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The disruption to healthcare provision as a result of the COVID-19 pandemic has compelled us to streamline healthcare delivery. This has given us an opportunity to implement healthcare technology, reform inter-disciplinary collaboration and ultimately enhance patient care. We discuss some of the advances made by the foot and ankle department at our hospital. These innovations have broad applicability and will hopefully ignite discussion amoung a number of healthcare teams about improving the future care of their patients.

Notch is a large cell-surface receptor known to be an essential player in a wide variety of developmental cascades. Here we show that Notch1 endogenously expressed in Chinese hamster ovary cells is modified with O-linked fucose and O-linked glucose saccharides, two unusual forms of O-linked glycosylation found on epidermal growth factor-like (EGF) modules. Interestingly, both modifications occur as monosaccharide and oligosaccharide species. Through exoglycosidase digestions we determined that the O-linked fucose oligosaccharide is a tetrasaccharide with a structure identical to that found on human clotting factor IX: Sia-alpha2,3-Gal-beta1, 4-GlcNAc-beta1,3-Fuc-alpha1-O-Ser/Thr. The elongated form of O-linked glucose appears to be a trisaccharide. Notch1 is the first membrane-associated protein identified with either O-linked fucose or O-linked glucose modifications. It also represents the second protein discovered with an elongated form of O-linked fucose. The sites of glycosylation, which fall within the multiple EGF modules of Notch, are highly conserved across species and within Notch homologs. Since Notch is known to interact with its ligands through subsets of EGF modules, these results suggest that the O-linked carbohydrate modifications of these modules may influence receptor-ligand interactions.

O-Linked fucose is an unusual carbohydrate modification in which fucose is linked directly to the hydroxyl groups of serines or threonines. It has been found on the epidermal growth factor-like modules of several secreted proteins involved in blood coagulation and fibrinolysis. We have recently reported the existence of an elongated form of O-linked fucose in Chinese hamster ovary cells consisting of a glucose linked to the 3'-hydroxyl of fucose (Glcbeta1,3Fuc- O-Ser/Thr). This structure is highly unusual for two reasons. First, in mammalian systems fucose is usually a terminal modification of N - and O-linked oligosaccharides. Here the fucose is internal. Secondly, terminal beta-linked glucose is extremely rare on mammalian glycoconjugates. Thus, the Glcbeta1,3Fuc structure is a very unique mammalian carbohydrate structure. Here we report the identification and initial characterization of a novel enzyme activity capable of forming this unique linkage: UDP-glucose: O-linked fucose beta1,3 glucosyltransferase. The enzyme utilizes UDP-glucose as the high energy donor and transfers glucose to alpha-linked fucose residues. The activity is linearly dependent on time, enzyme, and substrate concentrations and is enhanced in the presence of manganese ions. Activity is present in extracts of cultured cells from a variety of species (hamster, human, mouse, rat, chicken) and is enriched in brain and spleen of a normal adult rat. Thus, while this glycosyltransferase appears to be widespread in biology, it forms a very unique linkage, and it represents the first mammalian enzyme identified capable of elongating fucose.

In order to assess the benefit to patients with thin malignant melanoma (< 0.76 mm) of a 5-year clinical follow-up programme, we have studied 602 patients with a minimum time from primary surgery of 5 years. Tumour recurrence occurred in 24 patients (4% of all patients) but only five surgically treatable recurrences (< 1% of all patients) occurred within the 5-year period following primary surgery. After 5 years there were four surgically treatable recurrences, but their prognosis was generally poor. The remaining cases of tumour recurrence were not surgically treatable. In the face of an increasing incidence of melanoma, and the accompanying increase in demand for surgical treatment and outpatient review, we question the need for prolonged hospital follow-up of thin melanoma.

O-Linked fucose is an unusual form of glycosylation recently shown to modify the hydroxyls of serine or threonine residues at a strict consensus site within epidermal growth factor-like domains of several serum proteins. Here we demonstrate that Chinese hamster ovary cells modify numerous proteins with O-linked fucose and that the fucose is elongated on specific proteins. We have identified at least two forms of O-linked fucose elongation in Chinese hamster ovary cells: a disaccharide (Glcbeta1,3Fuc) and a larger oligosaccharide of indeterminate structure. Interestingly, it appears that the level of monosaccharide accumulates in the cells over time whereas the disaccharide does not. Analysis of the O-linked fucose-containing saccharides on individual proteins revealed that some proteins are modified with the monosaccharide only, whereas others are modified with monosaccharide and disaccharide, or monosaccharide and oligosaccharide. These results suggest that elongation of the O-linked fucose monosaccharide is a protein-specific phenomena. The presence of elongated O-linked fucose moieties suggests that a novel glycosylation pathway exists in mammalian cells with O-linked fucose as the core.

