First helminthological data on the Iberian adder, Vipera seoanei

The helminth fauna present in the gut contents of Iberian adders, Vipera seoanei (Squamata: Viperidae), were characterised and analysed in respect to biological and eco-geographic factors that may affect the occurrence and diversity of helminths in this species. A total of 317 samples of preserved stomachs and intestines, covering the distributional range of V. seoanei, were examined. Similar to other Vipera species from the Iberian Peninsula, the helminth fauna was also impoverished in V. seoanei, but unlike other Vipera species from Central and East Europe, helminths were mostly found in adult vipers, and occurred in vipers located at the periphery of the species range, characterised by low elevation, high temperature and precipitation levels, and abundant pastures.

Controlled Growth of the Self-Modulation of a Relativistic Proton Bunch in Plasma

A long, narrow, relativistic charged particle bunch propagating in plasma is subject to the self-modulation (SM) instability. We show that SM of a proton bunch can be seeded by the wakefields driven by a preceding electron bunch. SM timing reproducibility and control are at the level of a small fraction of the modulation period. With this seeding method, we independently control the amplitude of the seed wakefields with the charge of the electron bunch and the growth rate of SM with the charge of the proton bunch. Seeding leads to larger growth of the wakefields than in the instability case.

Transition between Instability and Seeded Self-Modulation of a Relativistic Particle Bunch in Plasma

We use a relativistic ionization front to provide various initial transverse wakefield amplitudes for the self-modulation of a long proton bunch in plasma. We show experimentally that, with sufficient initial amplitude [≥(4.1±0.4)  MV/m], the phase of the modulation along the bunch is reproducible from event to event, with 3%-7% (of 2π) rms variations all along the bunch. The phase is not reproducible for lower initial amplitudes. We observe the transition between these two regimes. Phase reproducibility is essential for deterministic external injection of particles to be accelerated.

Factors Associated with Willingness to be Vaccinated Against COVID-19 in a Large Convenience Sample

Willingness and reasons to be vaccinated against COVID-19 were examined among 26,324 respondents who completed a survey on willingness and questions related to Confidence in vaccine safety, Complacency about the disease, Convenience of vaccination, tendency to Calculate risks versus benefits, and Concern for protecting others. Willingness to be vaccinated differed by age (p < 0.001), by race and ethnicity (p < 0.001) and by level of education (p < 0.001). Willingness generally increased with age and education. Asians were most willing to be vaccinated, followed by non-Hispanic Whites, Hispanics, and non-Hispanic Blacks (p < 0.001). Occupational groups differed in willingness (p < 0.001). Retired and students were more willing than all others (p < 0.001) followed by disabled or unemployed, healthcare workers, and educators. First Responders were least willing to be vaccinated (p < 0.001) followed by construction, maintenance and landscaping, homemakers, housekeeping, cleaning and janitorial workers, and retail and food service. The strongest predictor of willingness was confidence with the safety of the vaccine (r = 0.723, p < 0.001), followed by concern with protecting others by being vaccinated (r = 0.574, p < 0.001), and believing COVID-19 was serious enough to merit vaccination (r = 0.478, p < 0.00). Using multiple regression, confidence in safety was the strongest predictor for all groups. Protecting others was strongest for 13 of 15 demographic groups and 8 of 11 occupational groups. College educated, non-Hispanic Whites, first responders, construction, maintenance and landscape workers, housekeeping, cleaning and janitorial workers all gave greater weight to complacency about the disease. These results can help in designing programs to combat vaccine hesitancy.

Proton Bunch Self-Modulation in Plasma with Density Gradient

We study experimentally the effect of linear plasma density gradients on the self-modulation of a 400 GeV proton bunch. Results show that a positive or negative gradient increases or decreases the number of microbunches and the relative charge per microbunch observed after 10 m of plasma. The measured modulation frequency also increases or decreases. With the largest positive gradient we observe two frequencies in the modulation power spectrum. Results are consistent with changes in wakefields' phase velocity due to plasma density gradients adding to the slow wakefields' phase velocity during self-modulation growth predicted by linear theory.

