Authors Kanai Garala, Thomas Laios, Trevor Lawrence First Published in Sage Journals - Hip International, June 15, 2018 Abstract Background: The Exeter V40 Orthinox stem is one of the most commonly used femoral components in total hip arthroplasty. Its design, material and finish has evolved significantly from the original design established by Ling and Lee over 3 decades ago. An early problem reported with the original Exeter stem was a high rate of stem fractures. It was thought that with the new Orthinox steel used in the V40 system, the rate of stem fractures would reduce. There are reports of the Exeter V40 stem failing in a variety of locations. Cases: This paper highlights the 3 locations where the Exeter stem may fail and estimates a rate of 0.262% for stem fractures due to the constant use of the Exeter stem throughout the career of the senior surgeon. Keywords: Exeter stem, fracture, incidence, total hip replacement To read this paper in full, please visit Sage Journals purchase content page. - - - REFERENCES 1.Fowler, J, Gie, G, Lee, A. Experience with the Exeter total hip replacement since 1970. Orthop Clin North Am 1988; 19: 477–489. Google Scholar | Medline | ISI 2.Davies, B, Branford White, H, Temple, A. A series of four fractured Exeter™ stems in hip arthroplasty. Ann R Coll Surg Engl 2013; 95: e130–e132. Google Scholar | Medline 3.Doorn, WJ, Biezen, FCV, Prendergast, PJ. Fracture of an Exeter stem 3 years after impaction allografting–a case report. Acta Orthop Scand 2002; 73: 111–113. Google Scholar | Medline 4.Hamlin, K, MacEachern, CF. Fracture of an Exeter stem: a case report. JBJS Case Connect 2014; 4: e66–e3. Google Scholar | Medline 5.Røkkum, M, Bye, K, Hetland, KR. Stem fracture with the Exeter prosthesis. 3 of 27 hips followed for 10 years. Acta Orthop Scand 1995; 66: 435–439. Google Scholar | Medline 6.Yates, PJ, Quraishi, NA, Kop, A. Fractures of modern high nitrogen stainless steel cemented stems: cause, mechanism, and avoidance in 14 cases. J Arthroplasty 2008; 23: 188–196. Google Scholar | Medline 7.Swarts, E, Kop, A, Jones, N. Microstructural features in fractured high nitrogen stainless steel hip prostheses: a retrieval study of polished, tapered femoral stems. J Biomed Mater Res A 2008; 84: 753–760. Google Scholar | Medline 8.Akinola, B, Mahmud, T, DeRoeck, N. Fracture of an Exeter stem-a case report. The Internet Journal of Orthopedic Surgery 2009; 16. Google Scholar 9.Reito, A, Eskelinen, A, Pajamäki, J. Neck fracture of the Exeter stem in 3 patients: a cause for concern? Acta Orthop 2016; 87: 193–196. Google Scholar | Medline 10.O’Neill, GK, Maheshwari, R, Willis, C. Fracture of an Exeter ‘cement in cement’ revision stem: a case report. Hip Int 2011; 21: 627–679. Google Scholar | SAGE Journals | ISI 11.Facek, M, Khatib, Y, Swarts, E. Prosthetic fracture of a cemented Exeter femoral stem (case report). Reconstructive Review 2016; 6. Google Scholar 12.Bergmann, G, Deuretzbacher, G, Heller, M. Hip contact forces and gait patterns from routine activities. J Biomech 2001; 34: 859–871. Google Scholar | Medline | ISI

Health Central by Sarah Ellis, health writer Aug 10, 2020 It’s a new virus, and medical experts are learning more each day about the ways it has the potential to affect patients in the months following diagnosis. One great thing modern medicine has given us is the ability to study and record the effects of different diseases in human beings. For the most part, doctors can tell patients what to expect and how to take care of themselves after a new diagnosis, whether it’s a viral infection or an autoimmune disease. But the coronavirus is a brand-new pathogen, leaving us all with so many questions. Medical experts are learning more about the way COVID-19 affects people – both in the first few weeks and months after their initial diagnosis. And there’s still so much to be discovered. “We are still in the learning phase of this disease,” says Rashid Chotani, M.D., Vice President of Medical Affairs at CareLife Medical in Fairfax, VA. “However, as the disease spreads across the globe, we have observed that the infectivity, symptoms, and severity of COVID-19 varies.” Essentially, COVID-19 infection looks different for different people, and it’s impossible to predict how your body might react. But here’s what to look out for based on available data, and what you can do to stay safe and healthy. 1. LUNG DAMAGE COVID-19 is thought of primarily as a respiratory disease, characterized by coughing and shortness of breath. So, it’s no surprise that some patients are experiencing lung damage as a result of their initial infection. A May 2020 study in The Lancet cited evidence from previous coronavirus infections, combined with emerging data on COVID-19, to confirm that significant lung damage is one possible complication of this new virus. In early June, a COVID-19 patient in her twenties, listed as being otherwise healthy, had to get a lung transplant at Northwestern Hospital in Chicago due to severe lung damage. She had spent six weeks on a ventilator prior to the procedure. “We’re going to be seeing areas of [lung] damage that people are going to be required to be on oxygen,” says Alejandro Comellas, M.D., director of the Institute for Clinical and Translational Science Clinical Research Unit at the University of Iowa in Iowa City. “We’re hoping that those areas are not going to be permanently damaged.” Even people with asymptomatic COVID-19 infection may show signs of lung inflammation, according to a May 2020 study published in Nature Research. Blood clotting from COVID-19 could also lead to a pulmonary embolism (blockage of a major artery in the lungs), which is life-threatening and can lead to permanent lung damage. Panagis Galiatsatos, M.D., pulmonary and critical care physician at Johns Hopkins Medicine in Baltimore, explains that there could be a variety of reasons for post-COVID-19 pulmonary fibrosis (lung damage). The patients could have had underlying lung disease without realising it. “Sometimes to have a lung disease manifest with symptoms, you need a trigger,” he says—in this case, that trigger being COVID-19 infection. Or, the damage could be caused by COVID-19 itself. “Our immune systems have to fight off an infection, and at the same time afterwards, they have to help with healing,” he explains. Think of it, he says, like a house fire: Your priority is to put the fire out, but then you have to rebuild from the damage it caused. This takes time. “Depending on how the pace goes, some parts of the lungs may heal faster than other parts, and that could create symptoms [like] shortness of breath and cough as lungs heal,” Dr. Galiatsatos explains. This process could take weeks or months, depending on your specific severity of illness. 