Development and Service Evaluation of an ad hoc Virtual Arthroplasty Clinic during COVID-19: Experiences from Irish National Orthopaedic Hospital.

Introduction: COVID-19 has had a significant impact on healthcare. It has forced orthopaedic surgeons to limit face-to-face patient contact. This resulted in the ad hoc creation of a virtual arthroplasty clinic (VAC) in Irish National Orthopaedic Hospital. We aimed to assess this new VAC and ascertain its effectiveness as an alternative to physical appointments during and following the pandemic. Materials and methods: Patients were followed-up in this VAC six weeks post-operatively. A service evaluation of this virtual arthroplasty clinic was carried out using a questionnaire created by the orthopaedic department. Results: A total of 30 patients requiring 6-week follow-up after the arrival of COVID-19 in Ireland were included. Average pre- and post-operative visual analogue scale score (VAS) was 8.1 and 2.3, respectively. Average pre- and postoperative Oxford hip and knee score was 19.1 and 39.2, respectively. Twenty-one patients (70%) were happy to have their six weeks post-operative e-outpatient consultation virtually. Twenty-six patients (86%) were happy with future virtual follow-up. Twenty-eight patients (93%) would be happy experiencing the whole process again. Eleven patients would be interested in having future joint replacement surgery, though ten of them (91%) stated COVID-19 would impact that decision. Conclusion: Most patients were happy to have their six-week appointment and future appointments virtually. Functional outcome scores had improved and pain scores had reduced at six-week follow-up, supporting the idea that virtual clinics are not inferior to physical clinics. Patients expressed concern about having a further joint replacement in the context of COVID-19.

Development and Service Evaluation of an ad hoc Virtual Arthroplasty Clinic during COVID-19: Experiences from Irish National Orthopaedic Hospital

@#Introduction: COVID-19 has had a significant impact on healthcare. It has forced orthopaedic surgeons to limit faceto-face patient contact. This resulted in the ad hoc creation of a virtual arthroplasty clinic (VAC) in Irish National Orthopaedic Hospital. We aimed to assess this new VAC and ascertain its effectiveness as an alternative to physical appointments during and following the pandemic. Materials and methods: Patients were followed-up in this VAC six weeks post-operatively. A service evaluation of this virtual arthroplasty clinic was carried out using a questionnaire created by the orthopaedic department. Results: A total of 30 patients requiring 6-week follow-up after the arrival of COVID-19 in Ireland were included. Average pre- and post-operative visual analogue scale score (VAS) was 8.1 and 2.3, respectively. Average pre- and postoperative Oxford hip and knee score was 19.1 and 39.2, respectively. Twenty-one patients (70%) were happy to have their six weeks post-operative e-outpatient consultation virtually. Twenty-six patients (86%) were happy with future virtual follow-up. Twenty-eight patients (93%) would be happy experiencing the whole process again. Eleven patients would be interested in having future joint replacement surgery, though ten of them (91%) stated COVID-19 would impact that decision. Conclusion: Most patients were happy to have their sixweek appointment and future appointments virtually. Functional outcome scores had improved and pain scores had reduced at six-week follow-up, supporting the idea that virtual clinics are not inferior to physical clinics. Patients expressed concern about having a further joint replacement in the context of COVID-19.

Infographics Improve Comprehension and Recall at the Orthopaedic Journal Club.

Information graphics, abbreviated to infographics, convey information using visualisations and images. This format of presenting research has been shown to be preferred by 80% of clinicians when compared to text articles. The weekly Journal Club was audited within our institution over a period of 10 weeks. Five weeks of article presentations using plain text abstract displays preceded 5 weeks of infographic display. A multiple-choice questionnaire was constructed weekly so as to test the attendees' recall and comprehension. A total of 1036 multiple-choice questions were answered across the 10 weeks, which included 553 questions (53.4%) based on the standard Journal Club format, and 483 questions (46.6%) on infographic displays. The use of infographics saw significantly improved test results from 42% to 65.8% (p < 0.001). Questions were answered correctly 1.5 times more often following infographic introduction. Infographics were preferred over plain text abstracts by 78% of team members. Infographics enhanced the audience's comprehension and recall of orthopaedic research when used as a presentation tool at the Journal Club. The majority of clinicians preferred infographic displays to plain text abstracts. Research was perceived as being more engaging, and thus more suitable for dissemination, such that key messages could be shared with surgeons, researchers and patients worldwide.

Drug use among men who have sex with men in Ireland: Prevalence and associated factors from a national online survey.

