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Aim The COVID-19 pandemic impacted the orthopaedic surgical ethos drastically. There was a lower threshold to manage fractures conservatively, in an attempt to curtail COVID-19 transmission rates amongst inpatients. This retrospective study evaluated our Orthopaedic department’s adherence to BOAST guidelines on ankle fractures, during COVID-19 and pre-COVID-19. Method Data on patient’s who presented with ankle fractures during the initial national lockdown in 2020 were compared against similar ankle fracture patterns one-year prior (pre-COVID) over a similar time frame. Patient clerking notes, operative notes, radiographical images and clinic letters were retrieved and compared against BOAST guidelines on ankle fractures. Management plans and time to surgery was extrapolated from these resources. Result Ankle fracture incidence rates increased by 79.8% during the COVID pandemic when compared with data from 2019. 28% of ankle fractures in 2020 were managed operatively when compared with 80% in 2019. Average time to surgery during the pandemic improved by 1.64. Adequate documentation for neurovascular status, as per BOAST guidelines, was 30.5% in 2019 and 27% in 2020. Pre- and post-reduction views were available in 87% of cases in 2019 and 83% in 2020. Conclusions As a third national lockdown is upon us, evaluation of BOAST guidelines on ankle fractures would be worth revising. Teaching and posters were distributed throughout the department as a strategy to improve adherence to BOAST guidelines on ankle fractures. Furthermore, regular follow up clinics at specific times and post-management follow up clinics would be worth analysing to identify changes in patient satisfaction and clinical outcome.

Introduction We present a rare case of lower leg atraumatic bilateral compartment syndrome (ABCS). To date there have only been three similar cases reported where no cause was identified. Case Study A 33-year-old male presented 12 hours following sudden onset lower leg pain. There was no history of trauma, drug, or alcohol use. On assessment he was in significant pain, not relieved by analgesia, and had clinically tense anterior compartments bilaterally. Both feet were held in fixed dorsiflexion. Creatinine kinase (CK) was 35,166 on admission. X-rays of both legs were normal. He was immediately taken to theatre for bilateral four compartment fasciotomies which revealed significant swelling in the anterior and lateral compartments with patchy pre-necrosis. Post-operatively he deteriorated, required intubation, and was admitted to ITU for acute haemofiltration to treat acute kidney injury secondary to rhabdomyolysis. Multiple operations were required for debridement, resulting in exposed tendons. Closure of the medial wounds was achieved primarily as an inpatient and he was discharged with bilateral lateral VAC dressings in situ. Lateral wounds were closed with Biodegradable Temporising Matrix followed by split skin grafting. In his second admission he suffered a pulmonary embolism. Literature Review and Discussion 20 case of ABCS have been reported, largely attributable to drugs, alcohol, or leg position. Most cases had an element of diagnostic delay. In addition to compartment pressure monitoring, testing CK can demonstrate muscle necrosis and supports the decision to proceed to surgery.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Dr Leung has received research support from Attune Medical (Chicago, IL). Dr Gallagher has received research funding from Attune Medical (Chicago, IL). Background Randomized evidence has shown that controlled oesophageal cooling is effective at reducing oesophageal thermal injury during radiofrequency (RF) ablation for atrial fibrillation (AF) compared to standard care. The effect of oesophageal cooling on ablation lesion formation in left atrial myocardium and patient outcomes at 12-months had not been previously studied. Purpose To determine the effect of oesophageal cooling on the formation of RF lesions, the ability to achieve procedural endpoints and long-term patient outcomes compared to standard care ablations. Methods Ablation results and patient outcomes from a double-blind randomized controlled trial were analysed (IMPACT trial NCT03819946). AF ablation was guided by Ablation Index technology (30W at 350-400 AI posteriorly, 40W at 450 AI anteriorly). A blinded 1:1 randomization assigned patients to the use of an oesophageal temperature control device to keep oesophageal temperature at 4 degrees during ablation or standard practice using a single-sensor temperature probe. Ablation parameters and 12-month outcomes were analysed. Results We recruited 188 patients. Procedure and fluoroscopy times were similar. First pass pulmonary vein isolation and reconnection at the end of the waiting period were similar in both randomized groups (51/64 vs 51/68; p = 0.54 and 5/64 vs 7/68; p = 0.76, respectively). Posterior wall isolation was also similar: 24/33 vs 27/38; p = 0.88. Ablation effect on myocardial tissue, measured in impedance drop, was also similar: 8.6Ω (IQR: 6-11.8) vs 8.76Ω (IQR: 6-12.2; p = 0.25) and median catheter tip temperature was the same at 25.5 degrees. Arrhythmia recurrence was similar at 12 months (20.3% vs 26.8%, from 142 completed assessments; p = 0.66). Conclusions Oesophageal cooling has been shown to be effective in reducing ablation-related oesophageal thermal injury during RF ablation. Ablation data show that this protection does not make it any more difficult to achieve standard procedural endpoints or clinical success at 12-months. Abstract Figure. Pyramid frequency plots of AI values

