems. This study aimed to present a comprehensive analysis of the multidisciplinary management of PAS in a tertiary care center.MethodsWe performed a retrospective case series of eight consecutive cases of PAS managed at a tertiary care government hospital between January 2023 and December 2024 (24 months). Data were collected from hospital records, including patient demographics, clinical presentation, imaging findings, surgical management, and maternal outcomes. All cases were managed by a dedicated multidisciplinary team.ResultsThe study included eight patients with a mean age of 29.6 years. All patients had undergone at least one previous cesarean section. The mean gestational age at diagnosis was 32 weeks, and the mean gestational age at delivery was 36.4 weeks. Six patients underwent cesarean hysterectomy, one had a hysterotomy with uterine artery embolization (UAE), and one had a conservative management approach. The mean estimated blood loss was 2.1 litres. There were no maternal deaths, and the most frequent complication observed was bladder injury (n=2).ConclusionsThis study highlights the importance of a multidisciplinary approach in the management of PAS. Early diagnosis, individualized management strategies, and a coordinated team of specialists can lead to favorable maternal outcomes, even in complex cases. Our results highlight the importance of establishing specialized centers of excellence for managing PAS.

Rheumatic diseases encompass a heterogeneous group of autoimmune and autoinflammatory disorders affecting joints, muscles, and connective tissue, with juvenile idiopathic arthritis (JIA) being the most prevalent among children. The introduction of biological agents in the treatment of childhood rheumatic diseases has significantly improved outcomes and quality of life. However, there is limited data on the use of biological agents in Jordanian children with these conditions. This study aims to evaluate the clinical indications for initiating biological agents and investigate the safety profile of biological therapy in Jordanian children. This retrospective study was conducted at Queen Rania Children's Hospital, including children (under 14 years of age) diagnosed with rheumatic diseases between January 2019 and December 2023. Data collected and reviewed included demographic characteristics, diagnosis, concomitant use of disease-modifying conventional synthetic antirheumatic drugs (csDMARD), indications for starting biological agents, age at initiation of therapy, and reported side effects during treatment. A total of 177 patients (57.6% females) with various rheumatic disorders were treated with biological therapy. The mean age at diagnosis was 7 years (range: 1-7 years), while the mean age at therapy initiation was 8.6 years (range: 4.2-14 years). JIA was the most common diagnosis in 110 patients (62%), followed by non-infectious uveitis in 18 patients (10.1%) and autoinflammatory disorders in 17 patients (9.6%). Concomitant therapy with DMARDs and corticosteroids was employed in 92.6% of cases (164 patients). A total of 290 biological treatments were administered, including infliximab (93; 32%), etanercept (71; 24.4%), adalimumab (48; 16.5%), tocilizumab (41; 14.1%), and anakinra (13; 4.4%). In 66 patients (37.2%), the biological agent was switched, primarily due to inefficacy (56 patients, 84.7%) or adverse events (10 patients, 15.3%). A total of 64 adverse events (36.1%) were reported, the most common being infections (29; 45.3%), local reactions (11; 17.1%), and infusion-related reactions (10; 15.6%). This retrospective study highlights the importance of evaluating the efficacy and safety of biological agents in treating childhood rheumatic diseases. The findings can help optimize treatment strategies and improve patient outcomes.

Proximal humerus fractures are prevalent in older adults, particularly women, primarily due to osteoporosis and increased fall risk. These fractures often result from low-energy falls in elderly patients, while in younger individuals, they are more likely to occur with high-energy trauma, which may involve additional injuries to soft tissue and neurovascular structures. Proper anatomical understanding, including key structures and blood supply, is crucial for effective management and to prevent complications.Several classification systems assist in guiding treatment for proximal humerus fractures, including Codman's, Neer's, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) system, and the Codman-Hertel system, whichhelps predict ischemia risk. Evaluation of proximal humerus fractures begins with Advanced Trauma Life Support (ATLS)protocols, emphasizing a thorough shoulder assessment, particularly focusing on skin integrity in elderly patients. Neurological and vascular examinations are essential due to the common occurrence of nerve injuries, especially involving the axillary nerve. Imaging typically includes multiple standard views, with advanced imaging reserved for complex cases and for assessing associated soft tissue injuries. Treatment options range from conservative management for stable fractures to surgical intervention for more complex cases. Surgical choices include techniques like fixation, nailing, and various arthroplasty options, with some procedures potentially offering advantages for older adults with bone quality or soft tissue challenges. Rehabilitation is a vital component of recovery, with emphasis on early mobility and gradual strengthening to restore function, especially in older patients. Complications following open reduction and internal fixation (ORIF) for proximal humerus fractures can include issues such as non-union, malunion, osteonecrosis, infection, joint stiffness, and fixation failure. In cases where non-union or fixation failure occurs, revision surgery or arthroplasty may be necessary. Joint stiffness may require further intervention if physical therapy is insufficient, while symptomatic osteonecrosis might also need surgical management. Malunion is generally better tolerated in older patients but may require correction in younger individuals. Other surgical options, such as hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA), share similar risks, including infection, fractures, complications at the tuberosity, stiffness, and instability. RSA may be favored when there are tuberosity or rotator cuff issues. Closed reduction with percutaneous pinning carries a high risk of pin migration and malunion, which can result in deformities, pain, and dysfunction. Proper anatomical knowledge is essential to avoid neurovascular injury and to manage common issues such as pin-site infections effectively.

