The management of tarsal tunnel syndrome: A scoping review.

Background: Tarsal tunnel syndrome, also known as posterior tibial neuralgia, is a compressive neuropathy of the posterior tibial nerve or one of its divisions (calcaneal, lateral plantar or medial plantar nerve) within the tarsal tunnel. This scoping review aims to systematically map and summarise current literature regarding the management of tarsal tunnel syndrome. Methods: PubMed, Embase, Emcare, Medline and Cinahl were searched using the terms 'tarsal tunnel', 'syndrome', 'entrapment', 'compression', 'posterior tibial', 'neuropathy' and 'neuralgia. Two stage title abstract screening was performed. Observational studies reporting the outcome of treatment of tarsal tunnel syndrome were included. Results: A total of 32 studies were included in the review. Excellent or good results are seen in 75.3 % of cases, with the remainder (24.7 %) achieving fair or poor outcomes. Factors which may influence outcome include patient age, symptom duration, aetiology, co-morbidities, pre-treatment symptom severity and nerve fibrosis. Conclusions: Although favourable outcomes are seen in the majority of cases, poor results are not uncommon. A range of prognostic factors are identified; however, firm conclusions cannot be drawn from the findings of individual low-quality studies. Further research in identifying prognostic factors may aid in clinical decision making and management of patient expectations. Level of evidence: Level IV Scoping review.

UK Nurses Delivering Physical Activity Advice: What Are the Challenges and Possible Solutions? A Qualitative Study.

There are a multitude of health benefits gained from regular physical activity (PA). Currently, PA advice implementation from NHS nurses is inadequate despite their ever-increasing role in lifestyle and preventive medicine. By assessing their knowledge of current PA guidance, this study proposed to investigate the issues with regular PA advice being given and expand upon nurses' proposed barriers and solutions. A qualitative approach using semi structured interviews was undertaken between March and August 2023 involving 13 NHS nurses. Thematic analysis was undertaken using Braun and Clarke's six step approach. Four themes and fifteen subthemes emerged as barriers and solutions in delivering PA advice. Intrinsic barriers included a lack of nurse knowledge on the topic and PA being seen as an afterthought. Extrinsic barriers included time pressures and a lack of staff engagement. Solutions involved increasing staff awareness of guidelines through teaching, policy, encouraging staff to be active and optimising PA advice delivery through a piecemeal approach and utilising online and visual resources. This study displayed an insight into nurses' thoughts on their consultations with patients regarding PA, and proposed several barriers and solutions. Further work is needed to improve nurses' PA knowledge and to assess the proposed strategies to improve its delivery.

UK physiotherapists delivering physical activity advice: what are the challenges and possible solutions? A qualitative study.

OBJECTIVES: Despite the known health benefits of physical activity (PA), PA levels are in decline. Healthcare professionals, including physiotherapists, have been identified as ideal conduits to promote PA, yet their knowledge and awareness of PA guidelines are poor. The aims of this study were to explore current knowledge of PA guidelines among UK physiotherapists and identify barriers and possible solutions to delivering PA advice. DESIGN: A qualitative approach using semistructured interviews that took place between March and May 2021. Data were analysed with a thematic approach using Braun and Clarke's six steps. SETTING: Various inpatient and outpatient clinical settings across six UK regions. PARTICIPANTS: Eighteen UK-based physiotherapists managing National Health Service patients were recruited through volunteer sampling in March 2021. RESULTS: Five themes and 16 subthemes (shown in parenthesis) were identified as barriers and solutions to delivering PA advice: physiotherapist intrinsic barriers (knowledge, fear/confidence); a lack of emphasis and priority given to PA (time constraints, minimal educational and staff training); patient barriers (compliance, expectations and fear of doing PA); increasing awareness of the PA guidelines (staff training, signposting awareness, use of social media and television campaigns); and optimising delivery (use of visual resources, good communication and approaches involving being individualised and gradual for patients with chronic conditions). CONCLUSIONS: In this study, physiotherapist participants seemed to have limited awareness of the PA guidelines despite recent updates and were faced with similar barriers to those previously reported in the literature. The solutions suggested could guide strategies to support physiotherapists being able to deliver PA advice. Further research is needed to evaluate the efficiency of any implemented solutions supporting the delivery of PA advice.