BACKGROUND: Little is known about the prevalence and determinants of drug use among men who have sex with men (MSM) in Ireland. The aims of this study were to measure the prevalence of recreational drug use among MSM in a national sample, and to identify sub-groups of MSM who may benefit from targeted preventive interventions. METHODS: The MSM Internet Survey Ireland (MISI) 2015 was a community-recruited, nationally-promoted, self-completed online survey for MSM. MISI 2015 included standardised questions on recreational drugs, poppers, and drugs associated with chemsex (i.e. crystal methamphetamine, GBL/GHB, mephedrone, ketamine). Multivariable-adjusted logistic regression was used to identify factors associated with use of these substances. RESULTS: In the previous year, 36% of MSM used recreational drugs, 33% used poppers, and 7% used drugs associated with chemsex. Five percent were diagnosed HIV-positive. Recreational drug users were significantly younger than non-users (median = 27 vs. 32 years; p < 0.001); popper users were significantly older than non-users (median = 34 vs. 28 years; p < 0.001). The odds of recreational drug use were higher among MSM diagnosed HIV-positive (vs. never tested; AOR 2.27, 95%CI 1.39-3.70). Use of poppers, and use of drugs associated with chemsex, were also higher among MSM diagnosed HIV-positive (vs. never tested; AOR 3.77, 95%CI 2.41-5.90, and AOR 5.87, 95%CI 3.08-11.18 respectively). CONCLUSIONS: The prevalence of recreational drug use is higher among MSM than in the general population in Ireland, and it is particularly high among MSM diagnosed HIV-positive. Targeted harm reduction messages and preventive interventions are warranted to complement population-based approaches to reducing drug use in this population.

Inequalities in HIV testing uptake and needs among men who have sex with men living in Ireland: findings from an internet survey.

OBJECTIVES: HIV disproportionately affects men who have sex with men (MSM) in Ireland. The aim of this study was to improve understanding of HIV testing among MSM living in Ireland to inform prevention and testing initiatives. METHODS: We used data from the MSM Internet Survey Ireland 2015 (MISI 2015), a cross-sectional survey of MSM living in Ireland. We identified factors associated with never having tested for HIV using univariable and multivariable logistic regression. We identified preferred sites for future tests and examined the relationships between unmet HIV testing needs and socio-demographic groups. RESULTS: More than one-third (n = 1006; 36%) of MSM had never tested for HIV. Multivariable logistic regression showed that untested men were more likely to be aged 18-24 years, live outside Dublin, have a lower level of education, be born in Ireland, identify as bisexual, be out to fewer people, and not have had sex with a man in the previous 12 months. The same groups of men also had the least knowledge about HIV and were least confident in accessing an HIV test. Men who had never tested for HIV were more likely to prefer testing by their general practitioner (GP) or using home sampling HIV kits and less likely to prefer testing in a sexual health clinic. CONCLUSIONS: HIV prevention and testing programmes for MSM should be targeted towards younger men, those living outside Dublin and those with lower levels of education. We recommend increased promotion and availability of free HIV testing services in a range of clinical and nonclinical settings (including self-sampling and home testing).

A cost analysis of the establishment of a dedicated orthopaedic outpatient injection clinic at a single institution.

INTRODUCTION: Traditionally orthopaedic injections were performed in a theatre setting. A dedicated outpatient injection clinic was established at our institution to attempt to provide injections more cost effectively. Our aim was to perform a cost analysis of orthopaedic injections performed in theatre, compared to those performed in a dedicated OPD injection clinic. METHODS: Patient data for all orthopaedic injections performed at a single institution from 2013 to 2014 was obtained using HIPE data. A detailed breakdown of costings for two scenarios; those performed in theatre and those in the dedicated OPD injection clinic was obtained from the hospital finance department. A unit cost per injection for theatre and OPD was derived from this financial information. RESULTS: A total of 487 injections were performed in 2013, with 491 performed in 2014. 134 (27.5%) injections were performed in the OPD in 2013 compared to 388 (79%) in 2014. The unit cost per injection was calculated as €52.13 for theatre and €23.85 for OPD, this represented a 115% decrease in cost per injection. CONCLUSION: The creation of a dedicated orthopaedic injection clinic resulted in considerable cost savings at our institution. We propose this may be a more cost-efficient model for delivery of injections in the orthopaedic setting.

The Irish National Joint Registry: where are we now?

BACKGROUND: Ireland is currently in the process of establishing a National Joint Registry. AIM: We aim to determine which implants and surgical techniques are currently being used by Irish orthopaedic surgeons and to examine the impact that a National Joint Registry may have on arthroplasty practice in Ireland. METHODS: The study consisted of a postal questionnaire sent to all public service consultant orthopaedic surgeons in The Republic of Ireland. RESULTS: We had a response rate of 76.6 %. Of this 76.6, 86.4 % regularly perform total hip arthroplasty (THA) and 84.7 % perform total knee arthroplasty. Of those who perform THA, 86.3 % use different implants in younger patients. Thirteen different femoral implants are used, and seven different knee implants. We conservatively estimate that at least 3,918 total hip arthroplasties and 2,604 total knee arthroplasties are performed in Ireland each year. At present we have no way to precisely monitor the number of arthroplasty procedures being performed, and we have no way of accurately monitoring the short- or long-term outcomes of the many implants used. CONCLUSIONS: The establishment of a National Joint Registry for Ireland would benefit the Irish orthopaedic community, and given the large number of procedures being performed, may also be of benefit to the international orthopaedic community.