The Windswept Foot: Dealing with Metatarsus Adductus and Toe Valgus

The windswept foot remains a reconstructive challenge. The hallux valgus associated with the medially displaced lesser metatarsal heads is hard to correct. Either the lesser metatarsal heads need to be displaced laterally or the deformity accepted. With the deformity, all the toes tend to be aligned into valgus with the position of the flexor and extensor tendons. Several treatment alternatives exist and may require a combination of open and percutaneous surgery. The authors think that, in severe metatarsus adductus, proximal correction of the first, second, and third metatarsals is required.

Distal Minimally Invasive Metatarsal Osteotomy ("DMMO" Procedure)

The use of a Shannon burr facilitates an osteotomy of the lesser metatarsals without requiring an open approach to the metatarsal. The end result that is aimed for is the same as for open surgery and therefore care needs to be taken to perform the bone cut in the appropriate manner. A description is provided of the surgical technique for distal minimally invasive osteotomy and its newer modifications-the distal intracapsular minimally invasive osteotomy and the distal oblique metatarsal osteotomy.

Endoscopic Management of Chronic Achilles Tendon Rupture

Chronic ruptures of the Achilles tendon are often missed injuries, which is challenging for the surgeon. The complications from reconstruction are a considerable concern. Primary repair may be attempted, but the missed injury often presents later than 4 weeks with gaps greater than 4 cm, necessitating more complex reconstructions using local tissues such as turn-down flaps and VY plasty, requiring large incisions in an unfavorable area of the body. We describe a step-by-step technique of endoscopic flexor hallucis longus reconstruction for chronic Achilles rupture, which decreases local complications. This article reviews the available literature for endoscopic flexor hallucis longus reconstruction.

Proton-driven plasma wakefield acceleration in AWAKE

In this article, we briefly summarize the experiments performed during the first run of the Advanced Wakefield Experiment, AWAKE, at CERN (European Organization for Nuclear Research). The final goal of AWAKE Run 1 (2013-2018) was to demonstrate that 10-20 MeV electrons can be accelerated to GeV energies in a plasma wakefield driven by a highly relativistic self-modulated proton bunch. We describe the experiment, outline the measurement concept and present first results. Last, we outline our plans for the future. This article is part of the Theo Murphy meeting issue 'Directions in particle beam-driven plasma wakefield acceleration'.

TM3-6 Symptomatic intracranial arachnoid cysts: a centre series

Objectives

To study the presentation, management and outcomes of symptomatic intracranial arachnoid cysts.

Design

Retrospective records review.

Subjects

All cases coded as intracranial cysts.

Methods

Patients admitted between Jan-2012 and Sep 2017. Of 56 cases, only 24 were arachnoid cysts. Median age 57 (range 8–81). Mean 49.1±5.0 years, 8 males and 16 females.

Results

Males were significantly younger (34.3±9.1 vs 56.5±5.2 year-old, p=0.03) and outnumbered females. Mean size of cysts was 58.8±6.1 mm (range 18.5–126 mm). Five were located frontally, one fronto-temporal and another fronto-parietal, two parietal and two parieto-occipital, two within third ventricle, one intraventricular, one supra sellar and one intra sellar while eight were posterior fossa. 12 patients had headache, five presented with cognitive and memory issues, five had visual problems, four with limb weakness and two had cerebellar signs. Eight had open fenestration, five endoscopic fenestration, four had aspiration with reservoir, two aspiration only, two marsupialisation, two received ICP monitor and one had no treatment. One reservoir was aspirated three times and another open fenestration had another surgical fenestration. Two had transient infection, two needed VP shunts and one had cysto-peritoneal shunt. mRS (0–2) improved significantly after the treatment (62.5% pre-surgery to 91.7% post-surgery, p=0.016).

Conclusions

Symptomatic arachnoid cysts are more common in young males. In the literature, the most common location is middle cranial fossa which is not the case in symptomatic arachnoid cysts as in our series. Although intervention is variable, they are associated with very good outcomes.

