Pathological Fracture of the Femur Following Chronic Osteomyelitis: A Case Report of This Rare Presentation in Adults.

Chronic osteomyelitis is a common presentation in orthopaedics, particularly in the context of deep abscesses. Fractures related to osteomyelitis can be seen in children but are rare in adults. We present the rare case of a pathological fracture related to osteomyelitis in a 53-year-old warehouse worker who was previously fit and well. He presented with a right-sided thigh abscess and after initial surgical management, further imaging detailed osteomyelitis that was treated with suppressive antimicrobial therapy. Seven months after discharge, the patient presented to our emergency department with a right-sided proximal fracture of the femur. Retrospectively, we were able to localise the fracture site to the site of the previous cloaca from the osteomyelitis. We discuss whether prophylactic fixation is required for patients with extensive cloaca following a chronic fracture.

Working together better for mental health in children and young people during a pandemic: experiences from North Central London during the first wave of COVID-19.

Direct risk from infection from COVID-19 for children and young people (CYP) is low, but impact on services, education and mental health (so-called collateral damage) appears to have been more significant. In North Central London (NCL) during the first wave of the pandemic, in response to the needs and demands for adults with COVID-19, general paediatric wards in acute hospitals and some paediatric emergency departments were closed. Paediatric mental health services in NCL mental health services were reconfigured. Here we describe process and lessons learnt from a collaboration between physical and mental health services to provide care for CYP presenting in mental health crisis. Two new 'hubs' were created to coordinate crisis presentations in the region and to link community mental health teams with emergency departments. All CYP requiring a paediatric admission in the first wave were diverted to Great Ormond Street Hospital, a specialist children's hospital in NCL, and a new ward for CYP mental health crisis admissions was created. This brought together a multidisciplinary team of mental health and physical health professionals. The most common reason for admission to the ward was following a suicide attempt (n=17, 43%). Patients were of higher acute mental health complexity than usually admitted to the hospital, with some CYP needing an extended period of assessment. In this review, we describe the challenges and key lessons learnt for the development of this new ward setting that involved such factors as leadership, training and also new governance processes. We also report some personal perspectives from the professionals involved. Our review provides perspective and experience that can inform how CYP with mental health admissions can be managed in paediatric medical settings.

Senescence Increases Choroidal Endothelial Stiffness and Susceptibility to Complement Injury: Implications for Choriocapillaris Loss in AMD.

PURPOSE: Age-related macular degeneration (AMD) commonly causes blindness in the elderly. Yet, it is untreatable in the large fraction of all AMD patients that develop the early dry form. Dry AMD is marked by the deposition of membrane attack complex (MAC) on choriocapillaris (CC), which is implicated in CC degeneration and subsequent atrophy of overlying retinal pigment epithelium. Since MAC is also found on the CC of young eyes, here we investigated whether and how aging increases choroidal endothelial susceptibility to MAC injury. METHODS: Monkey chorioretinal endothelial cells (ECs, RF/6A) were cultured to high passages (>P60) to achieve replicative senescence. We treated ECs with complement-competent human serum to promote MAC deposition and injury, which were assessed by flow cytometry and trypan blue exclusion assay, respectively. Stiffness of EC was measured by atomic force microscopy indentation while Rho GTPase activity was quantified by Rho G-LISA assay. RESULTS: Our findings reveal that senescent ECs are significantly stiffer than their normal counterparts, which correlates with higher cytoskeletal Rho activity in these cells and their greater susceptibility to complement (MAC) injury. Importantly, inhibition of Rho activity in senescent ECs significantly reduced cell stiffness and MAC-induced lysis. CONCLUSIONS: By revealing an important role of senescence-associated choroidal EC stiffening in complement injury, these findings implicate CC stiffening as an important determinant of age-related CC atrophy seen in dry AMD. Future studies are needed to validate these findings in appropriate animal models so new therapeutic targets can be identified for treatment of dry AMD.

Unusual mechanism of tendoachilles injury.

A 67-year-old woman sustained electric shock while using her hair dryer. During this process her left leg shot up in the air following which she could not walk properly with that leg. She attended the accident and emergency and, considering a possibility of an undisplaced fracture of the calcaneum, she was referred to the fracture clinic the next day. She was clinically diagnosed to have tendoachilles rupture and this was further confirmed by an ultrasound scan. Predisposing factors like drug intake or chronic inflammatory arthritis were excluded and she was treated with conservative management.