Von Willebrand disease stands as the most prevalent bleeding disorder seen in both medical and surgical practice. Due to recurrent bleeding episodes within the joints, many patients endure arthropathy, leading to substantial pain and restricted function. Total joint arthroplasty emerges as a final option for managing such cases. Nevertheless, the existence of von Willebrand disease presents several challenges in this regard. This review aims to explore the perioperative strategies tailored for patients with von Willebrand disease undergoing elective total joint arthroplasty.

ABSTRACT Background: Shift work can lead to sleep deprivation and circadian misalignment. Sleep disturbances have implications for patient care, clinician well-being, and overall healthcare performance. In the United Kingdom, otolaryngology operates a non-resident on-call structure at registrar and consultant levels, necessitating availability for remote consultation and potential on-site attendance overnight. Objectives: Whilst resident on-call rotas have been shown to have a detrimental effect on sleep quality, the impact of non-resident on calls remains under investigated. This study aims to assess the impact of non-resident on-call structures on sleep quality using smart phone sleep-tracking. Materials and Methods: Three consultants and three registrars monitored their sleep quality using the mobile phone application ‘Sleep cycle’ over a ten week on call cycle at a district general hospital. Data was collected prospectively and results analysed anonymously. Results: Sleep length was longest during off days (when clinicians had no clinical commitments the following day). The average sleep length for consultants was 7.07 h versus 6.97 h for registrars. There were variations in sleep quality across different work and on-call scenarios. For consultants, the highest average sleep quality was during on-call hours (80.00%). Sleep quality was lowest when a consultant was called for advice after 22:00h (54.00%), however, this increased to 73.00% when a consultant was required on site after 22:00 h. For registrars, average sleep quality was highest during off days at 83.00%. When registrars were contacted for advice overnight, average sleep quality was 68.67% and was lowest when registrars were called on-site after 22:00h (57%). Conclusion: Sleep length and quality are negatively affected by non-resident on-calls when clinicians are contacted after 22:00h. There is no measurable impact on sleep quality when clinicians are not disturbed whilst on-call remotely. NHS trusts should monitor the wellbeing of their doctors and consider the implications of overnight commitments when structuring elective rotas.

Simple SummaryMyeloma, a blood cancer, is rare and hard to diagnose. People often suffer irreversible organ damage by the time of diagnosis. Myeloma is preceded by a premalignant phase that is easily identifiable on a blood test. Currently, there is no screening for this, because most people do not progress to myeloma. We aimed to inform guidelines and screening by refining our understanding of how patients developing myeloma describe their symptoms and how those symptoms relate to organ damage. We found that patients rarely describe ‘bone pain’ but simply ‘pain’. Low-impact crush fractures of the backbones appear to be under-recognised as abnormal. At least 30% of patients have irreversible organ damage at diagnosis. People who developed myeloma fared better if they had previously been diagnosed to have the premalignant condition. Screening based on certain symptoms, possibly combined with imaging and laboratory results, may speed up the diagnosis of myeloma.Multiple myeloma (MM) patients risk diagnostic delays and irreversible organ damage. In those with newly diagnosed myeloma, we explored the presenting symptoms to identify early signals of MM and their relationships to organ damage. The symptoms were recorded in patients’ own words at diagnosis and included diagnostic time intervals. Those seen by a haematologist >6 months prior to MM diagnosis were classified as precursor disease (PD). Most (962/977) patients provided data. Back pain (38%), other pain (31%) and systemic symptoms (28%) predominated. Patients rarely complain of ‘bone pain’, simply ‘pain’. Vertebral fractures are under-recognised as pathological and are the predominant irreversible organ damage (27% of patients), impacting the performance status (PS) and associated with back pain (odds ratio (OR) 6.14 [CI 4.47–8.44]), bone disease (OR 3.71 [CI 1.88–7.32]) and age >65 years (OR 1.58 [CI 1.15–2.17]). Renal failure is less frequent and associated with gastrointestinal symptoms (OR 2.23 [CI1.28–3.91]), age >65 years (OR 2.14 [CI1.28–3.91]) and absence of back pain (OR 0.44 [CI 0.29–0.67]). Patients with known PD (n = 149) had fewer vertebral fractures (p = 0.001), fewer adverse features (p = 0.001), less decline in PS (p = 0.001) and a lower stage (p = 0.04) than 813 with de novo MM. Our data suggest subgroups suitable for trials of ‘symptom-directed’ screening: those with back pain, unexplained pain, a general decline in health or low-impact vertebral compression fractures.