2. HEART DAMAGE COVID-19 affects more than just your lungs: there is increasing evidence to show that the disease also takes a toll on your heart, with up to one in five COVID-19 patients showing signs of cardiac dysfunction (according to a March 2020 study in JAMA Cardiology). “We know COVID-19 can infect the heart, can infect the lungs and can infect the kidneys,” Dr. Galiatsatos says. “This virus seems to be able to impact a variety of organs, and it’s hard to predict how those organs will recover.” Dr. Chotani echoes this. “This is a very heterogeneous disease, as patients can die not only from lung failure, but also kidney failure, blood clots, liver abnormalities, and neurological manifestations,” he says. Research has increasingly shown that blood clotting associated with COVID-19 can lead to heart attacks or put stress on your heart due to lack of adequate blood flow. 3. NEUROLOGICAL EFFECTS Perhaps the scariest emerging long-term effect of COVID-19 is its potential impact on the brain. A June 2020 study in Neurology found evidence that some patients with severe COVID-19 illness exhibit signs of brain damage or brain injury (though the authors note that this is uncommon). “It’s difficult to know right now what the cause would be” of brain damage, Dr. Comellas notes. It could be that the virus targets the brain, or that the inflammation caused by the immune reaction is affecting blood flow to the area. In rare cases, serious blood clotting can lead to strokes in COVID-19 patients who are otherwise young and healthy. Or, Dr. Comellas explains, brain damage could occur as a result of hypoxia—low oxygen caused by the respiratory effects of the virus. In any case, more time and research can help identify the severity to which COVID-19 could put your brain health at risk. “There’s a real interest in understanding the neurocognitive effects in patients who survive COVID-19, especially in these severe cases,” Dr. Comellas explains, in the hope that more proactive steps can be taken to minimise them. 4. PSYCHOLOGICAL TRAUMA If a patient experiences severe illness from COVID-19, they are likely to feel some lasting psychological effects from their ordeal. “Of course, there’s going to be the psychological issues associated with acute illness,” Dr. Comellas says, such as post-traumatic stress disorder, depression, and anxiety. A 2014 analysis in The Lancet Respiratory Medicine found that up to 25% of critical illness survivors experience poor mental health outcomes and functional disabilities for at least one year after their hospital discharge. Similarly, Dr. Chotani explains, patients who have spent weeks in the ICU could experience lingering mental and physical health effects from that experience. “They may also suffer from post-intensive care syndrome (PICS),” he says, a condition characterised by “physical impairment due to malnutrition, cognitive impairment which can result in decreased memory, decreased attention, and decreased mental sharpness or ability to solve problems, and psychiatric impairment.” A mental health professional trained in cognitive behavioural therapy (CBT) can be key to helping you identify and confront your symptoms of PTSD or depression before they take over your life. You may want to consider therapy for yourself or a loved one who has recently had a life-changing experience with COVID-19. And to manage physical disabilities in the months after your recovery, continue to work with your team of healthcare providers to monitor your symptoms and address any emerging challenges. 5. CHRONIC FATIGUE Dr. Chotani notes that in previous studies of SARS (a coronavirus that spread throughout the world in the early 2000s), survivors sometimes showed signs of fatigue and muscle weakness for years afterwards. “What we know is that SARS survivors had poorer exercise capacity and health status and had chronic fatigue symptoms 3.5 years after being diagnosed,” he explains. “So, one possible long-term effect is chronic fatigue syndrome.” The specific cause of chronic fatigue syndrome is unknown, but one notable trigger is viral infections, which can cause significant stress to your internal organs. Unfortunately, it won’t be clear for a while which effects of COVID-19 are long-lasting or permanent. “I think we’re going to have to wait at least a year before we know whether some of the organs involved in infection could show some damage that we think has passed already,” Dr. Comellas explains. The hope is that some of these effects may lessen or disappear as the body recovers from illness. The key will be identifying survivors at different intervals for doctors to assess. “We need survivors at one-month intervals, three-month intervals, one-year intervals, and ten-year intervals … in order to get a complete picture,” Dr. Galiatsatos says. “It will take time for us to say in confidence what survival of COVID-19 looks like.” HOW TO STAY SAFE? Since doctors are still don't have a lot of answers or information, it’s crucial to stay attentive about protecting yourself from the virus. This is especially true if you fall into a high-risk category due to age or pre-existing conditions. Follow the social distancing guidelines: • Stay at least 1 metre apart from others • Wear a mask • Wash your hands frequently • Avoid public places where this level of distance is not possible In the meantime, do the best to keep yourself healthy. “If you do have pre-existing conditions, definitely make sure they are well-controlled,” Dr. Galiatsatos suggests. He notes that based on data from other viral infections, experts know that people with well-maintained diabetes or blood pressure have better outcomes from infection than those who don’t manage their conditions as well. “Being able to work with your doctor and have these pre-existing conditions well taken care of goes a long way to potentially keeping yourself safe if you catch the virus and end up developing symptoms,” he says. With the recent upswing in cases across the country, Dr. Chotani emphasises the urgency of being careful. “With the cases now re-spiking, we need to be extremely vigilant,” he says. “Follow the advice of public health, infectious disease and epidemiology experts, and not what others are saying or portraying. Also, make sure that you are taking your medications for your under-lying conditions (comorbidities) on time and staying healthy.” The best we can do right now is look out for ourselves and each other.

