Editor-in-Chief
These important subjects have been chosen to have free online access. This quarter we are devoting half of the issue to Sports Medicine, thanks to the untiring efforts of our Commissioning Editor for that topic, Professor Nicola Maffulli. In addition, the Bulletin has a section to celebrate its amazing archive, (see end of ‘In this Issue’). The British Medical Bulletin (BMB) on its website also has a fascinating section on the Nobel Prize-winners who wrote for the Bulletin and went on to win the accolade and the OUP blog often has input from the Bulletin authors and editors.
The first free online access review is Ethics of intensive care unit (ICU) triage during COVID-19 by ‘Vinay, Baumann and Biller-Andorno from the University of Zurich, Switzerland’. They say that the coronavirus disease 2019 (COVID-19) pandemic has placed ICU triage at the centre of bioethical discussions. National and international triage guidelines emerged from professional and governmental bodies and have led to controversial discussions about which criteria are ethically acceptable. This paper presents the main points of agreement and disagreement in triage protocols and reviews the ethical debate surrounding them. Points of agreement in the guidelines that are widely supported by ethical arguments are (i) to avoid using a first come, first served, policy or quality-adjusted life-years, and (ii) to rely on medical prognosis, maximizing lives saved, justice as fairness and non-discrimination. We need to improve outcome predictions, possibly aided by artificial intelligence; develop participatory approaches to drafting, assessing and revising triaging protocols and learn from experiences with implementation of guidelines with a view to continuously improve decision-making.
The second chosen free-to-view review is entitled Psychological factors associated with inflammatory bowel disease (IBD) by ‘Eugenicos and Ferreira from the University of Edinburgh, UK and the University of Nicosia, Cyprus’. They say that both depression and anxiety are identified as significant in IBD but whether these are a consequence of the disease or an active contributor to the disease remains controversial. The review aims to identify and critique recent evidence regarding mental health in IBD. Overall, both depression and anxiety affect disease activity, relapse and healthcare utilization. There is some controversy on whether depression and anxiety affect IBD outcomes differently depending on IBD subtype. The data support the need for depression and anxiety assessment to be incorporated in the routine management of IBD patients. More longitudinal research may further enlighten the role of depression and anxiety in IBD.
In the rest of the Bulletin, the third review is entitled An update on the role of anti-IL-12/IL23 agents in the management of inflammatory bowel disease by ‘Nigam and Limdi from the University of Oxford and the University of Manchester, UK’. They say that the aim of treatment in IBD is to control symptoms and suppress gut inflammation with minimal systemic side effects. A large proportion of patients are either primary non-responders or lose response to currently licensed therapies. The development of monoclonal antibodies is a promising therapeutic advance. Ustekinumab is currently approved for managing corticosteroid and biologic refractory IBD patients with a favourable safety profile. Despite a growing therapeutic armamentarium and convergence on the role of biological therapies in patients with greater disease severity there remains considerable uncertainty with selection and positioning of treatment. Results of phase 3 trials with IL-23 inhibitors incorporating clinical, biochemical and endoscopic parameters and also exploring biomarkers as predictors of response are urgently needed.
The fourth review is entitled: Mindfulness-based interventions (MBIs): an overall review by ‘Zhang, Lee, Mak, Ho and Wong from the Chnese University of Hong Kong’. They say MBIs are effective for many common mental and physical problems, including depression, anxiety, stress, insomnia, addiction, psychosis, pain, hypertension, weight control, cancer related symptoms and prosocial behaviours. Current evidence suggests benefits for healthcare professionals and within schools and workplaces although more studies are still needed to look into its efficacy on a variety of different problems. MBIs are relatively safe, but ethical aspects should be considered. There is inconclusive or only preliminary evidence on their effects on a wide range of disorders. Many mindfulness systematic review and meta-analysis indicate low quality of included studies, high-quality studies with adequate sample size and longer follow-up period are needed.
The fifth review is the first of six reviews under the Commissioning Editorship of Professor Maffulli. This one is entitled Small interfering RNAs in tendon homeostasis by ‘Gargano, Oliviero, Oliva and Maffulli from AOU San Giovanni di Dio e Ruggi D’Aragona, the University of Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine, London and Keele University, UK’. They say that tenogenesis and tendon homeostasis are guided by genes encoding for the structural molecules of tendon fibres. Small interfering RNAs (siRNAs), acting on gene regulation, can therefore participate in the process of tendon healing, siRNAs can be useful to study reparative processes of tendons and identify possible therapeutic targets in tendon healing. Many genes and growth factors involved in the processes of tendinopathy and tendon healing can be regulated by siRNAs. It is however unclear which gene silencing determines the expected effect. Gene dysregulation of growth factors and tendon structural proteins can be influenced by siRNA. It is not clear whether there is a direct action of the siRNAs that can be used to facilitate the repair of tendons.
The sixth review is entitled Medium-term results of arthroscopic treatment for femoroacetabular impingement by ‘Migliorini, Liu, Catalano, Trivellas, Eschweiler, Tingart and Maffulli from Aachen University, Germany; UCLA, USA; University of Salerno, Italy and the University of Keele, and Barts and the London School of Medicine, UK’. They say that femoroacetabular impingement (FAI) is a dynamic pathomechanical process of the femoral head–neck junction. Arthroscopic surgery for FAI has increased exponentially in the last decade, and this trend is expected to increase. FAI promotes quick rehabilitation and low complication rates in short term follow-up. Despite the growing interest on arthroscopic surgery for FAI, current evidence regarding the medium- and long-term role of arthroscopy are unsatisfactory.