Creating a sport and exercise medicine undergraduate syllabus: a delphi study.

BACKGROUND: Sport and Exercise Medicine (SEM) is a growing speciality in the United Kingdom (UK). This growth has not been replicated in SEM teaching at an undergraduate level and SEM-related topics in schools of medicine in the UK are under-represented. As SEM continues to develop as a specialty it is important to consider how it is embedded at all levels of training. The aim of this project was to establish a consensus on SEM-related skills and knowledge relevant for undergraduate medical students in the UK, ultimately creating a curriculum of learning objectives (LOs). METHODS: A modified Delphi survey was utilised to seek consensus on LOs suitable for incorporation into UK medical school curricula. An expert panel with adequate knowledge in the field was recruited. The initial curriculum was created by the research team using already established postgraduate SEM curricula. All learning objectives were sent to the expert panel for opinions in phases. Levels of agreement and comments made by the expert panel were reviewed after each phase until a consensus on each learning objective was made. RESULTS: The expert panel was made up of 45 individuals, with 35 also completing phase 2 (78% retention rate). The initial curriculum contained 58 learning objectives separated into 9 themes. In phase 1 31% (18/58) were accepted outright, 48% (28/58) were altered and 19% (11/58) were rejected. Two additional learning objectives were added. Of the 49 LOs included in phase 2, 98% (48/49) were accepted. The final curriculum was made up of 9 sub-themes and 48 LOs. CONCLUSION: Sport and Exercise Medicine is a broad ranging and rapidly growing speciality. It is important to establish SEM education in all levels of medical education, including undergraduate level. This is the first published version of a Delphi SEM curriculum for undergraduate medical teaching.

UK Doctors Delivering Physical Activity Advice: What Are the Challenges and Possible Solutions? A Qualitative Study.

Despite strategies to enable Health Care Professionals (HCPs) to give physical activity (PA) advice to patients, this appears to be rarely done in consultations. The aims of the present study were to gain an understanding of doctors' awareness of current PA guidelines and to explore their opinions on barriers and solutions. A qualitative approach using semi-structured interviews was adopted. This study included 15 doctors currently working in the UK's National Health Service (NHS). A thematic analysis approach was used to analyse the transcripts. Four themes and twelve sub-themes were deciphered. Intrinsic factors limiting the delivery of PA advice included a lack of knowledge of PA guidelines and PA being an afterthought. Barriers to delivering PA guidance included a lack of PA education, time pressures, and patient engagement. Solutions included staff training, incorporating PA into undergraduate training, and encouraging staff to be physically active. Methods to optimise PA guidance included individualised PA advice, local exercise services and schemes, utilising online and visual resources, and motivational interviewing. This study provides an updated insight into doctors' opinions on barriers and solutions to discussing PA with patients. It is clear that further work is needed to ensure greater awareness of PA guidelines amongst clinicians.

Gastrocnemius release is an effective management option for Achilles tendinopathy: a systematic review.

PURPOSE: This systematic review aims to summarise the outcomes of gastrocnemius release in the management of Achilles Tendinopathy. METHODS: A systematic review was performed according to PRISMA guidelines. A computer-based search was performed in PubMed, Embase, Cinahl, Scopus and ISI Web of Science. Two independent reviewers performed both title/abstract and full-text screening according to a-priori selection criteria. English-language original research studies reporting outcomes for gastrocnemius recession in patients with Achilles tendinopathy were included. Study quality and risk of bias were assessed using the MINORS criteria. RESULTS: Of the 229 articles identified following database searching, nine studies describing 145 cases of gastrocnemius recession were included in the review. Clinically important differences were reported across a range of validated patient reported outcome scores including VISA-A, FFI, FAAM and VAS pain score. Outcomes appear to be superior in patients with noninsertional Achilles tendinopathy, however further research is required to confirm this. Studies also reported an increase in ankle dorsiflexion range of motion and a good rate of return to sport/work. The overall complication rate was 10/123 (8.1%), with sural nerve injury being the most common complication, occurring in 5/123 (4.1%) of cases. CONCLUSION: The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment. LEVEL OF EVIDENCE: Level IV.