Volvulus of the cecum is a relatively insignificant cause of intestinal obstruction in the Western world, comprising

Background Auditory verbal hallucinations (AVH) are the most prevalent symptom in schizophrenia. They are associated with increased activation within the temporoparietal cortices and are refractory to pharmacological and psychological treatment in approximately 25% of patients. Low frequency repetitive transcranial magnetic stimulation (rTMS) over the temporoparietal cortex has been demonstrated to be effective in reducing AVH in some patients, although results have varied. The cortical mechanism by which rTMS exerts its effects remain unknown, although data from the motor system is suggestive of a local cortical inhibitory effect. We explored neuroimaging differences in healthy volunteers between application of a clinically utilized rTMS protocol and a sham rTMS equivalent when undertaking a prosodic auditory task. Method Single-blind placebo controlled fMRI study of 24 healthy volunteers undertaking an auditory temporoparietal activation task, who received either right temporoparietal rTMS or sham RTMS. Results The main effect of group was bilateral inferior parietal deactivation following real rTMS. An interaction of group and task type showed deactivation during real rTMS in the right superior temporal gyrus (STG), left thalamus, left postcentral gyrus and cerebellum. However, the left parietal lobe showed an increase in activation following right sided real rTMS, but this increase was specific to a non-linguistic, tone-sequence task. Conclusion rTMS does cause local inhibitory effects, not only in the underlying region of application, but also in functionally connected cortical regions. However, there is also a related, task dependent, increase in activation within selected cortical areas in the contralateral hemisphere; these are likely to reflect compensatory mechanisms, and such cortical activation may in some cases contribute to, or retard, some of the therapeutic effects seen with rTMS.

Atrial fibrillation (AF) is thought to be a progressive arrhythmia, starting with short paroxysmal episodes, until eventually, it becomes permanent. Evidence for this is limited to studies with short follow-up or with minimal cardiac rhythm monitoring. We utilised the continuous rhythm monitoring capabilities of implanted pacemakers to define better the natural history of AF. The study included 356 patients with pacemaker devices capable of continuous atrial rhythm monitoring (186 male, mean age (±SD) 79.5 ± 8.9 years). All clinical records, including history/physical examination reports, laboratory results, ECGs and Holter monitoring data were reviewed. Patients were included if AF episodes >30 s were documented. Permanent pacemaker diagnostic data were reviewed at least every 12 months. ACC/AHA/ESC guidelines were used to define AF episodes as paroxysmal, persistent or long-standing persistent/permanent. Study follow-up period (±SD) was 7.2 ± 3.1 years. Over the study period, 179 of 356 patients (50.3 %) had at least one episode of persistent AF. Of the 356 patients, 314 (88.2 %) had paroxysmal AF and 42 (11.8 %) had persistent AF at the time of diagnosis. The predominant AF subtype, at latest follow-up, was paroxysmal for 192 patients (53.9 %), persistent for 77 (21.6 %) and long-standing persistent/permanent for 87 (24.4 %). Univariable predictors of progression to persistent AF were (1) male gender, (2) increasing left atrial diameter (LAD), (3) reduced atrial pacing (AP) and (4) increasing ventricular pacing. Although many patients with AF will have persistent episodes, long-term continuous pacemaker follow-up demonstrates that the majority will have a paroxysmal, as opposed to persistent, form of the arrhythmia.

We report 45 procedures in 43 patients with stenting for treatment of extracranial vascular disease. Lesions treated are supra-aortic extracranial arteries and jugular vein stenoses. There was no significant difference in the result of two stents (Palmaz or Wallstent) in our series. The stenting is feasible and relatively safe for treating traumatic aneurysm, stenosis or salvaging complications of PTA. Endovascular stent placement for supraaortic artery stenosis is evolving from its controversial position to that of an acceptable alternate treatment. The number of patients receiving supraaortic stent is growing worldwide despite the limit in design and availability of stents. The most common and widely used stents are Palmaz and Wallstent.