Tens of thousands of people who are suffering long-term effects of coronavirus will benefit from a revolutionary on-demand recovery service, the head of the NHS has announced today. 5 July 2020 - NHS article. Nurses and physiotherapists will be on hand to reply to patients’ needs either online or over the phone as part of the service. The new ‘Your COVID Recovery’ service forms part of NHS plans to expand access to COVID-19 rehabilitation treatments for those who have survived the virus but still have problems with breathing, mental health problems or other complications. Coming on the day of the NHS’s anniversary, chief executive Sir Simon Stevens has hailed the new service as a great example of the way the health service is increasingly harnessing technology and innovation to enhance the face to face care that doctors, nurses, therapists and other staff can provide in a safe and convenient way. It follows the building of a new Seacole rehabilitation centre to help those most seriously affected by the deadly virus, with similar facilities expected to open across the country. Patients who have been in hospital or suffered at home with the virus will have access to a face-to-face consultation with their local rehabilitation team, usually comprising of physiotherapists, nurses and mental health specialists. Following this initial assessment, those who need it will be offered a personalised package of online-based aftercare lasting up to 12 weeks, available later this Summer. Accessible, on-demand, from the comfort of their own home, this will include: Access to a local clinical team including nurses and physiotherapists who can respond either online or over the phone to any enquiries from patients; An online peer-support community for survivors – particularly helpful for those who may be recovering at home alone; Exercise tutorials that people can do from home to help them regain muscle strength and lung function in particular, and; Mental health support, which may include a psychologist within the online hub or referral into NHS mental health services along with information on what to expect post-COVID. Sir Simon Stevens said: “COVID-19 has been the biggest challenge in the NHS’s history, and the fact that we have come through the first peak without services being overwhelmed and being able to give expert care to everyone who needed it, is testament all our frontline and support staff. “Now, as we celebrate the birthday of the NHS and look ahead to the next phase of our response, while in-person care will continue to be vital, the health service is embracing the best that new technology can offer us to meet the significant level of new and ongoing need. “Rolling out Your COVID Recovery, alongside expanding and strengthening community health and care services, is another example of how the NHS must bring the old and the new together to create better and more convenient services for patients.” NHS staff responded rapidly to the COVID-19 outbreak to care for more than 100,000 patients in hospital, and many more in the community. Thanks to their efforts everyone who could benefit from care was able to get it, and the overwhelming majority survived. However, evidence shows that many of those survivors are likely to have significant on-going health problems, including breathing difficulties, enduring tiredness, reduced muscle function, impaired ability to perform vital everyday tasks and mental health problems such as PTSD, anxiety and depression. The online portal will help ensure that people get the support they need to recover from the effects of the virus, including those associated with spending a long time on ventilation, while reducing the need to physically attend appointments for many. The first phase of the service will launch later this month, providing the latest advice on recovering from the virus, which will be available to all and continually improved and added to. The second phase, in which people who need it will be able to access personalised support packages, is in development by experts based in Leicester and will be made available later in the summer. In order to access this part of the site, patients will first attend a face-to-face assessment, which may include a walking test, to help personalise care and ensure people get the type of support and rehabilitation specific to their need, rather than a one-size-fits-all approach. For those who need ongoing care, they will be given a log-in to the new online site, which will be accessible from any web-enabled phone, tablet, television or computer. Where patients don’t already have access to a suitable device to use the online platform, printed materials will be made depending upon demand to ensure the service is accessible to all. Rehabilitation professionals will be able to access their patient’s data to enable remote care and monitoring, ensuring that anyone who might need further face-to-face checks or treatment can get it. Professor Sally Singh with a team from University Hospitals of Leicester NHS has been working with national clinical leaders to build the service and is now working with the NHS nationally to roll it out across the country. Professor Singh from the University of Leicester said: “We know the impact of COVID on people can be far reaching and complex, ‘Your COVID Recovery’ is specifically designed to support people in their recovery post-coronavirus, this will be one of the first sites in the world rolled out nationally seeking to address potential post-COVID symptoms and support people on the road to recovery. “We have brought together a wide range of experts representing a number of professional societies who have made valuable contributions to the site, to allow us to have a comprehensive package of information and advice. Importantly we have worked with people with first-hand experience of COVID to help shape the site and make sure the content was fit for purpose.” Alongside bringing back non-urgent services in a safe way and maintaining a high state of readiness for any future increase in COVID cases, local health leaders are currently working with councils and voluntary groups to plan how they will meet the additional ongoing demand for rehabilitation services post-COVID. While in many cases these services will be delivered by or within existing NHS facilities, where necessary plans may include using temporary facilities like the first NHS Seacole Centre, a dedicated rehabilitation and step-down facility which opened in Surrey at the end of May.