Creating a Sport and Exercise Medicine Masters syllabus for doctors: a Delphi study.

Objective: Sport and Exercise Medicine (SEM) Masters curricula vary. This Delphi study is aimed to create a consensus curriculum for doctors undertaking SEM Masters courses. Methods: A modified Delphi survey was used. An expert panel was established of individuals deemed to have adequate knowledge of the field. The research group developed the initial draft of the curriculum by collating and reviewing previously published UK-based postgraduate SEM-related curricula. There were two phases. In phase 1 the expert group either accepted, rejected or modified each learning objective (LO). During phase 2 the expert group were asked to accept or reject each LO that did not get accepted outright previously. The research group analysed the levels of agreements and the comments given by the expert panel after each phase. Results: The expert panel consisted of 45 individuals, with 35 completing phase 2 (78% retention rate). Of the 136 LOs initially collated: 71 (52%) were accepted outright, 60 (44%) were altered in some way and reincluded in phase 2, and 5 (4%) were removed after phase 1. The research group added 2 (1%) new LOs on reflection over comments made by the expert panel. The final curriculum contained 133 LOs, divided into 11 subthemes. Conclusions: The findings will better inform educators when developing SEM Masters curricula and inform students what they should look for when considering an SEM Masters. This consensus curriculum is an important step in standardising postgraduate SEM education.

The management of foot and ankle ganglia: A scoping review.

PURPOSE: A ganglion cyst is a benign soft tissue swelling filled with hyaluronic acid and other mucopolysaccharides. Whilst they most commonly present in the wrist region, their occurrence in the foot and ankle is not rare. This scoping review aims to systematically map and summarise current evidence regarding the management of ganglia of the foot and ankle, whilst identifying areas for further research. METHODS: This scoping review follows the frameworks of Arksey and O'Malley, Levac and Peters. A comprehensive search strategy was used to identify relevant articles, before a two-stage screening process was performed independently by two reviewers. RESULTS: A total of 2286 unique articles were identified, of which 12 were included in the review. A variety of conservative and surgical treatment strategies are reported, showing good outcomes. An overall pooled recurrence rate of 29.5% was seen across 8 studies. Aspiration alone showed the highest recurrence rate (78.1%), followed by aspiration and steroid injection (62%), steroid injection alone (37.5%) and surgical excision (17.6%). The pooled complication rate across six studies was 21/261 (8.0%), with the most common complication being paraesthesia, reported in 14/261 (5.4%) patients. CONCLUSIONS: There is a lack of high-quality research currently regarding the treatment of foot and ankle ganglia. Limited evidence suggests that there could potentially be associations between time to treatment, ganglion location and extent of surgical resection and recurrence rate. However, further research is required before any definitive conclusions can be drawn.

Should Arthroscopic Bone Marrow Stimulation Be Used in the Management of Secondary Osteochondral Lesions of the Talus? A Systematic Review.