Experimental Observation of Proton Bunch Modulation in a Plasma at Varying Plasma Densities

We give direct experimental evidence for the observation of the full transverse self-modulation of a long, relativistic proton bunch propagating through a dense plasma. The bunch exits the plasma with a periodic density modulation resulting from radial wakefield effects. We show that the modulation is seeded by a relativistic ionization front created using an intense laser pulse copropagating with the proton bunch. The modulation extends over the length of the proton bunch following the seed point. By varying the plasma density over one order of magnitude, we show that the modulation frequency scales with the expected dependence on the plasma density, i.e., it is equal to the plasma frequency, as expected from theory.

Experimental Observation of Plasma Wakefield Growth Driven by the Seeded Self-Modulation of a Proton Bunch

We measure the effects of transverse wakefields driven by a relativistic proton bunch in plasma with densities of 2.1×10^{14} and 7.7×10^{14}  electrons/cm^{3}. We show that these wakefields periodically defocus the proton bunch itself, consistently with the development of the seeded self-modulation process. We show that the defocusing increases both along the bunch and along the plasma by using time resolved and time-integrated measurements of the proton bunch transverse distribution. We evaluate the transverse wakefield amplitudes and show that they exceed their seed value (<15  MV/m) and reach over 300  MV/m. All these results confirm the development of the seeded self-modulation process, a necessary condition for external injection of low energy and acceleration of electrons to multi-GeV energy levels.

Can we use biomarkers of coagulation to predict which patients with foot and ankle injury will develop deep vein thrombosis?

BACKGROUND

Our aim was to determine whether plasma levels of Tissue Factor (TF), Vascular Cell Adhesion Molecule 1 (VCAM-1), Interleukin 6 (IL-6) or D-dimer after foot and ankle injury could predict which patients would develop deep vein thrombosis (DVT).

METHODS

Patients aged 18-60 years with acute foot and ankle injury had venous blood sample to measure TF, VCAM-1, IL-6 and D-dimer within 3 days of injury. Patients had bilateral lower limb venous ultrasound to assess for DVT on discharge from clinic.

RESULTS

21 of 77 patients were found to have DVT (27%). There was no statistically significant association between levels of TF, VCAM-1, IL-6 or D-dimer and subsequent development of DVT.

CONCLUSION

Tissue Factor (TF), Vascular Cell Adhesion Molecule-1 (VCAM-1), Interleukin-6 (IL-6) and D-dimer levels were not associated with development deep vein thrombosis in patients with acute foot and ankle injury.

Functional Outcomes of Local Pedicle Graft Interpositional Arthroplasty in Adults With Severe Freiberg's Disease

BACKGROUND

Conservative treatment or debridement is generally sufficient for Freiberg's disease grades I and II but operative intervention for the late stages of the disease process (III-V) is more challenging. Debridement alone is not sufficient and various forms of arthroplasty have been put forward. We have evaluated the outcomes of patients treated with an interpositional arthroplasty technique using a pedicle graft of periosteum and fat made into a "Rollmop" spacer for severe Freiberg's disease. No results have previously been reported for this technique.

METHODS

Twenty-five consecutive cases (23 patients) were performed from February 2009 to September 2016 (20 females, 5 males). Mean age at surgery was 52.6 years (range 19-70.5 years) with 92% affecting the second metatarsal. Twenty-three were primary cases and 2 were revision cases. Five cases were stage III, 12 were stage IV, and 8 were stage V. All patients underwent interpositional arthroplasty using a periosteum and fat pedicle graft from the affected metatarsal shaft as described by Myerson. Patients were evaluated using Manchester-Oxford Foot Questionnaire (MOXFQ) and American Orthopaedic Foot & Ankle Society Questionnaire (AOFAS). Mean follow-up was 3.5 years (0.6-7.6 years). Paired 2-tailed Student t tests were used to assess clinical significance.

RESULTS

Surgery allowed 8 patients to return to normal footwear, 10 patients returned to fashion footwear/heels, and 5 returned to sports. Nineteen cases (17 patients) were assessed with patient-reported outcome measures and all showed a clinically and statistically significant improvement in their scores. Mean pre- and postoperative VAS pain scores were 6.2 (range 4-9) and 1.8 (range 0-6) ( P < .05). Mean perioperative AOFAS scores were 45.6 (range 15-73) and 82.7 (range 57-100) ( P < .05). Mean perioperative MOXFQ scores were 60.0 (range 23-89) and 18.1 (range 0-80) ( P < .05).

