Orthoplastics Management of Open Lower Limb Fractures at a Major Trauma Centre: Audit of Adherence to BOAST4 Guidelines.

Introduction: The British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guide the optimal management of open lower limb fractures. Adherence of the newly established Orthoplastic service at the Major Trauma Centre covering the Southeast of England was audited in relation to these standards. Materials and methods: Audit standards were produced. Data were collected using hospital records and the Trauma Audit and Research Network database. All open lower limb fractures managed between August 2020-August 2022 were included. Data collected included patient and injury demographics, and information related to initial and definitive management. Results: Overall, 133 patients were identified, 70 men and 63 women, with an average age of 58 years. Women had a higher average age (69 years) and ASA grade (71% ASA 3 or higher). Low-energy injuries occurred in 69% of women compared to 78% of high-energy injuries in men (p<0.001). Among them, 108 (81%) were debrided within 24 h. The average time to first debridement was 18.78 h, and 95 (75%) were definitively closed within 72 h, 76 with primary closure, 7 with split-thickness skin graft, 7 with local flap and 36 with free flap. Overall, the post-operative infection rate was 13% with 94% of these fractures definitively closed within 72 h. Conclusion: Most open lower limb fractures occurred in older women with higher ASA grade, from low-energy mechanisms. Most injuries were definitively managed as per the BOAST guidelines, but further efforts are required to improve the adherence to initial debridement targets, including training, appropriate resource allocation and implementation of procedures and proformas to guide injury management and improve documentation.

Jejunal ischaemia following inferior mesenteric artery angioembolisation for type 2 endoleak.

We present a rare case of short-segment jejunal infarction following inferior mesenteric artery embolisation for type 2 endoleak in a patient who previously underwent endovascular repair of abdominal aortic aneurysm. Potential causes for the event might include thromboembolism or traumatic thrombosis of a jejunal branch of the superior mesenteric artery (SMA) caused by a buddy guide wire used to maintain the position of the long vascular sheath in the SMA hiatus. The condition was recognised on CT and treated with resection of the infarcted segment of the small bowel followed by primary anastomosis.

The Role of Sentinel Lymph Node Biopsy in the Management of Merkel Cell Carcinoma: A Systematic Review and Meta-analysis.

Background: Merkel cell carcinoma (MCC) is a rare cutaneous malignancy with high metastatic potential. Sentinel lymph node biopsy (SLNB) is used to assess locoregional spread, facilitate staging, and inform prognosis. Positive nodal status is associated with higher recurrence rates and reduced overall survival. Methods: A systematic search was conducted. Eligible articles included patients diagnosed with MCC, who would be candidates for or who had SLNB. The Covidence tool was used for screening and data extraction, including additional treatments, disease-free survival, overall survival, and recurrence. Methodological quality was assessed using the Newcastle-Ottowa Scale criteria. Results: SLNB was associated with increased likelihood of completion lymphadenectomy (223 versus 41), regional radiotherapy (2167 versus 808), and systemic chemotherapy (138 versus 31). Overall survival for patients undergoing SLNB was 81% at 2 years, 75% at 3 years, and 72% at 5 years (odds ratio: 0.79). Hazard ratio for positive SLNB versus negative was 3.36 (P < 0.001). Five-year disease recurrence was 23.3% in patients undergoing SLNB. Conclusions: Lymph node metastases are associated with reduced overall survival and increased recurrence of MCC. Determining nodal status early can inform prognosis, facilitate staging, and determine need for adjuvant treatment. Adjuvant treatments are associated with reduced mortality and improved overall survival; SLNB is an important influencer of their use. Early prophylactic intervention should be considered in MCC in both positive and negative nodal status to improve overall outcomes. Widespread use of SLNB will allow more accurate assessment of the role of nodal status on adjuvant treatment and long-term outcomes.

Advancing diabetes primary care education and knowledge in Nepal: A scoping review and case study discussion.

AIMS: Diabetes mellitus (DM) is a chronic disorder of insulin and glucose metabolism. It affects more than 463 million people worldwide and is expected to reach 700 million by 2045. In the Southeast Asian region, the prevalence of DM has tripled to 115 million due to rapid urbanization, unhealthy diet, sedentary lifestyles, and genetic factors. In Nepal, a developing country, DM affects 8.5% of adults, with an alarming increase in recent years. Lack of diabetes education and limited populational adoption of behavioural changes further hamper care. METHODS: In the present study, we performed a scoping review to determine the status of awareness, attitudes, and knowledge about diabetes in the Nepalese population with a focus on the educational initiatives that have been implemented. We also conducted a two-week international case study discussion among medical students to brainstorm viable intervention strategies. RESULTS: Our findings indicate that limited data is available on the level of education or initiatives to improve knowledge and practice among healthcare professionals and community members. Targeted studies of people with diabetes also present heterogeneous results due to differences in the sample population, geographic location, education, age, and gender. Accordingly, we propose five interrelated education-based strategies that leverage existing networks to expand community outreach and engagement, improve system resilience, and improve health outcomes. CONCLUSIONS: Effective education for healthcare professionals, community, and patients with diabetes is vital in improving diabetes outcomes in Nepal and South Asia. Collaboration, funding, and evaluation are key areas needing reform.