BACKGROUND: Osteochondral lesions of the talus are common, particularly after trauma. Arthroscopic bone marrow stimulation has emerged as the first-choice surgical treatment for small primary lesions less than 100 mm2. Individual studies on the topic are small and heterogeneous, and they have differed in their main findings; for this reason, systematically reviewing the available evidence seems important. QUESTIONS/PURPOSES: In this systematic review, we asked: (1) What patient-reported outcomes and pain scores have been observed after arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus? (2) What complications were reported? (3) What demographic and clinical factors were reported to be associated with better patient-reported outcome scores? METHODS: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using Embase, EmCare, PubMed, CINAHL, and Scopus (databases last searched June 23, 2021). A two-stage title/abstract and full-text screening process was performed independently by two reviewers. Randomized control trials, cohort studies, and observational studies published in English that evaluated the outcome of arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus were included. Case reports, review articles, commentaries, abstracts, and letters to the editor were excluded. A total of 12 articles (10 case series and two retrospective comparative studies) involving 446 patients were included. Of these, 111 patients with a mean age of 33 years (range 20 to 49) received arthroscopic bone marrow stimulation for a secondary osteochondral lesion of the talus. The Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess the methodologic quality of included studies. The MINORS is a numerical score ranging from 0 to 16 for studies with no comparison group and 0 to 24 for comparative studies, with higher quality studies receiving higher scores. Of the 10 noncomparative case series, the highest score was 10 of 16, with a median (range) score of 7.5 (4 to 10), while the two comparative studies scored 22 of 24 and 19 of 24, respectively. RESULTS: Studies varied widely in terms of patient-reported outcome measures such as the American Orthopaedic Foot and Ankle Society score (AOFAS), with inconsistent reporting across studies regarding whether or how much patients improved; there was variation in some effect sizes with regard to improvement seeming close to or below the minimum clinically important difference (MCID). Although no perioperative complications were reported in any included studies, 34% (26 of 77, in seven studies that reported on this endpoint) of patients who underwent a revision procedure. One study found a negative association between lesion size and AOFAS and VAS score. No other studies reported on factors associated with patient-reported outcome scores, and most studies were far too small to explore relationships of this sort. CONCLUSION: We found that arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus yielded inconsistent and often small improvements in patient-reported outcomes, with approximately one in three patients undergoing a revision procedure. Reported outcomes likely represent a best-case scenario, inflated by low-level study designs and major sources of bias that are known to make treatment effects seem larger than they are. Therefore, the use of arthroscopic bone marrow stimulation in such patients cannot be recommended, unless we are able to refine selection criteria to effectively identify patients who show a substantial clinical benefit. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Efficacy of high dose Allopurinol in reducing left ventricular mass in patients with left ventricular hypertrophy by comparing its efficacy with Febuxostat - a randomized controlled trial.

OBJECTIVE: : To determine the efficacy of high-dose allopurinol in reducing left ventricular mass in patients with left ventricular hypertrophy by comparing its efficacy with febuxostat.. METHODS: The randomised controlled interventional study was conducted at Mayo Hospital, Lahore, Pakistan, from April to December 2015, comprising patients with left ventricular hypertrophy on echocardiography. They were randomly divided into two equal groups, with Group A receiving allopurinol and Group B receiving febuxostat. Primary endpoint was reduction in left ventricular mass and left ventricular mass index as calculated by echocardiography. Patients were followed at third and sixth month of enrolment to detect regression. Patients were investigated for eosinophil's count, urine for micro albuminuria and renal function tests to monitor side effects of allopurinol. SPSS 20 was used for data analysis. RESULTS: There were 76 patients divided into two groups of 38(50%) each. Mean reduction in left ventricular mass between baseline and at six months in Group A and Group B was 35.474±13.54 and 21.921±3.33 respectively (p=0.0001) while mean reduction in left ventricular mass index between baseline and at six months was 17.26±4.36 and 17.63±21.07 respectively (p=0.0001). Greater improvement was observed in Group A.. CONCLUSIONS: Allopurinol was found to be more effective than febuxostatin reducing the left ventricular mass and left ventricular hypertrophy independent of blood pressure.

Frequency of Type-2 diabetes mellitus in Nephropathic patients and comparison of mean magnesium levels in Nephropathic patients with and without Type-2 diabetes mellitus.