CONCLUSION

This novel interpositional arthroplasty technique using a "rollmop" of periosteum and fat for severe Freiberg's disease produced significant improvements in pain, functional outcome, and patient satisfaction without donor site morbidity. Furthermore, it allowed patients to return to desired footwear and sporting activities. The functional outcome and joint range of motion was superior after a K-wire was no longer placed across the joint, and we believe it is essential to avoid this to permit early range-of-motion exercises.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Acceleration of electrons in the plasma wakefield of a proton bunch

High-energy particle accelerators have been crucial in providing a deeper understanding of fundamental particles and the forces that govern their interactions. To increase the energy of the particles or to reduce the size of the accelerator, new acceleration schemes need to be developed. Plasma wakefield acceleration^1–5, in which the electrons in a plasma are excited, leading to strong electric fields (so called ‘wakefields’), is one such promising acceleration technique. Experiments have shown that an intense laser pulse^6–9 or electron bunch^10,11 traversing a plasma can drive electric fields of tens of gigavolts per metre and above—well beyond those achieved in conventional radio-frequency accelerators (about 0.1 gigavolt per metre). However, the low stored energy of laser pulses and electron bunches means that multiple acceleration stages are needed to reach very high particle energies^5,12. The use of proton bunches is compelling because they have the potential to drive wakefields and to accelerate electrons to high energy in a single acceleration stage¹³. Long, thin proton bunches can be used because they undergo a process called self-modulation^14–16, a particle–plasma interaction that splits the bunch longitudinally into a series of high-density microbunches, which then act resonantly to create large wakefields. The Advanced Wakefield (AWAKE) experiment at CERN^17–19 uses high-intensity proton bunches—in which each proton has an energy of 400 gigaelectronvolts, resulting in a total bunch energy of 19 kilojoules—to drive a wakefield in a ten-metre-long plasma. Electron bunches are then injected into this wakefield. Here we present measurements of electrons accelerated up to two gigaelectronvolts at the AWAKE experiment, in a demonstration of proton-driven plasma wakefield acceleration. Measurements were conducted under various plasma conditions and the acceleration was found to be consistent and reliable. The potential for this scheme to produce very high-energy electron bunches in a single accelerating stage²⁰ means that our results are an important step towards the development of future high-energy particle accelerators^21,22.

Electron acceleration to very high energies is achieved in a single step by injecting electrons into a ‘wake’ of charge created in a 10-metre-long plasma by speeding long proton bunches.

Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis

BACKGROUND

Our aim was to determine the evidence for thromboprophylaxis for prevention of symptomatic venous thromboembolism (VTE) in adults with foot or ankle trauma treated with below knee cast or splint. Our secondary aim was to report major bleeding events.

METHODS

MEDLINE and EMBASE databases were searched for randomized controlled trials from inception to 1st June 2015.

RESULTS

Seven studies were included. All focused on low molecular weight heparin (LMWH). None found a statistically significant symptomatic DVT reduction individually. At meta-analysis LMWH was protective against symptomatic DVT (OR 0.29, 95% CI 0.09-0.95). Symptomatic pulmonary embolism affected 3/692 (0.43%). None were fatal. 86 patients required LMWH thromboprophylaxis to prevent one symptomatic DVT event. The overall incidence of major bleeding was 1 in 886 (0.11%).

CONCLUSIONS

Low molecular weight heparin reduces the incidence of symptomatic VTE in adult patients with foot or ankle trauma treated with below knee cast or splint.

Treating osteomyelitis of major limb amputations with a modified Lautenbach technique

INTRODUCTION

Major lower limb amputation significantly increases the energy cost of walking for patients. Complications such as osteomyelitis may require further surgery, and can lead to shortening of the stump. In these cases, the aim should be to treat infection without shortening the limb further. We present a series of patients with established osteomyelitis of the amputation stump, managed using a modified Lautenbach technique.

METHOD

Six patients with either above or below knee amputations, in the practice of a single orthopaedic surgeon, were studied. Ages range from 39 to 64 years, and reasons for amputation included infection, pain, and necrosis. All patients had osteomyelitis in the amputation stump confirmed on MRI.

