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There has been much debate regarding the aetiology and pathogenesis of hallux valgus and it appears to be multifactorial with contracture or tightness of the Achilles tendon and more specifically the gastrocnemius being implicated as an intrinsic factor. The purpose of this study was to look at the association of gastrocnemius tightness, genu valgum and hallux valgus. A prospective case-control study with 25 patients in each group was carried out over a 12-month period. The case group observed adult patients who were referred primarily because of symptomatic hallux valgus and were assessed for the following: hallux valgus stage; presence or absence of isolated gastrocnemius tightness; presence or absence of genu valgum. The control group excluded those with pre-existing hallux valgus, genu valgum and rheumatoid arthritis and were assessed for isolated gastrocnemius tightness. There was a statistically significant association between the presence of genu valgum and hallux valgus when comparing both groups with a p <.001. There was also a statistically significant association between the Silfverskiöld test and the presence of hallux valgus, as well as the Silfverskiöld test and the presence of genu valgum with a p <.001. This study is the first to describe the association of gastrocnemius tightness, genu valgum and hallux valgus. Further studies are required to assess this relationship but knowledge and awareness of it can be applied by clinicians when considering the most appropriate management options with patients. [ABSTRACT FROM AUTHOR]

• Intraosseous schwannoma are a rare but important lytic bone lesion on imaging. • There may be an association between primary intraosseous schwannoma and monoclonal gammopathy of undetermined significance (MGUS). • Definitive diagnosis of intraosseous schwannoma is based on a classical histological appearance. • Intraosseous schwannoma is benign and can be treated by local surgical excision alone including in the setting of MGUS. Schwannomas are slow-growing, benign tumours normally originating from the schwann cells of the nerve sheath. Intraosseous schwannomas account for 0.175% of primary bone tumours and are extremely rare, especially outside the axial skeleton. Monoclonal gammopathy has been associated with soft tissue schwannomas but never with the intraosseous variety. A 55-year-old woman with a background of monoclonal gammopathy of undetermined significance (MGUS) presented with a 2-year history of right thigh pain. CT scan showed a well defined, lytic lesion with a thin peripheral rim of sclerosis in the midshaft of the femur. MRI displayed a hyperintense, well marginated and homogenous lesion. Definitive diagnosis was made based on the classical histopathological appearance of schwannoma. We managed our patient with local curettage and prophylactic cephalomedullary nailing based on her high mirel score. Intraosseous schwannomas are poorly understood but most commonly reported in middle-aged women. Radiologically, their differential diagnosis includes malignant bone tumours, solitary bone cysts, aneurysmal bone cysts and giant cell tumours. As a result, they are usually diagnosed incidentally on histology. Although malignant transformation is possible in soft tissue schwannomas, all intraosseous schwannomas reported to date have been benign. This case demonstrates the importance of suspecting intraosseous schwannoma as a differential diagnosis for lytic bone lesions to avoid the overtreatment of patients. We also highlight monoclonal gammopathy of undetermined significance as a potential risk factor for a poorly understood disease and make recommendations about the appropriate management of these lesions. [ABSTRACT FROM AUTHOR]

Parkinson's disease (PD) is a common neurodegenerative disease characterized by progressive dopaminergic neurodegeneration with a concomitant increase in oxidative stress and neuroinflammation in the substantia nigra pars compacta (SNc). Recent studies have focused on targeting neuroinflammation and oxidative stress to effectively treat PD. The present study evaluated the neuroprotective effect of thymoquinone (TQ) against 1-methyl-4-phenyl 1,2,3,6 tetrahydropyridine (MPTP)-induced oxidative stress and neuroinflammation in a PD mouse model. TQ (10 mg/kg body weight [ b. wt. ]) was administered for 1 week prior to MPTP (25 mg/kg b. wt.). MPTP administration caused oxidative stress as evidenced by decreased activities of superoxide dismutase and catalase, a depletion of reduced glutathione, and a concomitant rise in malondialdehyde. It also significantly increased pro-inflammatory cytokines and elevated inflammatory mediators such as cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) in the striatum. Immunohistochemical analysis revealed dopamine neuron loss in the SNc and decreased dopamine transporters in the striatum following MPTP administration; however, these were rescued by TQ treatment. TQ treatment further restored antioxidant enzymes, prevented glutathione depletion, inhibited lipid peroxidation, and attenuated pro-inflammatory cytokines. TQ also decreased the raised levels of inflammatory mediators, such as COX-2 and iNOS. Therefore, TQ is thought to protect against MPTP-induced PD and the observed neuroprotective effects are attributed to its potent antioxidant and anti-inflammatory properties. Moreover, the in vitro analysis found that TQ significantly inhibited α-synuclein aggregation and prevented cell death induced by pre-formed fibrils. Thus, TQ not only scavenges the MPTP-induced toxicity but also prevents α-synuclein-fibril formation and its associated toxicity. • MPTP exposure decreased SOD, catalase, and GSH and increased MDA. • TQ treatment prior to MPTP significantly normalized SOD, catalase, GSH, and MDA. • TQ also normalized the MPTP-induced increase of inflammatory cytokines. • TQ rescued the dopamine neuron loss due to MPTP exposure in vivo. • TQ prevented α-syn aggregation and α-syn-induced toxicity in SH-SY5Y cells. [ABSTRACT FROM AUTHOR]