Purpose. To assess the risk of surgical delay in elderly hip fracture patients on anti-platelet agents.Methods. Records of 180 patients aged over 65 years with either an intertrochanteric or femoral neck fracture were reviewed. The clopidogrel group included 10 patients on clopidogrel alone and 11 others on clopidogrel and aspirin, whereas the control group included 69 on aspirin alone and the remaining 90 not on any anti-coagulants. The 2 groups were compared with regard to time to surgery, preoperative American Society of Anesthesiologists (ASA) score, pre- and post-operative haemoglobin levels, in-patient complication rates, duration of hospital stay, and 30-day mortality.Results. In the clopidogrel and control groups respectively, the mean times to surgery were 7.2 and 2.1 days (p=0.03, t-test), the mean preoperative ASA scores were 3.35 and 2.8 (p=0.29, t-test), the mean preoperative haemoglobin levels were 119 and 115 g/l (p=0.5, t-test), the mean postoperative haemoglobin levels were 98 and 96 g/l (p=0.68, t-test), the mean durations of hospital stay were 7.4 and 3.1 days (p=0.02, t-test). The 30-day mortalities were 6/21 (29%) and 6/159 (4%) [p=0.0003, Fisher's exact test].Conclusion. Surgical delay in elderly patients on anti-platelet agents with hip fracture was associated with higher mortality. Despite the risk of increased blood loss, we suggest early surgery be carried out by an experienced surgeon to expedite the operating time. Pooled platelets should be given intravenously one to 2 hours preoperatively.

We have found that double opposing rectangular advancement flaps in the forehead may be easily performed under either local or general anaesthesia, and are associated with high patient satisfaction and low morbidity. We claim no originality for the mode of reconstruction, but highlight its broad spectrum of application and its popularity with junior plastic surgeons passing through our unit., We have found that the term 'H-fla' provides a readily communicated alternative to 'double opposing rectangular advancement flaps'.

We describe the use of a simple hand support for use during microsurgical cases.

Community awareness of the sustainable use of land, water and vegetation resources is increasing. The sustainable use of these resources is pivotal to sustainable farming systems. However, techniques for monitoring the sustainable management of these resources are poorly understood and untested. We propose a framework to benchmark and monitor resources in the grains industry. Eight steps are listed below to achieve these objectives: (i) define industry issues; (ii) identify the issues through growers, stakeholder and community consultation; (iii) identify indicators (measurable attributes, properties or characteristics) of sustainability through consultation with growers, stakeholders, experts and community members, relating to: crop productivity; resource maintenance/enhancement; biodiversity; economic viability; community viability; and institutional structure; (iv) develop and use selection criteria to select indicators that consider: responsiveness to change; ease of capture; community acceptance and involvement; interpretation; measurement error; stability, frequency and cost of measurement; spatial scale issues; and mapping capability in space and through time. The appropriateness of indicators can be evaluated using a decision making system such as a multiobjective decision support system (MO-DSS, a method to assist in decision making from multiple and conflicting objectives); (v) involve stakeholders and the community in the definition of goals and setting benchmarking and monitoring targets for sustainable farming; (vi) take preventive and corrective/remedial action; (vii) evaluate effectiveness of actions taken; and (viii) revise indicators as part of a continual improvement principle designed to achieve best management practice for sustainable farming systems. The major recommendations are to: (i) implement the framework for resources (land, water and vegetation, economic, community and institution) benchmarking and monitoring, and integrate this process with current activities so that awareness, implementation and evolution of sustainable resource management practices become normal practice in the grains industry; (ii) empower the grains industry to take the lead by using relevant sustainability indicators to benchmark and monitor resources; (iii) adopt a collaborative approach by involving various industry, community, catchment management and government agency groups to minimise implementation time. Monitoring programs such as Waterwatch, Soilcheck, Grasscheck and Topcrop should be utilised; (iv) encourage the adoption of a decision making system by growers and industry representatives as a participatory decision and evaluation process. Widespread use of sustainability indicators would assist in validating and refining these indicators and evaluating sustainable farming systems. The indicators could also assist in evaluating best management practices for the grains industry.