RESULTS

At a mean follow-up of 3.75 years (range 7 months to 6 years) all six patients had no clinical or haematological evidence of infection, and had returned to independent living. Stump length was preserved in all cases, including in one patient who underwent two procedures to ensure complete debridement.

CONCLUSIONS

We believe that this case series is the largest so far published regarding this modification of the Lautenbach Procedure. This operation treats infection effectively without further loss of bone length, and no patients so far have developed significant complications.

Marjolin's squamous cell carcinoma of the hallux following recurrent ingrown toenail infections

Marjolin's squamous cell carcinoma (SCC) affecting the toe is rare. Due to resemblance with benign conditions it can often result in misdiagnosis. We report a case of Marjolin's SCC affecting the proximal hallux in a patient with recurrent ingrown toenail infections. A 58-year-old woman with a background of wedge resections for ingrown toenail and distal phalanx amputation for osteomyelitis presented with pain and hyperkeratotic raised ulcer around the proximal phalanx. MRI scan revealed soft tissue mass infiltrating the proximal phalanx with biopsies confirming a SCC. The patient underwent first ray amputation and made a good clinical recovery and remains disease free. Due to clinical similarities with benign conditions, awareness of Marjolin's SCC as a potential diagnosis when treating patients with recurrent ingrown toenail is imperative. We recommend patients with recurrent ingrown toenail or ulceration with a background of chronic infection have biopsies performed to exclude potential malignancy.

A critical evaluation of venous thromboembolism risk assessment models used in patients with lower limb cast immobilisation

BACKGROUND

There is a recognised link between lower limb cast immobilisation and the development of venous thromboembolism (VTE). Our aim was to assess the diagnostic accuracy of risk assessment models (RAMs) applicable to this patient group. This has not been done before.

METHODS

A literature and guideline review identified five RAMs. They were used to retrospectively risk assess a consecutive series of patients who were diagnosed with symptomatic VTE following lower limb injury treated with a cast (Group I). A case-matched cohort who did not suffer symptomatic VTE (Group II) was also retrospectively risk assessed. The RAMs' diagnostic performance indicators were calculated.

RESULTS

Groups I and II consisted of 21 patients each. There was no significant difference in the mean age or total number of VTE risk factors between Groups I and II (p=.957 and p=.878 respectively). The Plymouth (2010) RAM achieved the highest accuracy (54.8%).

CONCLUSIONS

Each RAM demonstrated significant limitations. Two displayed very limited clinical utility. Three recommended chemical thromboprophylaxis to all patients because they weighted lower limb immobilisation as an absolute risk factor for the development of VTE. Cast immobilisation should not be considered an absolute risk factor when risk assessing patients who all have casts. Prospective evaluation with a larger patient cohort is required.

Stress Fractures of the Foot

Stress fractures of the foot and ankle may be more common among athletes than previously reported. A low threshold for investigation is warranted and further imaging may be appropriate if initial radiographs remain inconclusive. Most of these fractures can be treated conservatively with a period of non-weight-bearing mobilization followed by gradual return to activity. Early surgery augmented by bone graft may allow athletes to return to sports earlier. Risk of delayed union, nonunion, and recurrent fracture is high. Many of the patients may also have risk factors for injury that should be modified for a successful outcome.

Vitamin D insufficiency and deficiency in patients with fractures of the fifth metatarsal

INTRODUCTION

The fifth metatarsal is a common site for both acute and stress fractures in the foot. They are usually isolated low-energy or stress fractures. Vitamin D deficiency has been associated with fragility fractures in many parts of the body. We believe that low Vitamin D could be a significant aetiological factor in fractures of the fifth metatarsal.

METHODOLOGY

A prospective study of patients with fractures of the fifth metatarsal was conducted. Patients presenting to fracture clinic with these fractures had their vitamin D and calcium levels measured. We also conducted a literature review of studies of vitamin D levels in the Northern Hemisphere between 1990 and 2014.