There is currently no specific treatment for coronavirus (COVID-19), but you can often ease the symptoms at home until you recover. If you have a high temperature, it can help to: - Get lots of rest - Drink plenty of fluids (water is best) to avoid dehydration - Drink enough so your urine is light yellow and clear - Take Paracetamol or Ibuprofen if you feel uncomfortable TREATING A COUGH If you have a cough, it's best to avoid lying on your back. Lie on your side or sit upright instead. To help ease a cough, try having a teaspoon of honey. But do not give honey to babies under 12 months. If this does not help, you could contact a pharmacist for advice about cough treatments.Information: Do not go to a pharmacy in person. If you or someone you live with has coronavirus symptoms, you should all stay at home.Try calling or contacting the pharmacy online instead.Things to try if you're feeling breathless If you're feeling breathless, it can help to keep your room cool.Try turning the heating down or opening a window. Do not use a fan as it may spread the virus. - - - YOU COULD ALSO TRY Breathing slowly in through your nose and out through your mouth, with your lips together like you're gently blowing out a candle Sitting upright in a chair Relaxing your shoulders, so you're not hunched leaning forward slightly – support yourself by putting your hands on your knees or on something stable like a chair. Try not to panic if you're feeling breathless. This can make things worse. WHAT TO DO IF YOUR SYMPTOMS GET WORSE It's important to get medical help if your symptoms get worse. Urgent advice: - Use the 111 online coronavirus service if: - You feel you cannot cope with your symptoms at home - Your symptoms get worse and you're not sure what to do ONLY CALL 111 IF YOU CANNOT GET HELP ONLINE. BABIES AND CHILDREN Call 111 if you're worried about a baby or child. If they seem very unwell, are getting worse, or you think there's something seriously wrong, call 999. Do not delay getting help if you're worried. Trust your instincts.

The rapid spread of the coronavirus has sparked worldwide alarm. The World Health Organisation (WHO) has declared this rapidly spreading outbreak a pandemic. Many countries are struggling with a rise in confirmed cases. All over the world people are advised to be prepared for disruptions to daily life, causing stress to individuals, families and communities. Our fears arise from a misaligned ratio of stress to resiliency. The more resilient we become the less stress we will feel. But this is a subject that I will be expanding on further in my future posts. Here's an edited version of a recent Harvard Medical School article on the subject. - - - Can vitamin C be used to treat patients with COVID-19? Some critically ill patients with COVID-19 have been treated with high doses of intravenous (IV) vitamin C in the hope that it will hasten recovery. However, there is no clear or convincing scientific evidence that it works for COVID-19 infections, and it is not a standard part of treatment for this new infection. A study is underway in China to determine if this treatment is useful for patients with severe COVID-19; results are expected in the fall. The idea that high-dose IV vitamin C might help in overwhelming infections is not new. A 2017 study found that high-dose IV vitamin C treatment (along with thiamine and corticosteroids) appeared to prevent deaths among people with sepsis, a form of overwhelming infection causing dangerously low blood pressure and organ failure. Another study published last year assessed the effect of high-dose vitamin C infusions among patients with severe infections who had sepsis and acute respiratory distress syndrome (ARDS), in which the lungs fill with fluid. While the study's main measures of improvement did not improve within the first four days of vitamin C therapy, there was a lower death rate at 28 days among treated patients. Though neither of these studies looked at vitamin C use in patients with COVID-19, the vitamin therapy was specifically given for sepsis and ARDS, and these are the most common conditions leading to intensive care unit admission, ventilator support, or death among those with severe COVID-19 infections. Regarding prevention, there is no evidence that taking vitamin C will help prevent infection with the coronavirus that causes COVID-19. While standard doses of vitamin C are generally harmless, high doses can cause a number of side effects, including nausea, cramps, and an increased risk of kidney stones. - - - Is the antiviral drug Remdesivir effective for treating COVID-19? Scientists all over the world are testing whether drugs previously developed to treat other viral infections might also be effective against the new coronavirus that causes COVID-19. One drug that has received a lot of attention is the antiviral drug Remdesivir. That's because the coronavirus that causes COVID-19 is similar to the coronaviruses that caused the diseases SARS and MERS — and evidence from laboratory and animal studies suggests that Remdesivir may help limit the reproduction and spread of these viruses in the body. In particular, there is a critical part of all three viruses that can be targeted by drugs. That critical part, which makes an important enzyme that the virus needs to reproduce, is virtually identical in all three coronaviruses; drugs like Remdesivir that successfully hit that target in the viruses that cause SARS and MERS are likely to work against the COVID-19 virus. Remdesivir was developed to treat several other severe viral diseases, including the disease caused by Ebola virus (not a coronavirus). It works by inhibiting the ability of the coronavirus to reproduce and make copies of itself: if it can't reproduce, it can't make copies that spread and infect other cells and other parts of the body. Remdesivir inhibited the ability of the coronaviruses that cause SARS and MERS to infect cells in a laboratory dish. The drug also was effective in treating these coronaviruses in animals: there was a reduction in the amount of virus in the body, and also an improvement in lung disease caused by the virus. The drug appears to be effective in the laboratory dish, in protecting cells against infection by the COVID virus (as is true of the SARS and MERS coronaviruses), but more studies are underway to confirm that this is true. Remdesivir was used in the first case of COVID-19 that occurred in Washington state, in January 2020. The patient was severely ill, but survived. Of course, experience in one patient does not prove the drug is effective. Two large randomised clinical trials are underway in China. The two trials will enrol over 700 patients and are likely to definitively answer the question of whether the drug is effective in treating COVID-19. The results of those studies are expected in April or May 2020. Studies also are underway in the United States, including at several Harvard-affiliated hospitals. It is hard