Diabetic foot complications result in substantial morbidity and mortality, fortunately they can be prevented. Our study measured the frequency of patient-reported diabetes-related foot problems and foot self-care practices among diabetic patients attending Abdallah Khalil Diabetes Center, Khartoum state, Sudan. This was a descriptive cross-sectional health facility-based study conducted at Abdallah Khalil Diabetes Center in Omdurman, Khartoum in the period from January to March, 2021. A convenience sample of 194 (n=250) Sudanese diabetic patients, aged 20 and above were in enrolled in this study. A pretested interviewer-administered questionnaire was used to obtain data on socio-demographic and clinical characteristics, patient-reported foot problems and foot self-care practices, data was analyzed using SPSS 23, chi-square and multi-variate logistic regression tests were used to measure associations and predictive factors among different variables. 194 patients were included in this study (response rate: 77.6%), mean diabetes duration 10.20±8.07 years, 60.3% were female, 47.4% were unemployed and 10.8% were retired, illiterate participants represented (28.9%). 80.4% reported having at least one or more sensory peripheral neuropathy symptoms, 36.6% reported one or more peripheral vascular disease symptoms in the previous month, and 29.4% had a history of foot ulceration. Reported foot self-care practices were overall suboptimal; 55.2 average scores (25-36), only 4.1% attained good scores (37-48). 24.7$ and 27.8% never or rarely examine the bottom of their feet each day. On multivariate logistic regression HbA1c was found to be predictive of foot ulceration (p value 0.038), while duration and peripheral vascular disease were found to be predictive of amputations. (p value 0.001 and 0.021, respectively). Diabetes related foot complications were frequently reported by our study participants, yet adoption of preventive foot self-care practices was of average levels, making it something very vital and urgent to carry out routine foot care educational programs and sessions. Future research for assessing the effectiveness of the preventive programs is going to be needed. Key words: Diabetes Mellitus, Diabetic Foot, Self-Care, Ulcer, Amputation [ABSTRACT FROM AUTHOR]

The weekend warrior has long been prey to musculoskeletal injuries as a result of intermittent, high intensity activity. The Achilles tendon is known to be particularly vulnerable in this population cohort but during the COVID-19 lockdowns in Ireland and all over the world there has been a certain level of detraining and deconditioning among all age groups and populations. Throughout the worldwide restrictions, viral internet challenges and dances have encapsulated the spirit of a global community with the 'Jerusalema' dance being no exception. The rise of this particular viral sensation was at the detriment of the Achilles tendons of three middle aged gentlemen on who we base our case series. Over the space of ten days three cases of Achilles tendon rupture repair presented to the emergency department in Midlands Regional Hospital Tullamore (MRHT) with the mechanism of tendon rupture being through the 'Jerusalema' dance. These patients were surgically managed in line with local institution practice and postoperative outcomes were good with no complications noted. Follow up is ongoing. This retrospective case series is based on the impact of the 'Jerusalema Dance' on presentations of Achilles tendon rupture to the Emergency Department in a single regional hospital from January to March 2021. We used these cases in conjunction with a review of current literature to highlight the benefit of an integrated Achilles Tendon rehabilitation programme in this at-risk patient cohort. This paper highlights the dangers inherent when well intentioned, but physically deconditioned individuals endeavour to perform a physical exercise which is deceptively demanding. Going forward, viral challenges such as the 'Jerusalema' may contribute to new and interesting mechanisms of injuries in our 'weekend warrior' cohort. In addition to this, given the global deconditioning seen due to the COVID 19 pandemic and subsequent lockdowns we may see a higher rate of Achilles tendon injuries in the near future across a multitude of patient cohorts. Level one evidence suggests that conservative treatment is just as effective as surgical treatments in the majority of patients with an Achilles tendon rupture, as long as a protocol of rehabilitation with early weightbearing is performed. Our accelerated rehabilitation programme in MRHT is in line with others however internal audit and new literature in the future may enable us to refine it further. • Achilles Tendon Rupture is common amongst the conditioned and deconditioned population. • Surgical and conservative management options are widely explored in the literature. • Viral dance challenges such as the Jerusalema offer new and interesting patterns of injury. • An early weightbearing rehabilitation programme after TA rupture shows lower re-rupture rates. [ABSTRACT FROM AUTHOR]