RESULTS

Forty patients with fifth metatarsal fractures were studied (22 metatarsal base fractures, 6 shaft fractures, and 2 stress fractures). The average patient age was 49 (range 22-83). 12 patients (30%) had a Vitamin D level consistent with deficiency, and a further 14 (35%) had a level consistent with insufficiency. Average Vitamin D levels in winter fractures were significantly lower (52.23nmol/L) than for those sustained in summer (76.73nmol/L).

CONCLUSIONS

Hypovitaminosis D was common in patients with fifth metatarsal fractures. Vitamin D supplementation has been shown in animal studies to improve fracture healing rates, and in humans to decrease the risk of fragility fracture. It should be part of regular practice to check Vitamin D levels in these patients, and supplement where necessary.

Risk factors of hepatocellular carcinoma recurrence after liver transplantation: accuracy of the alpha-fetoprotein model in a single-center experience

BACKGROUND

Recurrence of hepatocellular carcinoma (HCC) and cirrhosis after a liver transplantation (LT) is a major concern, and a strict Milan criteria selection of candidates does not accurately discriminate the relapse rate after LT.

PURPOSE

This study sought to analyze the risk factors affecting tumor recurrence after LT for related cirrhosis HCC and the application of the French prognostic model (preLT alpha-fetoprotein [AFP], size, number) in a single center.

METHODS

In a retrospective observational study of LT for HCC and cirrhosis, clinicopathological features were analyzed. Also, the preoperative and postoperative AFP model score was calculated with a cutoff of 2.

RESULTS

Of 480, 109 patients underwent cadaveric LT for HCC. Eight of them had a relapse (7%). High AFP level, AFP model score >2, high pathological tumor-node-metastasis (pTNM) stage, poor differentiation, macrovascular-microvascular invasion, infiltration, and R1 margin were statistically significant (P < .05) for recurrence. Also, in the preoperative model, AFP score >2 was a predictor of worse survival (1-, 3-, 5-, 10-year survival of 81%, 51%, 30%, 30% vs 90%, 76%, 73%, 69% in ≤2, with P = .005). Regarding the postoperative model, similar results were found (1-, 3-, 5-, 10-year survival of 84%, 47%, 37%, 37% vs 90%, 78%, 73%, 52%, P = .028) between AFP model score >2 and ≤2, respectively. However, Milan and up-to-7 criteria were not accurate in recurrence nor in survival.

CONCLUSIONS

The French AFP model has proven to be a more discerning prognostic tool than other established criteria in the prediction of recurrence and survival. Also, in postoperative prognosis, pathological risk factors for relapse such as pTNM, differentiation grade, macrovascular-microvascular invasion, infiltration, and R1 margin have been predictors of recurrence.

Open, Arthroscopic, and Percutaneous Cheilectomy for Hallux Rigidus

Cheilectomy consists of excision of the dorsal exostosis and part of the metatarsal head. It is typically performed for patients in the earlier stages of hallux rigidus presenting with dorsal pain and dorsiflexion stiffness in the absence of through-range symptoms, rest pain, and plantar pain and with negative result on grind test. If joint motion-preserving surgery is appropriate, then cheilectomy is generally considered to be the first-line surgical choice. In addition to the standard open technique, minimally invasive surgery in the form of either percutaneous or arthroscopic surgery is available. The indications, surgical techniques, and outcomes are discussed.

Optimizing CIGB-300 intralesional delivery in locally advanced cervical cancer

BACKGROUND

We conducted a phase 1 trial in patients with locally advanced cervical cancer by injecting 0.5 ml of the CK2-antagonist CIGB-300 in two different sites on tumours to assess tumour uptake, safety, pharmacodynamic activity and identify the recommended dose.

METHODS

Fourteen patients were treated with intralesional injections containing 35 or 70 mg of CIGB-300 in three alternate cycles of three consecutive days each before standard chemoradiotherapy. Tumour uptake was determined using (99)Tc-radiolabelled peptide. In situ B23/nucleophosmin was determined by immunohistochemistry.