Combating malaria in Kenya through collaborative population health education: a systematic review and pilot case study.

BACKGROUND: Malaria continues to be a public health problem in Kenya, with an estimated 37.2 million people at high risk of the disease. The disease burden is compounded by inequalities in health service availability, housing, socioeconomic conditions, and access to education. OBJECTIVES: We aimed to determine the status of community-based, health education interventions. Based on the findings, to develop an educational module for medical students to combat malaria in Kenya. METHODS: A systematic review was conducted to identify different educational interventions, their successes and limitations, and legal challenges leading to low uptake and adherence to malaria prevention interventions from 2000-2023. Consequently, a 6-week online educational pilot was conducted with healthcare students from Kenya, Japan, the UK, and Cyprus. RESULTS: Despite developing a national malaria strategy and monitoring and evaluation strategies, Kenya has not been able to meet the incidence reduction targets set by the World Health Organisation, underscoring the need for more work in identifying the barriers to implementing strategies and optimising the distribution of public health interventions. Student teams proposed innovative solutions, including two-tier malaria control strategies, maternal malaria clinical education, community awareness through schools and NGOs, and a 10-year health system strengthening and immunisation plan. CONCLUSIONS: Public education regarding prevention strategies and increasing their adoption remains a key challenge in combating malaria in Kenya. In this regard, digital tools can facilitate international collaborative health education and exchange of best practices, allowing students and faculty to engage across boundaries and prepare them to be future-ready physicians connected to the global community.

Quality of life improvements after bariatric surgery in reproductive age women with and without PCOS: a cohort study.

BACKGROUND: Obesity can negatively influence quality of life (QoL). Polycystic ovarian syndrome (PCOS), associated with obesity, presents with sub-fertility, hyperandrogenism, and/or insulin resistance. These features can also negatively influence QoL. This study aimed to determine whether bariatric surgery improves QoL in women of reproductive age, with and without PCOS. We hypothesized greater QoL improvements would be seen post-operatively in women with PCOS. METHODS: Women undergoing bariatric surgery (N.=77) completed questionnaires exploring health-related quality of life (HR-QoL) prior to and at 3, 6 and 12 months post-surgery. Weight loss, symptoms, and association with change in QoL were assessed. RESULTS: Bariatric surgery resulted in significant QoL improvements, independent of PCOS status. Oligo/amenorrhea was reported in 68% of women at baseline, decreasing to 35% by 12 months. Sixty-five percent of women whose menstrual irregularity resolved over follow-up had PCOS. Hirsutism was reported in 64% of women at baseline (all of whom had PCOS), decreasing to 19% by 12 months. Weight loss at 12-months was 45.8±20.7 kg for women without PCOS compared to 44.3±16.8 kg in women with PCOS (P=0.07). Weight loss was moderately associated with 12-month QoL improvements for both groups. CONCLUSIONS: Bariatric surgery provides significant physical and psychological health benefits for women with obesity both with and without PCOS. Surgery can also ameliorate the clinical syndrome of PCOS, including oligomenorrhoea, hirsutism, and subfertility, with subsequent QoL benefits. Psychological support perioperatively may aid QoL outcomes by acknowledging factors influencing QoL beside absolute weight loss.

Topographical anatomy of the annulus of Zinn.

The anatomy and even existence of a common tendinous origin of the extraocular eye muscles, or annulus of Zinn, has widely been debated in anatomical literature. This study explored the anatomical origins of the recti muscles, their course into the orbit and the dural connections of the common tendinous origin with the skull base. Twenty orbits of ten adult human cadavers were dissected. The orbital apex and its dural connections were photographed. Histological examination of apical specimens was performed. In all cadavers, extraocular muscles were observed to have a common tendinous origin at the orbital apex, continuous with dural connections extending into the skull base. Accessory slips of the medial rectus were observed across all cadavers. Dual heads of the lateral rectus were observed in fourteen orbits of seven cadavers. The origin of the levator palpebrae superioris appeared to be contiguous with the superior rectus at the common tendinous origin in all but one cadaver. These results support the existence of a common tendinous origin of the extraocular muscles, that is continuous with the skull base dura. In addition, they support the existence of variations in orbital anatomy including dual or accessory muscle slips of the extraocular muscles.

Linking hsp90's role as an evolutionary capacitator to the development of cancer.

This paper links Heat Shock Protein Hsp90 as an evolutionary capacitator with the development of cancer. Hsp90 stabilises proteins associated with cancer in a number of ways. Canalisation allows for the accumulation of malignant mutations in the genome, and selection of beneficial phenotypes when cancer cells are stressed, allowing oncogenic development and progression. Hsp90 may allow for mutational 'big bangs' that can trigger primary malignant transformation. Hsp90 buffers catastrophic mutations in the oncogenome to prevent protein degradation and cellular apoptosis. Hsp90 was found to prevent the degradation of mutated p53, encouraging uncontrolled proliferation of cancer cells. Hsp90 buffering of mutations in response to cytotoxic therapy can lead to expression of beneficial phenotypes when Hsp90 is supressed and development of drug resistance. Trials with Hsp90 inhibitors have shown some success as an adjunctive therapy in preventing cancer progression, development of drug resistance, and even re-sensitisation to therapy after chemoresistance has developed.