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Aims: This study aimed to identify the face and construct validity of the Precision OS trauma module proximal femoral nail procedure. Secondary outcomes included perceived use of simulation in surgical training, with structured feedback from participants.Methods: A comparative interventional study was carried out in a regional orthopaedics trauma unit hospital. Volunteers were stratified into novice, intermediate and expert groups based on self-reported levels of experience. Each participant carried out a simulated proximal femoral nail on an immersive virtual platform following instruction on its use, with objective metrics such as time and x-rays, and novel metrics calculated by the simulation module recorded. Face validity was also assessed.Results: The proximal femoral nail module demonstrated construct validity. Kruskal Wallis test demonstrated a statistically significant difference across all group's novel performance (p=.018). Intermediate surgeons performed significantly better than novices (P=.022), with shorter procedural times (P=.018) Three of the intermediate group achieved the proficiency level set by the expert group, with no significant difference noted between these two groups (=.06). Time taken to completion for expert surgeons was less than intermediate group, although this did not reach significance (P=.19).Conclusion: The proximal femoral nail module on the Precision OS platform demonstrated good face, and construct validity. Further research evaluating use of virtual platform simulation in surgical trauma training is needed. [ABSTRACT FROM AUTHOR]

Introduction: The positive learning experiences of students on surgical rotations which subsequently influence career choice may be delineated into practical and interpersonal themed factors. It remains unclear the relative impact each component has on the student experience and subsequent specialisation.Aims: We evaluate the influence of having senior resident mentor during practical simulation in orthopaedic surgery has on medical student interest in surgery; their comfort in theatre; and its role in enhancing knowledge acquisition within the rotation.Methods: Medical students undergoing clinical rotations in a Regional University Hospital were randomised to undertaking a virtual reality simulated operation independently or performing under the guidance of an experienced resident. Baseline levels of interest in surgery, comfort in theatre, perceived barriers to surgical learning and entry to surgery were established and compared to answers following completion of the tutorial. Qualitative feedback was collected regarding the benefits and limitations to the experience. Presented according to CONSORT guidelines.Results: Participants in the trainee guided group achieved significantly higher simulated performance scores compared to the control (p < 0001), with an increase in interest in orthopaedic surgery from baseline expressed to a statistically significant degree (p = 0.01). Participants in the unsupervised group demonstrated no significant increase in interest in Orthopaedic surgery (p = 0.3). 100% participants strongly agreed it was a beneficial learning experience which would be useful in surgical curricula.Conclusion: Surgical trainee guided simulation led to improved performance and interest in orthopaedic surgery, while virtual practical experience was felt to be a useful learning tool independent of supervision. Further research is needed to establish the role of interpersonal interactions in student surgical experience. [ABSTRACT FROM AUTHOR]

Background: A national ransomware attack on the Irish Health Service Executive left the Healthcare system bereft of access to IT systems, electronic patient records, and the national imaging system. Widespread disruption to internal and external referral pathways, and both trauma and elective Orthopaedic services occurred as a result. The purpose of this paper to discuss the challenges faced by Regional trauma units and adjustments made to overcome these.Methods: Issues occurring as a result of the IT cybersecurity attack were discussed at regional level. Local and specialist centre adaptations were collated to identify effective modifications to established practice in the wake of the IT attack.Results: The main areas affecting Orthopaedic regional practice were identified, including internal referrals, interhospital referrals to both regional and specialist centres, outpatient clinics, and elective practice. Strategies to overcome these were collated and shared between regional centres, including the use of secure messaging systems to safely transmit relevant clinical information between services, use of radiological hard copies, and integration of imaging resources to the outpatient department to expedite clinical review.Conclusion: The national cyberattack necessitated rapid adaptations to overcome the challenges faced as a result of reduced clinical and radiological access. While the recent cyberattack highlights the vulnerability of electronic systems, and the need for vigilance including staff training on cybersecurity; Changes implemented by regional centres also illustrate the potential for further development and expansion of current clinical practices. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are a significant cause of morbidity and mortality in elderly patients. Timely surgical fixation and early mobilisation are the cornerstone to successful outcomes. The Irish Hip Fracture Database (IHFD) was established in 2012 and publishes annual reports on hip fracture care. This paper describes the trends in surgical fixation in Ireland during a 7-year period (2013-2019), assesses for compliance with guidelines and compares the most recent published reports from ten international hip fracture registries.Methods: All published IHFD reports were systematically reviewed and tabulated. Data corresponding to demographics, fracture type, surgical fixation and post-operative management was plotted and analysed. Ten international hip fracture registries were identified and reviewed. Data was extracted corresponding to the IHFD dataset.Results: A total of 21,684 hip fractures were recorded during this period. The majority of patients were female (70.16%), >80 years old (58.26%), admitted from their own home (82.13%) and ASA grade 3 (53%). The majority of undisplaced and displaced intracapsular fractures were treated with hemiarthroplasty, 62% and 88% respectively. There has been a decline in the use of dynamic hip screw (DHS) for intertrochanteric fractures with intramedullary nails being favoured.Conclusion: Despite greater awareness of hip fracture care through the IHFD and the introduction of Best Practice Tariffs (BPT), further improvements are needed. Ireland compares well to international standards but has low rates of compliance to NICE guidelines for surgical fixation. [ABSTRACT FROM AUTHOR]