RESULTS

Maximum tumour uptake for CIGB-300 70-mg dose was significantly higher than the one observed for 35 mg: 16.1 ± 8.9 vs 31.3 ± 12.9 mg (P = 0.01). Both, AUC24h and biological half-life were also significantly higher using 70 mg of CIGB-300 (P < 0.001). Unincorporated CIGB-300 diffused rapidly to blood and was mainly distributed towards kidneys, and marginally in liver, lungs, heart and spleen. There was no DLT and moderate allergic-like reactions were the most common systemic side effect with strong correlation between unincorporated CIGB-300 and histamine levels in blood. CIGB-300, 70 mg, downregulated B23/nucleophosmin (P = 0.03) in tumour specimens.

CONCLUSION

Intralesional injections of 70 mg CIGB-300 in two sites (0.5 ml per injection) and this treatment plan are recommended to be evaluated in phase 2 studies.

DNA methylation and differential gene regulation in photoreceptor cell death

Retinitis pigmentosa (RP) defines a group of inherited degenerative retinal diseases causing progressive loss of photoreceptors. To this day, RP is still untreatable and rational treatment development will require a thorough understanding of the underlying cell death mechanisms. Methylation of the DNA base cytosine by DNA methyltransferases (DNMTs) is an important epigenetic factor regulating gene expression, cell differentiation, cell death, and survival. Previous studies suggested an involvement of epigenetic mechanisms in RP, and in this study, increased cytosine methylation was detected in dying photoreceptors in the rd1, rd2, P23H, and S334ter rodent models for RP. Ultrastructural analysis of photoreceptor nuclear morphology in the rd1 mouse model for RP revealed a severely altered chromatin structure during retinal degeneration that coincided with an increased expression of the DNMT isozyme DNMT3a. To identify disease-specific differentially methylated DNA regions (DMRs) on a genomic level, we immunoprecipitated methylated DNA fragments and subsequently analyzed them with a targeted microarray. Genome-wide comparison of DMRs between rd1 and wild-type retina revealed hypermethylation of genes involved in cell death and survival as well as cell morphology and nervous system development. When correlating DMRs with gene expression data, we found that hypermethylation occurred alongside transcriptional repression. Consistently, motif analysis showed that binding sites of several important transcription factors for retinal physiology were hypermethylated in the mutant model, which also correlated with transcriptional silencing of their respective target genes. Finally, inhibition of DNMTs in rd1 organotypic retinal explants using decitabine resulted in a substantial reduction of photoreceptor cell death, suggesting inhibition of DNA methylation as a potential novel treatment in RP.

Arthroscopic anatomic reconstruction of the lateral ligaments of the ankle with gracilis autograft

Lateral ankle sprains are common; if conservative treatment fails and chronic instability develops, stabilization surgery is indicated. Numerous surgical procedures have been described, but those that most closely reproduce normal ankle lateral ligament anatomy and kinematics have been shown to have the best outcomes. Arthroscopy is a common adjunct to open ligament surgery, but it is traditionally only used to improve the diagnosis and the management of any associated intra-articular lesions. The stabilization itself is performed open because standard anterior ankle arthroscopy provides only partial visualization of the anterior talofibular ligament from above and the calcaneofibular ligament attachments cannot be seen at all. However, lateral ankle endoscopy can provide a view of this area that is superior to open surgery. We have developed a technique of ankle endoscopy that enables anatomic positioning of the repair or fixation of the graft. In this article we describe a safe and reproducible arthroscopic anatomic reconstruction of the lateral ligaments of the ankle using a gracilis autograft. The aim of this procedure is to obtain a more physiological reconstruction while maintaining all the advantages of an arthroscopic approach.

The effect of lower limb cast immobilization on calf muscle pump function: a simple strategy of exercises can maintain flow

BACKGROUND

We have investigated the role of the calf muscle pump in casted patients. An audit of venous thromboembolism (VTE) in casted patients showed that the thrombosis occurred in the casted leg; this has not been previously assessed. We postulated that local factors play a major role, and we set out to assess the calf muscle pump in casted patients and to determine whether this can be optimized despite below-knee cast immobilization.

METHODS

We measured the flow in the popliteal vein using a validated method of Doppler ultrasound measurement of peak velocity with and without a below-knee plaster cast.

RESULTS

We demonstrated that a simple strategy of toe and ankle exercises can maintain venous return despite below-knee cast immobilization.