to predict when the drug could be approved for use and produced in large amounts, assuming the clinical trials indicate that it is effective and safe. - - - Is a lost sense of smell a symptom of COVID-19? What should I do if I lose my sense of smell? Increasing evidence suggests that a lost sense of smell, known medically as anosmia, may be a symptom of COVID-19. This is not surprising, because viral infections are a leading cause of loss of sense of smell, and COVID-19 is caused by a virus. Still, loss of smell might help doctors identify people who do not have other symptoms, but who might be infected with the COVID-19 virus — and who might be unwittingly infecting others. A statement written by a group of ear, nose and throat specialists (otolaryngologists) in the United Kingdom reported that in Germany, two out of three confirmed COVID-19 cases had a loss of sense of smell; in South Korea, 30% of people with mild symptoms who tested positive for COVID-19 reported anosmia as their main symptom. On March 22nd, the American Academy of Otolaryngology-Head and Neck Surgery recommended that anosmia be added to the list of COVID-19 symptoms used to screen people for possible testing or self-isolation. In addition to COVID-19, loss of smell can also result from allergies as well as other viruses, including rhinoviruses that cause the common cold. So anosmia alone does not mean you have COVID-19. Studies are being done to get more definitive answers about how common anosmia is in people with COVID-19, at what point after infection loss of smell occurs, and how to distinguish loss of smell caused by COVID-19 from loss of smell caused by allergies, other viruses, or other causes altogether. Until we know more, tell your doctor right away if you find yourself newly unable to smell. He or she may prompt you to get tested and to self-isolate. - - - Are Chloroquine and Hydroxychloroquine effective for treating COVID-19? Recently, there has been considerable discussion of whether two related drugs — I and Hydroxychloroquine — that have been available for decades to treat other illnesses might also be effective in treating COVID-19. The drugs are primarily used to treat malaria and several inflammatory diseases, including systemic Lupus Erythematous (lupus) and rheumatoid arthritis. No drug is perfectly safe, but these drugs are quite safe when used for just the several days they might be needed to treat COVID-19. They are also cheap, already available at our local drug stores, and relatively free of side effects. The question, of course, is whether they are effective against the coronavirus that causes COVID-19. Are they effective in killing the virus in a laboratory dish? And are they effective in killing the virus in people? If the answer to the first question is "no," there's no point in getting an answer to the second question. There is strong evidence that both drugs kill the COVID-19 virus in the laboratory dish. The drugs appear to work through two mechanisms. First, they make it harder for the virus to attach itself to the cell, inhibiting the virus from entering the cell and multiplying within it. Second, if the virus does manage to get inside the cell, the drugs kill it before it can multiply. But do the drugs work in people with COVID-19? Many studies are underway to get an answer to this question, but as of March 24, 2020, only two have issued preliminary results. One report, published in February 2020, claimed that Chloroquine had been used in more than 100 patients in China who had COVID-19. The scientists stated that their results demonstrated that Chloroquine is superior to the control treatment in inhibiting the worsening of pneumonia, improving lung imaging findings, eliminating the virus from the body, and shortening the duration of the disease. These claims are exciting. However, the report provided virtually no evidence in support of the claims. First of all, this was not a randomised, double-blind controlled trial, the gold standard for research studies. Second, no evidence was presented as to how severe the pneumonia was, nor whether findings on lung x-rays or CT scans really improved. Third, although they claim the drug made the virus disappear, they didn't report what the levels of the virus were before versus after the treatment. In short, not much evidence. Another small study was conducted by a group of scientists in southern France, a region hard hit by COVID-19. This, also, was not a randomised trial. Instead, the scientists compared 26 patients who received Hydroxychloroquine to 16 who did not: after six days, the virus was gone from the body in 70% of those given the treatment, compared to only 12.5% of those who weren't. The drug appeared to be as effective in the sickest patients as in the least sick, but the study was too small to be sure about that. The study also was too small to say that people who received the treatment were protected against a prolonged illness or death. There are many studies underway, and we should have more solid answers within a few months. - - - I heard that certain blood pressure medicines might worsen symptoms of COVID-19. Should I stop taking my medication now just in case I do get infected? Should I stop if I develop symptoms of COVID-19? You are referring to angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), two types of medications used primarily to treat high blood pressure (hypertension) and heart disease. Doctors also prescribe these medicines for people who have protein in their urine, a common problem in people with diabetes. At this time, the American Heart Association (AHA), the American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA) strongly recommend that people taking these medications should continue to do so, even if they become infected. Here's how this concern got started. Researchers doing animal studies on a different coronavirus (the SARS coronavirus from the early 2000s) found that certain sites on lung cells called ACE-2 receptors appeared to help the SARS virus enter the lungs and cause pneumonia. ACE inhibitor and ARB drugs raised ACE-2 receptor levels in the animals. Could this mean people taking these drugs are more susceptible to COVID-19 infection and are more likely to get pneumonia? The reality today: Human studies have not confirmed the findings in animal studies. Some studies suggest that ACE inhibitors and ARBs may reduce lung injury in people with other viral pneumonias. The same might be true of pneumonia caused by the COVID-19 virus. Stopping your ACE inhibitor or ARB could actually put you at greater risk of complications from the infection, since it's likely that your blood pressure will rise and heart problems would get worse. The bottom line: The AHA, ACC, and HFSA strongly recommend continuing to take ACE inhibitor or ARB medications, even if you get sick with COVID-19. - - - Should I go to the doctor or dentist for non-urgent appointments? During this period of social