Acute dural sinus and deep venous thrombosis may lead to venous hypertension, congestion, edema and then hemorrhage. We reviewed 41 patients with 5 different stages of imaging presentation and increment increasing dural sinus pressure.The early Stages I or II may not need thrombolysis, but Stage III and IV should start as early as possible. Stage II may require thrombolysis if it fails in the trial of anticoagulation. All Stage V patients' results with fatality with or without thrombolysis.

Case report A 28 year old gentleman presented after an episode of collapse with loss of consciousness. He gave a history of non-specific malaise and myalgia over the previous 7 days, with fever, a generalised rash and a non productive cough. He developed progressive shortness of breath with sharp, pleuritic chest pain that was unresponsive to antibiotics in the community.

Evidence indicates that user acceptance of modern artificial limbs by amputees would be significantly enhanced by a system that provides appropriate, graded, distally referred sensations of touch and joint movement, and that the functionality of limb prostheses would be improved by a more natural control mechanism. We have recently demonstrated that it is possible to implant electrodes within individual fascicles of peripheral nerve stumps in amputees, that stimulation through these electrodes can produce graded, discrete sensations of touch or movement referred to the amputee's phantom hand, and that recordings of motor neuron activity associated with attempted movements of the phantom limb through these electrodes can be used as graded control signals. We report here that this approach allows amputees to both judge and set grip force and joint position in an artificial arm, in the absence of visual input, thus providing a substrate for better integration of the artificial limb into the amputee's body image. We believe this to be the first demonstration of direct neural feedback from and direct neural control of an artificial arm in amputees

There is no ‘gold standard’ non-invasive test to diagnose myocarditis. It is a clinico-histopathological diagnosis.1 Clinical manifestations include: heart failure, chest pain (from either pericarditis or angina from coronary artery spasm/inf lammation), sudden cardiac death and arrhythmias (sinus tachycardia, ectopics, ventricular tachycardia, heart blocks). Examination may reveal raised JVP, pulmonary crackles, a gallop rhythm or a pericardial rub.

The election of the Labour government in May 1997 has seen the continuation of advanced market reforms intended to modernize the UK National Health Service (NHS). The planning and implementation of information systems and technology (IS/IT) following these structural changes is both widespread and significant. An information strategy for the NHS, published recently, is intended to provide an initial seven-year program of life-long electronic health records for everyone in the United Kingdom. This article explores the potential role of these systems in the specific provision of the new primary health care groups. It argues that, if primary care physicians adopt appropriate delivery channels and service packages and are proactive in the use of IS/IT, then the outcome will produce more patient choice, less nonattendance, and consequently improved primary health care provision.

Primary cardiac tumors are rare entities with a frequency between 0.0017% to 0.28%. We report a 53 year old male with a primary cardiac myofibroblastic sarcoma that presented with a hemorrhagic pericardial effusion. A review of the literature is presented with a brief discussion of the clinical presentation diagnosis and treatment of benign and malignant primary cardiac tumors.

Introduction The practice of atrial fibrillation (AF) ablation is increasing exponentially. At present, these procedures are performed in a small number of surgical tertiary centres. In order to meet the growing demand it will be necessary to expand this service. We sought to assess patient satisfaction, procedural success and complication rates for AF ablation performed via a newly established district general hospital (DGH) service. Methods We prospectively surveyed patients undergoing AF ablation, between November 2007 and November 2010, at Eastbourne DGH. Patient symptoms were assessed before and at least 12 months after AF ablation by telephone questionnaire, procedural satisfaction was also assessed. Procedural details (procedural time, fluoroscopy time, ablation technique) and complications were all accurately recorded for every case. Results In 278 patients 314 procedures (average 1.13 procedures/pt) were performed (160 for persistent AF [PersAF], 134 for paroxysmal AF [PAF]). Mean age 63.8±10.7 years, 70% male. Of the PAF cases 75 procedures were performed with the PVAC (Medtronic, USA) and 56 with the Mesh (Bard, USA) catheter. The remaining three PAF procedures were performed with LASSO, Artic front cyroablation balloon and the Amigo robot (Catheter Robotics, Inc.) and weren9t used in the analysis. Mean procedural time was 107.9±35.9 min, fluroscopy time was 32.1±11.3 min. Both measures were significantly shorter in the PVAC PAF group (p Conclusion Our 3 year experience shows that AF ablation can be safely performed in a DGH settings with high procedural success rates and low complication rates. There was no need for acute surgical intervention in any of our cases.

Case report A 28 year old gentleman presented after an episode of collapse with loss of consciousness. He gave a history of non-specific malaise and myalgia over the previous 7 days, with fever, a generalised rash and a non productive cough. He developed progressive shortness of breath with sharp, pleuritic chest pain that was unresponsive to antibiotics in the community.