Publication rates of presentations at the Irish Orthopaedic Association annual meeting.

BACKGROUND: Presentation of scientific research at national and international meetings is an important forum for the dissemination of knowledge. Subsequent publication of a full-text paper in a peer-reviewed journal is the expected outcome of such presentations. The publication rate from these meetings is highly variable. AIMS: To determine the publication rate of abstracts presented at the Irish Orthopaedic Association's Annual Conference and to determine which factors are associated with progression to full-text publication. METHODS: We reviewed the proceedings from the Irish Orthopaedic Association's National Meeting over a 4 year period. We searched the Pubmed database using author names, institution names, and keywords from each abstract's title, to determine how many presented articles progressed to full-text publication. RESULTS: Sixty-six of 203 were published, 97 % within 5 years of presentation. Laboratory based studies presenting novel or innovative findings were more likely to be published than clinical studies. Clinical studies were more likely to be published if they were prospective and had a longer period of follow-up. Retrospective audits were less likely to be published, even with a large cohort size. Changes in authorship of presented papers were related to a longer delay in time to full-text publication. CONCLUSIONS: Thorough planning of research studies is essential to ensure a timely progression to full-text publication in a peer-reviewed journal. Most studies will be published within 5 years of initial presentation.

The effect of inclement weather on ankle fracture management in an Irish trauma unit.

INTRODUCTION: Ireland is unfamiliar with extreme weather conditions. Such conditions occurred in winter 2009-2010 and 2010-2011, with much of the country being affected by snow and ice. We reviewed the effect that these conditions had on the treatment of ankle fractures in our trauma unit. MATERIALS AND METHODS: The study period was from November until February for four consecutive years from 2008-2009 until 2011-2012. We compared two winters with extreme weather with two winters with regular weather conditions. Information from Met Eireann was compared with demographics from patient records to differentiate ice-related injuries from non-ice-related injuries. Ankle fractures were classified using the Lauge-Hansen classification. We compared waiting times in A&E, waiting times for theatre, delays relating to injury severity, and overall length of stay for both groups. RESULTS: We identified 44 ice-related injuries and 67 non-ice-related injuries. Ice-related injuries trended towards more severe fracture configurations using the Lauge-Hansen classification. Patients sustaining ankle injuries during inclement weather were significantly younger than patients sustaining injuries during regular weather conditions. There were no other significant differences between the two groups. DISCUSSION: Ice-related injuries trended towards a greater severity of fracture configuration. We identified no significant increase in the time to treatment or overall length of stay of patients sustaining ankle fractures during these times. Ice-related injuries did not have greater rates of complications. These results are a testament to the trauma staff in this unit who absorbed the increased workload without compromising patient care.

Research in higher surgical training: which rotation?

BACKGROUND: Orthopaedic higher surgical trainees in Ireland are allocated to one of eight training rotations. Each trainee is expected to publish at least one research paper per year during training. AIM: To assess the research productivity of each training rotation over a 10-year period. METHODS: A PubMed search was performed for each orthopaedic unit affiliated to higher surgical training (HST) in order to identify full-text research papers published between 2001 and 2010. The results were analysed to determine which training rotations are most productive in terms of research. RESULTS: We identified 267 papers published from 16 units over the 10-year period. There were substantial differences in the number of papers published from each unit, and substantial differences between the eight set trainee rotations. CONCLUSIONS: It is essential that each trainee makes an honest assessment of their potential for conducting and producing valuable and relevant research, and chooses an HST rotation that is appropriate to their needs. Publication of research articles is easier to achieve on some HST rotations than on others.

Perceptions of superinfection risk among gay men with diagnosed HIV who have unprotected anal intercourse.

This paper explores how men who have sex with men (MSM) with diagnosed HIV who engage in unprotected anal intercourse (UAI) perceive the potential risk of superinfection and how they respond to it. Semistructured interviews were carried out with 42 MSM recruited via community-based agencies throughout England and Wales. The interviews examined sexual risk taking and the ways in which men sought to manage the risks they perceived. All participants had heard of superinfection and one-third considered it a personal risk when they had UAI with men with the same sero-status. The risk of being superinfected with HIV was often situated among a number of other concerns that men felt they needed to manage when having sex. There was significant uncertainty about the likelihood of acquiring an additional strain of HIV, which was exacerbated by competing, and often conflicting, advice from a variety of expert sources. Men frequently drew upon lay and expert understandings of viral load and infectiousness to rationalize engagement in UAI with other diagnosed positive men. HIV health-care providers should seek to find consensus on how to discuss superinfection with MSM, taking account of the array of other physical and social risks associated with sex.