distancing, it is best to postpone non-urgent appointments with your doctor or dentist. These may include regular good visits or dental cleanings, as well as follow-up appointments to manage chronic conditions if your health has been relatively stable in the recent past. You should also postpone routine screening tests, such as a mammogram or PSA blood test if you are at average risk of disease. Many doctor's surgeries have started restricting surgery visits to urgent matters only, so you may not have a choice in the matter. As an alternative, doctor's offices are increasingly the so-called telehealth services. This may mean appointments by phone call, or virtual visits using a video chat service. Ask to schedule a telehealth appointment with your doctor for a new or ongoing non-urgent matter. If, after speaking to you, your doctor would like to see you in person, he or she will let you know. What if your appointments are not urgent but also don't fall into the low-risk category? For example, if you have been advised to have periodic scans after cancer remission, if your doctor sees you regularly to monitor for a condition for which you're at increased risk, or if your treatment varies based on your most recent test results? In these and similar cases, call your doctor for advice. - - - Is it safe to take Ibuprofen to treat symptoms of COVID-19? Some French doctors advise against using ibuprofen (Motrin, Advil, many generic versions) for COVID-19 symptoms based on reports of otherwise healthy people with confirmed COVID-19 who were taking an NSAID for symptom relief and developed a severe illness, especially pneumonia. These are only observations and not based on scientific studies. The WHO initially recommended using paracetamol instead of ibuprofen to help reduce fever and aches and pains related to this coronavirus infection, but now states that either paracetamol or ibuprofen can be used. Rapid changes in recommendations create uncertainty. Since some doctors remain concerned about NSAIDs, it still seems prudent to choose paracetamol first, with a total dose not exceeding 3,000 milligrams per day. However, if you suspect or know you have COVID-19 and cannot take paracetamol, or have taken the maximum dose and still need symptom relief, taking over-the-counter ibuprofen does not need to be specifically avoided. - - - How reliable is the test for COVID-19? Tests are becoming more widely available and are being processed in commercial labs and academic centres across the country. In the US, the most common test for the COVID-19 virus looks for viral RNA in a sample taken with a swab from a person's nose or throat. Currently, you can expect the test results within three to four days. Likely the turnaround time for results will be shorter over the next few weeks. If a test result comes back positive, it is almost certain that the person is infected. A negative test result is less definite. An infected person could get a so-called "false negative" test result if the swab missed the virus, for example, or because of an inadequacy of the test itself. We also don't yet know at what point during the course of illness a test becomes positive. If you experience COVID-like symptoms and get a negative test result, there is no reason to repeat the test unless your symptoms get worse. If your symptoms do worsen, call your doctor or local or state healthcare department for guidance on further testing. You should also self-isolate at home. Wear a mask if you have one when interacting with members of your household. And practice social distancing.

A quick recap on medical scanners used at my clinic. Medical scanners allow doctors to see inside patients' body. This painless procedure involves combining X-rays / magnetic fields and a computer to create images of a patient's organs, bones, and other tissue. It shows far more detail than a regular X-ray. ​ Both MRI and CT scans provide diagnostic images of the inside of a patients' body. They, however, accomplish this task in distinctly different ways. ​ MRI scan (Magnetic Resonance Imaging) allows doctors to see inside a patient's body in great anatomical detail. It involves combining X-rays / magnetic fields and a computer to create images of patients' organs, bones, blood vessels, nerves, etc. Thus, it shows far more detail than a regular X-ray. MRI is generally used to scan soft tissue. ​ CT or CAT scans (Computerised Tomography) combine several X-rays to produce detailed images of structures inside the body. CT scans typically take diagnostic images more quickly compared to MRI. For example, a CT scan can usually be completed in less than 5 minutes, while MRI takes about 30 minutes.

Former Birmingham City star Ricky Otto is looking forward to a ‘kickabout’ in a local five-a-side hall as he recovers from his second hip replacement operation in six years. Ricky retired from professional football in 2000 and is now a Pastor at the ARC (A Radical Church) Birmingham, based in Lozells. “To be honest, I have been too busy to even think about football for a long time now, but for some reason, I’m itching to get out there and have a kickabout." Ricky’s first hip replacement operation was carried out six years ago by Mr Trevor Lawrence, an orthopaedic consultant and Spire Parkway Hospital in Solihull. "It all went so well that as soon as I realised I needed a second replacement, I had no thoughts about seeing anyone other than Mr Lawrence – even though he is an Aston Villa fan.” joked Ricky. “By this time, I was heavily involved in my pastoral work, so I had my sights set on an early return to work. Instead, just days after leaving the hospital, I was able to do bits of work on the email and telephone, but I was up and about with virtually no pain whatsoever within eight weeks. I’ve stuck to my physiotherapy routine and done plenty of exercise, so everything is going well. Now I’ve set myself a ‘target’ of late July when I hope to get out and play some ‘light duty’ football.” Surgeon Mr Lawrence said Ricky’s target was ‘very achievable’ as long as he gets the okay from his physio first. “I wouldn’t suggest full-contact football, but for someone who has kept themselves in good shape as Ricky has done, then a friendly kickabout shouldn’t be a problem. He would certainly be able to take part in non-contact sports such as tennis or golf with very little trouble – in fact, joint replacement patients are actually encouraged to exercise regularly to keep the muscles surrounding their joints in good condition.” As for Ricky, he said: “It may seem young to have two hip replacements at just over 50 years old, but when the pain in your hip is so bad, you can hardly sleep, never mind do exercise, then that is the time to consider surgery. I would advise anyone in a similar situation to the one I found myself in to visit their GP and get expert advice on what action they should take. I think they will find a new hip does wonders to improve their quality of life.”

