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3rd December 2021
The use of ultrasound imaging for the detection of both a partial and complete rupture of the Achilles tendon has been found to be a highly sensitive modality according to a systematic review and meta-analysis by a team from Department of Emergency Medicine, University of California, US.
The Achilles tendon is the strongest tendon in the body and rupture of the tendon has become a common problem among athletes involved in activities such as running, jumping and ball sports. An acute rupture of the tendon will often result in a sudden onset of pain and in some cases an audible “snapping” sound can be heard at the site of injury, leading to significant pain and disability. However, the diagnosis tendon rupture is not always clinically clear and any delay or misdiagnosis can result in a significant patient morbidity and in fact, it has been suggested that sush injuries are often misdiagnosed as an ankle sprain in 20% to 25% of patients.
The use of ultrasound imaging for the diagnosis of Achilles tendon rupture has been described in the literature although there have been no meta-analytic studies assessing the overall performance of this imaging modality as a diagnostic tool in emergency departments. For the present study, the US team sought to systematically evaluate the sensitivity and specificity of ultrasound imaging for detecting complete and partial Achilles tendon ruptures in patients who were treated surgically.
The researchers performed a literature search in all the major databases for studies that included at least 5 patients and which reported on the sonographic diagnosis of Achilles tendon rupture compared with surgery as the reference standard. The set the primary outcome measure as complete tear of the Achilles tendon and they calculated the sensitivity, specificity and positive/negative likelihood ratios.
The literature search identified 15 eligible studies with 808 patients, all of whom were suspected of having an acute Achilles tendon injury. In addition, the ultrasound imaging procedure used was similar across all studies. The overall sensitivity of ultrasound for detecting a complete rupture was 94.8% (95% CI 91.3% – 97.2%) and the specificity 98.7% (95% CI 97.03% – 99.6%). The positive likelihood ratio was 74 and the negative likelihood ratio 0.05. Based on these results, it was therefore 74 times more likely that there would be a positive ultrasound in a patient with a complete Achilles tendon rupture compared to a patient without such a rupture. Similarly, there is a 20-fold decrease in the odds that a negative ultrasound will occur in a patient with a complete rupture.
There were 13 of the 15 studies which enabled assessment of a partial Achilles tendon rupture. The corresponding sensitivity was 93.7% (95% CI 95.3% – 98.7%) and the specificity was 97.4% (95% CI 95.3% – 98.7%). The positive likelihood ratio was 35.6% and the negative likelihood ratio 0.07.
Discussing their results, the authors suggested in the presence of a normal Achilles tendon on ultrasound, there is a very low likelihood that the patient had suffered a complete tendon rupture. For a partial rupture, the low negative likelihood ratio (0.07) indicated that it was 14-fold less likely that a negative ultrasound would occur in a patient with a partial tendon rupture.
They concluded that ultrasound imaging is a useful and valuable modality to minimise the misdiagnosis of a partial or complete Achilles tendon rupture with an emergency department.
Aminlari A et al. Diagnosing Achilles Tendon Rupture with Ultrasound in Patients Treated Surgically: A Systematic Review and Meta-Analysis. J Emerg Med 2021
23rd November 2021
The use of eye protection, mainly in the form of face shields appears to reduce the incidence of COVID-19 infection among healthcare workers. This is the conclusion of an analysis by a team from the Institute for Evidence-Based Healthcare, Bond University, Australia.
It has become widely recognised that the COVID-19 virus gains cellular entry via interaction with the angiotensin converting enzyme 2 (ACE2) surface receptor. Moreover, these receptors are also present on the corneal and conjunctival surfaces and therefore might serve as an entry portal for the virus. In fact, it was recognised as early as 1919, that the eye could be a route for the transmission of infections. More recently, a small study among Indian healthcare workers found that no COVID-19 infections were recorded among community health workers after the addition of face shields to their personal protective equipment. Furthermore, more, albeit, indirect support for a protective effect against the virus from eye-wear, comes from a Chinese study, which found that the incidence of COVID-19 infection was less among those wearing glasses for more 8 hours per day.