OBJECTIVE: The objective of this study was to determine the frequency of Type 2 diabetes mellitus (T2DM) in patients with nephropathy (i.e. Chronic Kidney Disease Stage 1 to 3) and to compare the mean magnesium levels in diabetic nephropathic patients and non-diabetic nephropathic patients. METHODS: This cross-sectional study was conducted in department of Medicine, Mayo Hospital Lahore from August 2014 to February 2015. Using non-probability purposive sampling 200 nephropathic (Chronic Kidney Disease Stage 1 to 3) patients were selected. Patients were assessed for T2DM and divided in two groups on the basis of presence or absence of DM. Magnesium levels were recorded in both groups. Percentages, mean, standard deviation and unpaired t-test was used to assess the data. SPSS was used for analysis of information. RESULTS: Total number of cases were 200, 43.5% (n=87) out of them were between 25-50 years of age while 56.5% (n=113) patients were between 51-70 years. The Mean+SD was calculated to be 51.38+11.51 years. The male patients were 48.5 %(n=109) while 51.5 %(n=91) were females. The frequency of DM in patients with nephropathy was 25.5% (n=51). Comparison of mean magnesium levels in nephropathic patients with and without diabetes was done. The results showed nephropathic patients having diabetes had 1.54+0.301 mg/dL magnesium levels while cases without diabetes had 1.92+0.313 mg/dL levels of magnesium, p value was calculated as 0.001 showing a significant difference between the two groups. CONCLUSION: The frequency of diabetes mellitus is higher among patients with nephropathy while on comparison of mean magnesium levels, nephropathic patients with diabetes had significant lower levels of magnesium as compared to without diabetes.

Correlation between Serum Uric Acid Level and Microalbuminuria in Type-2 Diabetic Nephropathy.

OBJECTIVE: To measure the correlation between microalbuminuria and serum uric acid level in Type-2 diabetic nephropathy. METHODS: This cross-sectional study was done in department of Medicine, Mayo hospital Lahore from August 2014 to February 2015. A total of 200 patients with Type-2 diabetic nephropathy were enrolled in the study. Demographic data and contact details were obtained. Serum Uric acid and microalbuminuria by albumin to creatinine ratio (ACR) in random urine sample was measured at the time of inclusion of patients. All the information was collected through a pre-defined proforma. Pearson correlation coefficient and t-test were used to assess correlation and significance respectively. RESULTS: Out of 200 cases, 29%(n=58) were between 16-40 years of age while 71%(n=142) were between 41-65 years of age, Mean ± SD was calculated as 48.1±10.26 years, 48.5%(n=97) were male and 51.5%(n=103) were females, Mean serum uric acid level was calculated as 6.99±1.01 mg/dL while microalbuminuria was calculated as 5.63±1.08 mg/mmol, r value was 0.0838 which is a positive correlation. CONCLUSION: The results of our study concluded that level of serum uric acid and microalbuminuria are significantly correlated to nephropathy in patients having Type-2 diabetes mellitus.

Ten-year pattern of red blood cell use in the North of England.

BACKGROUND: An understanding of current and changing patterns of red blood cell (RBC) use will help predict future demands and aid future planning for transfusion services. It can also highlight areas where efforts to optimize RBC use are most likely to be productive. STUDY DESIGN AND METHODS: Surveys were conducted in two 14-day periods of all RBC transfusions in a geographic region of England supplied by a single blood center. Data collection was prospective and used preprinted paper forms. Results were compared with two previous studies covering a period of 10 years. RESULTS: The clinical fate of 8025 units of RBCs was recorded consistent with data on more than 99% of units issued and transfused during the survey period. The overall RBC transfusion rate has decreased from 45.5 to 36 units per 100,000 population from 1999 and 2009. Twenty-nine percent were used for surgical indications indicating a further decrease in surgical use compared to previous surveys. This decrease was limited solely to recipients of 50 to 80 years of age. Use for medical and obstetric/gynecologic indications has not changed significantly over 10 years. CONCLUSION: Further decreases in surgical RBC use may be achievable but the aging population is likely to demand more blood for nonsurgical indications and efforts should be directed to optimizing use in these recipients. Comparative data on transfusion rates between regions or countries may be a useful tool for improving blood use.

Creutzfeldt-Jakob disease.

Creutzfeldt-Jakob disease is a prion related disease, characterized by rapidly progressive dementia, associated with myoclonus and ataxia. A 55-year-old male, who initially developed depressive symptoms and obsessive-compulsive disorder one year before presentation, and in due course, developed ataxia, forgetfulness and disorientation in time and space followed by myoclonic jerks with increasing difficulty in walking, finally becoming bed bound and developing startle response to sound and touch, presented in mute and bed bound state. On the basis of typical clinical syndrome, suggestive electroencephalography and magnetic resonance imaging, and absence of any other cause, diagnosis of Creutzfeldt-Jakob disease was made.