Our hobbies and pastimes play a major part in our life – helping to keep our bodies fit and our minds active. But, as we age, we can develop osteoarthritis, which threatens our ability to continue playing even non-contact sports such as tennis, badminton or golf. Trevor Lawrence, a consultant orthopaedic surgeon at the Spire Parkway Hospital in Solihull, is a keen golfer who says that there are options for people suffering from osteoarthritis that can help them stay out on the fairways. “At my own golf club, some of my fellow players had also become my patients when they began to suffer the typical symptoms of osteoarthritis (when the cartilage in joints wears away), causing pain in the wrist, knees or hips,” he explained. But it certainly does not mean having to hang up your golf bag! “Often golfers notice the signs of arthritis before those who don’t play the game do,” Mr Lawrence said. “They might struggle to bend down to pick up the ball or fully follow through with their swing because of pain in their hips and knees. “If they have arthritis in their fingers, gripping the club firmly becomes an issue, while degeneration in the wrist can cause problems with ‘cocking the wrist’ before striking the ball. “There will also be problems actually managing to complete a full round because of pain in either the knee or hips or sometimes in both. “In a typical round of golf, players walk about five miles – in some cases, the pain will start kicking in around the thirteenth or fourteenth hole, so they find they either can’t play their shots properly for the rest of the game, or they simply cannot walk the rest of the course.” When a fellow golfer suffering from osteoarthritis presents at Mr Lawrence’s clinic, he tries to provide hope that they can still carry on with the game they love by making minor changes in the way they actually play the game. “Sometimes players can successfully learn to adapt their swing, although this can be difficult – they can always make smaller changes,” he explained. “Make sure you warm up before actually stepping up to the first tee. Stretch the hamstrings, loosen the shoulders and flex the groin area to warm up the muscles. A few minutes of gentle twisting and bending activity will ease some of the stiffness. “Golfers with osteoarthritis can also try adapting their gear. The world’s top players usually have clubs with very stiff shafts, but players with painful joints need to use more flexible and less rigid clubs. “If you are thinking of changing your clubs, your golf professional should be able to offer you some good advice. For example, a club shaft with more ‘whip’ will make both hitting and getting the ball into the air that bit easier. Selecting a more lightweight graphite club will also help.” Mr Lawrence also pointed to the availability of oversized ‘thicker’ grips that can be fitted to all club handles. This will mean you don’t have to close your hands tightly around the handle, thus taking pressure off arthritic fingers. And for the golfers struggling to get around the course, Mr Lawrence says: “Try cutting the weight of your golf bag by taking out anything you don’t think you’ll need. For example, people insist on carrying the full amount of golf clubs when, in most cases, they will only use half of them during that round. “If you presently carry your bag, look at investing in a trolley – or better still, an electric trolley as it will mean much less strain on your shoulder and back joints. “I realise that many players aren’t keen on hiring a buggy as they think it takes away from the ‘exercise’ part of the game, but at least it means you are out there still playing. Also, if in the long term you do need surgery to continue playing, then at least your time using a buggy means your swing won’t be quite as rusty when you get back onto the course.” Simple lifestyle changes such as losing weight to reduce the pressure on joints can help ease some of the pain of osteoarthritis. “A golf swing puts a lot of force through the hip and the knee particularly, both areas where osteoarthritis typically appears,” said Mr Lawrence. “It means that in some cases, players do eventually have to undergo knee or hip replacement surgery as the pain, even with medication, becomes too much. But the upside is they can return to enjoying their golf for many years to come.”

Hip op patients assured surgery is ‘life-changing.’ With more and more people in their fifties – and younger – facing a hip replacement, a Birmingham Orthopaedic Surgeon is reassuring anyone who has concerns about how long it will last that, thanks to advances in implant technology and surgical techniques, they can look forward to a better quality of life for many years to come. It is a commonly held belief that people are in their 60s or 70s when they undergo a hip replacement, so anyone else is just too young to need this kind of surgery. However, during the past three years, Trevor Lawrence BSc (Hons) MBChB FRCS (Orth) – a consultant with the Heart of England Foundation Trust in Birmingham, Solihull’s Spire Parkway Hospital and one of the UK’s leading specialists in this field – has seen a threefold increase in patients under the age of 50. This upswing is partly due to a move away from resurfacing surgery, resulting in major complications. Still, Mr Lawrence believes that a rise in osteoarthritis is a key factor, along with the fact that people who lead active lives are determined to maintain their fitness. Indeed, M G, 56, who lives in Hollywood, plays football, badminton and golf again after a second hip replacement operation. He says: Young, active people, want the tried and tested implants that are going to give them relief from pain and a quality of life. This means they can continue to do the activities they enjoy, so I am happy to reassure them that the surgery I perform has a track record spanning 40 years and demonstrates the best outcomes, as evidenced by the National Joint Registry. With more and more people in their fifties – and younger – facing a hip replacement, a Birmingham Orthopaedic Surgeon is reassuring anyone who has concerns about how long it will last that, thanks to advances in implant technology and surgical techniques, they can look forward to a better quality of life for many years to come. After about eight months, and once I’d regained my strength, nothing seemed impossible. “Having my other hip replaced was much easier because I knew what to expect and was confident that, thanks to Mr Lawrence, I’d be able to walk easily, get back to my normal routine and, most importantly, take up the sport again. So I would say to anyone facing this kind of surgery to go ahead because the difference it makes is life-changing.” For Knowle, mum of two SW, finding out, at the age of 37, that she would need to have both hips replaced because of osteoarthritis came as a real shock. However, she returned to work just four weeks after her surgery, was back in the gym within three months and now doesn’t think twice about going horse-riding, skiing, swimming and running. “My problems started when I began to experience a catching sensation, and then my leg would just give way,” explains S. “At first, I thought it was just one of those things, but it got steadily worse over the years until I couldn’t walk properly. I won’t deny it; I was worried about the scar, but Mr Lawrence did a great job, and now it just doesn’t bother me.” T M from Solihull was 48 when hip problems impacted her mobility. As a result, she was forced to give up her job in event management. However, once she had received an exact diagnosis and Mr Lawrence had given her a new hip, T was quick to resume her active lifestyle. “Friends can’t remember that I used to walk with a stick, and people who expect me to limp are amazed that my mobility is so good,” she says. During my recovery, I did all the physio by the book and then, because I could get back to aerobics and combat training, I lost weight and regained my fitness. My hip replacement proved to be a major turning point because since then, I’ve been on a beach holiday and go walking in the Lake District, which I love.” Mr Lawrence advises that pain and lack of mobility determine the right time for surgery and says there is well-documented evidence that if it is performed well, upwards of 90 per cent of patients will have a well-functioning hip for 40 years more. Furthermore, once muscle strength has been built up, he sees no reason why patients who have enjoyed an active lifestyle, including playing the sport, shouldn’t get back to doing what they enjoy. Surgery certainly changed everything for M G, who had his first hip replacement aged 49. He says: “Before the operation, I was struggling to sleep and finding it difficult to put my shoes on, let alone tie the laces. Afterwards, the nagging ache I’d lived with for so long had gone, I tentatively started to play indoor football again after about eight months, and once I’d regained my strength, nothing seemed impossible. “Friends can’t remember that I used to walk with a stick, and people who expect me to limp are amazed that my mobility is so good.” “During my recovery, I did all the physio by the book and then, because I was able to get back to aerobics and combat training, I lost weight and regained my fitness. My hip replacement proved to be a major turning point because since then, I’ve been on a beach holiday and go walking in the Lake District, which I love.” Mr Lawrence advises that pain and lack of mobility determine the right time for surgery and says there is well-documented evidence that if it is performed well, upwards of 90 per cent of patients will have a well-functioning hip for 40 years more. Furthermore, once muscle strength has been built up, he sees no reason why patients who have enjoyed an active lifestyle, including playing sports, shouldn’t get back to doing what they enjoy.