The seventh review is Non-steroidal anti-inflammatory drugs and gabapentinoids for chronic lumbar pain by ‘Migliorini, Maffulli, Eschweiler, Tingart and Baroncini from The University of Aachen, Germany; The University of Salerno, Italy and the University of Keele, and Barts and the London School of Medicine, UK’. They say that several pharmacological therapies have been proposed for the management of chronic low back pain (LBP), but no consensus has been reached. Exploring effective conservative alternatives to the surgical intervention is of especial interest. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAID) and gabapentinoids for chronic LBP are debated. Several clinical studies showed controversial results, and the most effective and safe class of drugs has not yet been clarified. The effects of selective and non-selective NSAIDs and gabapentinoids in chronic LBP are probably over-estimated. The effect of behavioural changes, including exercise, should be explored, alone or in combination with drugs.
The eighth review is Prolotherapy for chronic low back pain by ‘Giordano, Murrell and Maffulli from the University of Salerno, Italy; the Emirates-Integra Medical and Surgical Centre, Dubai and the Queen Mary University of London and Keele University, UK’. They say that LBP is common and imposes major societal burdens for patient suffering and costs. Prolotherapy injections are used for musculoskeletal conditions including tendinopathies, osteoarthritis and LBP to enhance soft-tissue healing. This review aims to clarify the place of prolotherapy in chronic LBP. Considering the level of evidence and the quality of the studies assessed using the modified Coleman Score, prolotherapy is an effective management modality for chronic LBP patients in whom conservative therapies failed. The presence of co-interventions and the clinical heterogeneity of the work contributes to confound the overall conclusions. The analysis of the studies included in the review, using appropriate tools, showed how their quality has decreased over the years, reflecting the need for appropriately powered well planned and performed randomized control trials.
The ninth review is Failure and progression to total hip arthroplasty among the treatments for femoral head osteonecrosis by ‘Migliorini, Maffulli, Baroncini, Eschweiler, Tingart and Betsch from the University of Aachen, Germany; the University Salerno, Italy; the Universit of Heidelbberg, Germany and the Queen Mary University of London and Keele University, UK’. They state that osteonecrosis of the femoral head (ONFH) often leads to secondary osteoarthritis and total hip arthroplasty. There has been increasing focus on the early intervention in ONFH patients to preserve the native hip articulation, reduce pain and improve function. Efficacy of surgical strategies for ONFH is debated. Several clinical studies showed controversial results, and the best treatment has not yet been clarified. To provide an overview over current treatment options for ONFH compares their failure rates. core decrompression (CD) augmented with autologous bone grafting plus the implantation of bone marrow concentrate can decrease the rate of failure and progression to THA rates compared to CD alone.
The tenth review is High-fat diet, adipokines and low-grade inflammation are associated with disrupted tendon healing by ‘Elli, Schiaffini, Macchi, Spezia, Chisari and Maffulli from the Universities of Milan, Rome, Padua, Catania and Salerno in Italy and the Queen Mary University of London and Keele University, UK’. They say that the aetiopathogenesis of tendinopathy is uncertain, but inflammation may play a role in the early phase of tendinopathy and in tendon healing response. They investigated the most up-to-date evidence about the association between obesity, high-fat diet and tendinopathy, focusing on the role of adipokines, inflammatory pathways and molecular changes. A high-fat diet negatively affects tendon quality, increasing the risk of rupture and tendinopathy. The secretion of adipokines is strictly related to fat ingestion and body composition and can potentially act on tendon physiology and injury. Adipokines, low-grade inflammation and fat intake play a role in disrupting tendon healing and setting up tendinopathy. Further high-quality research is needed to better define the molecular pathways involved.
The eleventh review is Matrix-induced autologous chondrocyte implantation versus autologous matrix-induced chondrogenesis for chondral defects of the talus by ‘Migliorini, Maffulli, Baroncini, Knobe, Tingart and Eschweiler from The University of Aachen, Germany; the University of Salerno, Italy; the Queen Mary University of London and Keele University, UK and the Lucerne Cantonal Hospital, Switzerland’. They say that chondral defects of the talus are common and their treatment is challenging. Membrane-induced autologous chondrocyte implantation (mACI) and autologous matrix-induced chondrogenesis (AMIC) have been proposed as management for chondral defects of the talus. It is debated whether AMIC provides greater outcomes compared to mACI for chondral regeneration. Several clinical studies showed controversial results, and the best treatment has not yet been clarified. To investigate whether AMIC provide superior outcomes than mACI at midterm follow-up. However, AMIC involves one single surgical procedure, no articular cartilage harvest, and hence no morbidity from it, no need for chondrocyte expansion in a separate laboratory setting. For these reasons, AMIC may be preferred to mACI.
From the archive
The BMB has an extensive archive dating back to 1943. Each quarter the journal publishes a paper from that archive. This quarter I thought it would be interesting to look at a piece, ‘Planning for head injuries’ written by Geoffrey Jefferson. This is a history of the development of neurosurgery as a specialty in the UK and the development of specialist centres for carrying it out. Previously general surgeons had carried out the surgery with the guidance of the local Professors of Neurology. Sir Geoffrey Jefferson was educated in Manchester and during World War 1 worked in the Anglo-Russian Hospital in Petrograd, then in France. He was the UK’s first professor of neurosurgery in Manchester. He lectured on the possibilities for the future of artificial intelligence. He died in 1961.
The original link is: https://academic.oup.com/bmb/article/3/1-3/5/487075.You can access the collected articles more easily and more fully by visiting the ‘Highlights from the BMB Archive’ collection: (http://bit.ly/2nTsFIH)’. Enjoy!
NJV
May 2021.