Background: The recent SARS-CoV2/COVID-19 pandemic has caused a change in most aspects of our daily lives. Our health systems have had to adjust at an unprecedented rate to accommodate care for patients affected by the virus. As a result there has been widespread disruption to trauma and elective services throughout the Orthopaedic community Worldwide. We discuss the changes facing orthopaedic residents in training and the adaptations that have been made.Methods: We discuss the challenges posed from a reduction in caseload to surgeons in training, teaching activities, patient interaction, workforce reinforcement and support networks in Ireland.Results: A structured deployment of residents has taken place ensuring maximum exposure to operative cases to maintain competency. Teaching activities have been virtualised into a new curriculum that provides trainees with convenient access to a wide range of specialists at defined time periods during the week. Strategies have been employed to reinforce the workforce in anticipation of an acute reduction in staff due to the Covid-19 virus.Conclusions: The changes have been rapid and despite many of these adjustments being borne out of necessity, the innovation displayed will almost certainly alter how training is ultimately delivered long after the crisis has ceased. [ABSTRACT FROM AUTHOR]

Background: Anterior T-wave inversion (ATWI) on electrocardiography (ECG) in young white adults raises the possibility of cardiomyopathy, specifically arrhythmogenic right ventricular cardiomyopathy (ARVC). Whereas the 2010 European consensus recommendations for ECG interpretation in young athletes state that ATWI beyond lead V1 warrants further investigation, the prevalence and significance of ATWI have never been reported in a large population of asymptomatic whites.Objectives: This study investigated the prevalence and significance of ATWI in a large cohort of young, white adults including athletes.Methods: Individuals 16 to 35 years of age (n = 14,646), including 4,720 females (32%) and 2,958 athletes (20%), were evaluated by using a health questionnaire, physical examination, and 12-lead ECG. ATWI was defined as T-wave inversion in ≥2 contiguous anterior leads (V1 to V4).Results: ATWI was detected in 338 individuals (2.3%) and was more common in women than in men (4.3% vs. 1.4%, respectively; p < 0.0001) and more common among athletes than in nonathletes (3.5% vs. 2.0%, respectively; p < 0.0001). T-wave inversion was predominantly confined to leads V1 to V2 (77%). Only 1.2% of women and 0.2% of men exhibited ATWI beyond V2. No one with ATWI fulfilled diagnostic criteria for ARVC after further evaluation. During a mean follow-up of 23.1 ± 12.2 months none of the individuals with ATWI experienced an adverse event.Conclusions: ATWI confined to leads V1 to V2 is a normal variant or physiological phenomenon in asymptomatic white individuals without a relevant family history. ATWI beyond V2 is rare, particularly in men, and may warrant investigation. [ABSTRACT FROM AUTHOR]