CONCLUSION

This is the first study to examine the effect of the calf muscle pump in the presence of a plaster cast. Major muscle groups such as the flexor hallucis longus and gastrocsoleus extend beyond the field of control of the cast and can still be recruited.

CLINICAL RELEVANCE

We recommend that all patients treated with a below-knee cast be given a program of exercises that can be comfortably performed with the cast; this could provide a useful, inexpensive, and safe thromboprophylaxis strategy acting at the site of greatest risk and targeting a major cause of VTE.

Clinical and radiographic evaluation of the cavus foot: surgical implications

The key to successful management of the cavovarus foot is identifying the pathoanatomy and dysfunction that are driving the deformity and producing the symptoms. There is no substitute for a thorough clinical evaluation of the foot, evaluating the static alignment and dynamic function. Plain films alone are not sufficient to determine the diagnosis, but they are necessary for procedure selection and correction planning. This is especially true for assessing the degree of hindfoot varus. Some issues are difficult to diagnose, and imaging plays an important role.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Permanent genetic resources added to molecular ecology resources database 1 December 2012-31 January 2013

This article documents the addition of 268 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Alburnoides bipunctatus, Chamaerops humilis, Chlidonias hybrida, Cyperus papyrus, Fusarium graminearum, Loxigilla barbadensis, Macrobrachium rosenbergii, Odontesthes bonariensis, Pelteobagrus vachelli, Posidonia oceanica, Potamotrygon motoro, Rhamdia quelen, Sarotherodon melanotheron heudelotii, Sibiraea angustata, Takifugu rubripes, Tarentola mauritanica, Trimmatostroma sp. and Wallago attu. These loci were cross-tested on the following species: Alburnoides fasciatus, Alburnoides kubanicus, Alburnoides maculatus, Alburnoides ohridanus, Alburnoides prespensis, Alburnoides rossicus, Alburnoides strymonicus, Alburnoides thessalicus, Alburnoides tzanevi, Carassius carassius, Fusarium asiaticum, Leucaspius delineatus, Loxigilla noctis dominica, Pelecus cultratus, Phoenix canariensis, Potamotrygon falkneri, Trachycarpus fortune and Vimba vimba.

Osteochondral lesions of the talus: defining the surgical approach

It has become clear that contrary to the previously held belief that osteochondral lesions of the talus occurred anterolaterally and posteromedially, there is a much wider spread across the talus. Lesions can now be mapped by their biology and geography, and from this the ideal procedure and the ideal surgical approach can be selected. Familiarization with a range of skills, such as posterior ankle arthroscopy and malleolar osteotomies, are required to be able to perform this surgical plan.

Hand dominance in orthopaedic surgeons

Handedness is perhaps the most studied human asymmetry. Laterality is the preference shown for one side and it has been studied in many aspects of medicine. Studies have shown that some orthopaedic procedures had poorer outcomes and identified laterality as a contributing factor. We developed a questionnaire to assess laterality in orthopaedic surgery and compared this to an established scoring system. Sixty-two orthopaedic surgeons surveyed with the validated Waterloo Handedness Questionnaire (WHQ) were compared with the self developed Orthopaedic Handedness Questionnaire (OHQ). Fifty-eight were found to be right hand dominant (RHD) and 4 left hand dominant (LHD). In RHD surgeons, the average WHQ score was 44.9% and OHQ 15%. For LHD surgeons the WHQ score was 30.2% and OHQ 9.4%. This represents a significant amount of time using the non dominant hand but does not necessarily determine satisfactory or successful dexterity transferable to the operating room. Training may be required for the non dominant side.

Radiological assessment of metatarsus adductus

Metatarsus adductus is the most common congenital foot abnormality. Whilst there is a growing body of evidence describing many aspects of this condition, basic questions regarding aetiology, management and treatment remain controversial. Diagnosis is achieved with clinical and radiological examination. The latter is particularly important for the diagnosis of mild cases. An extensive literature review is presented outlining the development of various radiological methods of angular measurement used in the diagnosis and classification of metatarsus adductus. In addition, the review highlights a spectrum of values obtained for each angle and the validity were reported.