For the present study, the Australian team set out to examine the potential contribution of eye protection towards the transmission of COVID-19. Searching the main databases (e.g., PubMed, Embase etc) the team looked for studies in which reported on the use of any form of eye protection, including face shields, goggles or modified snorkel masks, with or without face masks, comparative studies (i.e., without eye protection) and where the outcomes such as laboratory confirmed COVID-19 infection had been confirmed.
While identifying 898 articles, only 5 observational and therefore non-randomised studies were ultimately included in the analysis. This included three before and after studies, one case-control and one retrospective analysis. The limited data also precluded the use of a meta-analysis and since the studies did not adjust for potential confounders, there was a risk of bias designed as serious for two studies and moderate for the remaining three.
Eye protection used included face shields (three studies) and wraparound eyewear, goggles and full face shields or visors. From the three studies that reported before and after data, there was a statistically significant reduction in COVID-19 infections with the use of eye protection. For example, compared to no eye protection, the odds ratios (ORs) for a protective effect from the three studies ranged from 0.04 to 0.6, i.e., a reduction in risk from between 96% to 40%. In contrast, the single case controlled study suggested a reduced risk of infection among those not using eye protection.
The authors concluded that these studies provided suggestive evidence that face shields provide some protective effect but accepted that it was not possible to determine whether the protection against the virus arose from either reduced inhalation or ocular transmission.
Byambasuren O et al. The effect of eye protection on SARS-CoV-2 transmission: a systematic review Antimicrob Resist Infect Control 2021
18th November 2021
Hormone replacement therapy (HRT) use for the management of menopausal symptoms in women with a history of breast cancer is associated with a significant increase in the risk of disease recurrence according to a meta-analysis by researchers from Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy. Although there have been major advances in the treatment of breast cancer, the blocking of oestrogen is associated with several adverse effects which negatively impact on a patient’s quality of life. HRT use is the most effective treatment for symptoms related to a reduction in the level of oestrogen although its use in breast cancer survivors is generally avoided. Among healthy women, the use of oestrogen only HRT leads to a reduced risk of breast cancer but when oestrogen is combined medroxyprogesterone, the risk is increased. Though it is generally advised that the use of HRT is avoided in patients with a history of breast cancer it has been suggested that there is insufficient evidence to contra-indicate HRT in breast cancer survivors.
With some uncertainty over whether HRT increases the risk in breast cancer survivors who experience oestrogen depletion-related symptoms, the Italian team decided to perform a systematic review and meta-analysis to assess the overall safety of systemic HRT use and its impact on disease recurrence in breast cancer survivors. They searched all of the main databases but restricted their search to articles published in English, randomised, placebo-controlled trials with breast cancer survivors and any studies reporting on the recurrence of breast cancer.
The literature search identified 12 studies of which, only 4 were included in the final analysis examining the effect of HRT on 4050 breast cancer survivors. All trials had randomised patients to either HRT or placebo with a total of 2022 patients randomised to HRT, either oestrogen/progestogen combinations or tibolone.
There was a low degree of heterogeneity in studies and compared to the placebo group, the use of HRT significantly increased the risk of breast cancer recurrence (hazard ratio, HR = 1.46, 95% CI 1.12 – 1.91, p = 0.006). In subgroup analysis, among patients with hormone receptor-positive tumours, the risk of disease recurrence was also significantly increased in those using hormonal therapy (HR = 1.80, 95% CI 1.15 – 2.82, p = 0.010). In contrast, in patients with hormone receptor-negative disease, there was no significant increase in risk (HR = 1.19, 95% CI 0.80 – 1.77, p = 0.39). In a further analysis, the risk of breast cancer recurrence was no different between combined HRT and tibolone (HR = 1.51 95% CI 0.84 – 2.72).
Based on these findings, the authors concluded that future research should focus on finding alternatives to hormone replacement therapy for women who have survived breast cancer yet experience symptoms related to oestrogen deficiency.
Poggio F et al. Safety of systemic hormone replacement therapy in breast cancer survivors: a systematic review and meta-analysis. Breast Cancer Res Treat 2021