M S from Knowle struggled for years with pain in her joints after developing rheumatoid arthritis at the age of just 46. Now at 70 years young, she is once again pain-free and enjoying life after having her right hip reconstructed and both knees replaced by orthopaedic surgeon Trevor Lawrence BSc (Hons) MBChB FRCS (Orth). Unfortunately, when M underwent her original hip replacement operation, it was not successful. She developed a deep-seated infection and, despite going back to her surgeon, reached the stage where she required almost daily dressings to her leg. The consultant treating M’s arthritis referred her to Mr Lawrence, who specialises in complex hip and knee surgery, and after a series of tests, X-rays and an exploratory operation, he was able to set her on the road to recovery. During a 16-week hospital stay, M's hip was removed, and she was put on a course of antibiotics before being allowed home. Then, in January 2011, only once Mr Lawrence was convinced the infection had gone, did he replace M’s hip. “The infection had done a great deal of damage, and there was no guarantee the surgery would work, but what really impressed me was that Mr Lawrence was completely straight with me and so very caring,” says M. “He was totally honest about the prognosis, visiting me around three times a week while I was in the hospital and talking me through the surgery, but he never tried to gloss over anything. Afterwards, I had no more pain. It was remarkable.” As a consequence of M’s hip problems, her knees were out of alignment, so Mr Lawrence carried out further surgery, replacing her right knee in January 2012 and the left knee six months later. M does the exercises her physiotherapist recommended every day and is mobile and pain-free. “It may not sound like much to most people, but being able to go up and down the stairs unaided is wonderful,” adds M, who has returned to swimming and enjoys walking, theatre trips and travelling with her husband, M. M S from Knowle, 70, is pain-free and enjoying an active life again after having her right hip reconstructed and both knees replaced. “My hip replacement was unsuccessful, and despite the original surgeon’s efforts to sort it out, a deep-seated infection had taken hold by the time I went to Mr Lawrence for a consultation. “There was no guarantee that the surgery he was proposing would work, but what impressed me was his honesty – he was straight with me about the prognosis right from the outset – and the fact that he was so very caring. “Trevor Lawrence has given me back my life, and if I could, I would knight him.”

HF was just 14 when he took up ballroom dancing in 1947 and continued to enjoy it as his main hobby until 2011, when years of general wear and tear took their toll, and he underwent a staged bilateral knee replacement. Birmingham orthopaedic surgeon Trevor Lawrence BSc (Hons) MBChB FRCS (Orth) replaced both knees within three months of each other. After recuperating, Henry was whirling wife Doreen around the dance floor once again. “D and I have all our medals, entered different competitions and won a few trophies – we even competed in Blackpool – but I’d become really bow-legged, and although I was dancing through the pain in my knees, we knew something had to be done,” says Henry, 80, who worked for Rover Group for 38 years. Mr Lawrence is pioneering new techniques to ensure patients are not just pain-free but that they can also get back to leading an active life and uses the Signature knee replacement system to provide a knee that fits perfectly and feels completely natural. It offers key advantages over conventional total knee replacement in that surgery is more accurate but less invasive, so patients recover more quickly. “Mr Lawrence is a genius. He’s done a marvellous job, and you can hardly tell I’ve had surgery,” adds Henry. “The improvement in my overall mobility after I’d completed my aftercare package of massage, physiotherapy and acupuncture was amazing, and to my great delight, I was no longer in pain.” Henry had done his research and went to his first consultation with Mr Lawrence armed with a number of questions. He came out of the meeting feeling very confident of a positive outcome. “I’d heard that Mr Lawrence was one of the best and was impressed with his credentials and the results he’d achieved with the Signature knee system,” says Henry. “He’s a wonderful man, and I’ve recommended lots of people with knee problems to go and see him.” Years of general wear and tear had left Henry Fontaine bow-legged, and in a great deal of pain, but following a staged bilateral knee replacement, he was soon able to whirl wife Doreen around the dance floor once again. “Mr Lawrence is a genius. I was impressed with his credentials and the results he’d achieved with the Signature knee system, and he’s done such a marvellous job that you can hardly tell I’ve had knee surgery. “I’d certainly recommend anyone struggling with knee problems to go and see Trevor Lawrence. He’s a wonderful man.”