Skin puckering an uncommon sign of underlying humeral neck fracture: a case report.

Skin puckering is a sign that is well associated with certain fractures such as supracondylar humeral fractures in children. To our knowledge, there has been only one clinical report of skin puckering associated with fractured neck of humerus of an adult. This is a second such case of fractured proximal humerus in an adult presenting with skin puckering and the first from the Republic of Ireland. Skin puckering is suggestive of soft tissue interposition and may be an important clinical sign indicating the need for internal fixation.

Correlation of intra-articular osseous measurements with posterior cruciate ligament length on MRI scans.

Six patients with a clinical diagnosis of chronic posterior cruciate ligament (PCL) rupture, based on a positive posterior drawer test, had a normal appearance of the PCL on an MRI scan. It is postulated that the PCL had been ruptured but healed in a lengthened state. 12 volunteers with no history of knee trauma underwent an MRI scan of the knee. In this control group (n = 12), there was a close correlation between the lateral femoral condylar width in the sagittal plane and the PCL length, with a ratio of 2:1 (95% confidence interval (CI) = 1.817-2.095). In the clinically abnormal group (n = 6), the ratio was 1.49:1 (95% CI = 1.206-1.782) (p< 0.0005). In conclusion, the ratio of the lateral femoral condylar width in the sagittal plane to the PCL length is a useful index for diagnosing PCL attenuation and lengthening in the presence of a normal morphological MR appearance.

Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus.

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.

Criminal prosecutions for HIV transmission: people living with HIV respond.

This paper presents an analysis of responses to the first criminal convictions for HIV transmission in England and Wales within a sample of people living with HIV. These findings represent an important contribution to the development of well-informed prosecution policy. The responses were collected during 20 focused group discussions with a community and web-recruited sample of heterosexual African men and women, and gay and bisexual men (n = 125) living with diagnosed HIV in London, Manchester and Brighton. The vast majority (90%) of comments made were critical of the implementation and impact of criminalization. In particular, respondents expressed concern about the way in which criminal convictions conflict with messages about shared responsibility for 'safer sex', and the extent to which such cases will exacerbate existing stigma and discrimination related to HIV. Most felt that the successes achieved by human rights approaches to HIV prevention, treatment, and care were placed under threat by the growing culture of blame encouraged by criminal prosecutions.

Intraosseous mandibular lipoma (IML): a case report and review of the literature.

Intraosseous mandibular lipoma (IML) is a rare benign tumour and is infrequently associated with unerupted teeth. This report describes an IML associated with an unerupted impacted mandibular wisdom tooth.

Management of sudden sensorineural hearing loss - a national survey.

The management of Sudden Sensorineural Hearing loss is a controversial issue and there is no universally agreed protocol in its management The aim of this study was to ascertain the referral trends, treatment strategies, and outcome of treatment adopted by the Consultant Otorhinolarygologists in this country. A postal questionnaire was sent to all 32 Consultants in the Republic of Ireland, which achieved 21(65.62%) responses. Patients were referred to 13(61.9%) respondents within two weeks of the onset of symptoms and 3(14.28%) Consultants were referred patients within twenty four hours of the onset of symptoms. All specialists routinely performed full blood count and erythrocyte sedimentation rate, 15(71.42%) routinely assess fasting blood sugar and 5(23.80%) investigate fasting lipids and perform a syphilis screen. MR imaging to outrule vestibular schwanoma is performed by 11(52.38%) respondents. When treated within two weeks of the symptoms 6(28.57%) of the respondents were optimistic about recovery of hearing upon treatment whereas 2(9.52%) considered recovery of useful hearing less likely if treated more than two weeks after onset The triple therapy with oral vasodilators, oral steroids, and Carbogen inhalation was favoured by 9(42.85%). Oral steroid was the sole therapeutic modality by 4(19.04%). The opinion of Consultants was that the referral trend from the primary care physician is appropriate and 20(95.23%). Consultants considered an optimistic outcome if treated within two weeks. The investigations and management protocol for sudden sensorineural hearing loss is not uniform which is consistent with the treatment strategies world wide.

Necrotizing sialometaplasia: an unusual bilateral presentation associated with antecedent anaesthesia and lack of response to intralesional steroids. Case report and review of the literature.

Necrotizing sialometaplasia is a self-limiting, variably ulcerated benign process affecting minor salivary glands. Accurate histological diagnosis is paramount, as it has been mistaken for malignancy, which has resulted in excessively aggressive and unnecessary radical surgery. A unique case of bilateral necrotizing sialometaplasia, presenting with anaesthesia of the greater palatine nerves, is described. An attempt at active therapy with intralesional steroids had no effect on the course of the condition.