Background: High false-positive rates and cost of additional investigations are an obstacle to electrocardiographic (ECG) screening of young athletes for cardiac disease. However, ECG screening costs have never been systematically assessed in a large cohort of athletes.Objective: This study investigated the costs of ECG screening in athletes according to the 2010 European Society of Cardiology (ESC) recommendations and the Seattle and refined interpretation criteria.Methods: Between 2011 and 2014, 4,925 previously unscreened athletes aged 14 to 35 years were prospectively evaluated with history, physical examination, and ECG (interpreted with the 2010 ESC recommendations). Athletes with abnormal results underwent secondary investigations, the costs of which were based on U.K. National Health Service Tariffs. The impact on cost after applying the Seattle and refined criteria was evaluated retrospectively.Results: Overall, 1,072 (21.8%) athletes had an abnormal ECG on the basis of 2010 ESC recommendations; 11.2% required echocardiography, 1.7% exercise stress test, 1.2% Holter, 1.2% cardiac magnetic resonance imaging, and 0.4% other tests. The Seattle and refined criteria reduced the number of positive ECGs to 6.0% and 4.3%, respectively. Fifteen (0.3%) athletes were diagnosed with potentially serious cardiac disease using all 3 criteria. The overall cost of de novo screening using 2010 ESC recommendations was $539,888 ($110 per athlete and $35,993 per serious diagnosis). The Seattle and refined criteria reduced the cost to $92 and $87 per athlete screened and $30,251 and $28,510 per serious diagnosis, respectively.Conclusions: Contemporary ECG interpretation criteria decrease costs for de novo screening of athletes, which may be cost permissive for some sporting organizations. [ABSTRACT FROM AUTHOR]

Background: Accurate knowledge of causes of sudden cardiac death (SCD) in athletes and its precipitating factors is necessary to establish preventative strategies.Objectives: This study investigated causes of SCD and their association with intensive physical activity in a large cohort of athletes.Methods: Between 1994 and 2014, 357 consecutive cases of athletes who died suddenly (mean 29 ± 11 years of age, 92% males, 76% Caucasian, 69% competitive) were referred to our cardiac pathology center. All subjects underwent detailed post-mortem evaluation, including histological analysis by an expert cardiac pathologist. Clinical information was obtained from referring coroners.Results: Sudden arrhythmic death syndrome (SADS) was the most prevalent cause of death (n = 149 [42%]). Myocardial disease was detected in 40% of cases, including idiopathic left ventricular hypertrophy (LVH) and/or fibrosis (n = 59, 16%); arrhythmogenic right ventricular cardiomyopathy (ARVC) (13%); and hypertrophic cardiomyopathy (HCM) (6%). Coronary artery anomalies occurred in 5% of cases. SADS and coronary artery anomalies affected predominantly young athletes (≤ 35 years of age), whereas myocardial disease was more common in older individuals. SCD during intense exertion occurred in 61% of cases; ARVC and left ventricular fibrosis most strongly predicted SCD during exertion.Conclusions: Conditions predisposing to SCD in sports demonstrate a significant age predilection. The strong association of ARVC and left ventricular fibrosis with exercise-induced SCD reinforces the need for early detection and abstinence from intense exercise. However, almost 40% of athletes die at rest, highlighting the need for complementary preventive strategies. [ABSTRACT FROM AUTHOR]

[Display omitted] • Silver nanoparticles (SNPs) were successfully synthesized from myrrh. • The herb myrrh acts as a reducing agent and stabilizer. • Myrrh silver nanoparticles (MSNPs) had antiparasitic effects on Leishmania major. • MTT assay showed decreased promastigote viability in vitro. • Synthesized MSNPs can be considered a candidate drug for nanomedicine applications. The drugs used to treat cutaneous leishmaniasis (CL) cannot effectively penetrate lesions. Nanogold and nanosilver have been used for treating or enhancing drug delivery in CL. The present study used Commiphora molmol (myrrh) to synthesize silver nanoparticles (MSNPs). The MSNPs were characterized using transmission electron microscopy and energy-dispersive spectroscopy. In addition, antiparasitic effect of myrrh silver nanoparticles (MSNPs) was assessed on Leishmania major both in vitro and in vivo. Five concentrations of MSNPs (10, 50, 80, 100, and 150 μl/100 μL) were used to study their effect on L. major cultures in vitro , and MSNPs were also applied topically to subcutaneous lesions in mice in vivo. The results showed that the MSNPs were 49.09 nm in size. MSNPs, showed a marked and significant (p ≤ 0.05) growth inhibition of L. major promastigotes which was concentration dependent. Overall, the higher concentrations (100, 150 μl/100 μL had a significantly greater inhibitory effect for the MSNPs in comparison to the chemical nanoparticles (CNPs) and pentostam at the same concentrations. Lesions healed completely in 21 d after MSNP treatment in vivo , while pentostam, a commercial drug, and CNPs showed a moderate healing effect on the lesions. Thus, MSNPs were more effective than pentostam and CNPs both in the in vivo and in vitro studies. MSNPs can therefore be promising candidates for various nanomedicine applications. [ABSTRACT FROM AUTHOR]