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The proven beneficial effects of low-load blood flow restriction training on strength gain has led to further exploration into its application during rehabilitation, where the traditional use of heavy loads may not be feasible. With current evidence showing that low-load blood flow restriction training may be less well tolerated than heavy-load resistance training, this review was conducted to decipher whether intermittently deflating the pressure cuff during rest intervals of a training session improves tolerance to exercise, without compromising strength. Four databases were searched for randomized controlled trials that compared the effect of intermittent versus continuous blood flow restriction training on outcomes of exercise tolerance or strength in adults. Nine studies were identified, with six included in the meta-analysis. No significant difference in rate of perceived exertion was found (SMD-0.06, 95% CI-0.41 to 0.29, p=0.73, I 2=80%). Subgroup analysis excluding studies that introduced bias showed a shift towards favoring the use of intermittent blood flow restriction training (SMD-0.42, 95% CI-0.87 to 0.03, p=0.07, I 2=0%). There was no significant difference in strength gain. Intermittent cuff deflations during training intervals does not improve tolerance to exercise during blood flow restriction training.

Background: Supermicrosurgery has allowed the replantation/revascularization of the pulp, but how does this currently compare with more proximal digit replantation/revascularization? Methods: In a retrospective case study over a 5-year period at our institute, a total of 21 patients (n = 21) had either finger or pulp replantation-revascularization posttrauma. All pulp replants had a single-vessel anastomosis viz., “artery-to-artery” or “artery-to-vein” only, with venous outflow dependent on the skin-shave technique, while more proximal replants had both arterial and venous anastomoses. Age, sex, ischemic time, handedness, smoker status, and injury-replant interval were compared between the two groups, with all procedures performed by a single surgeon. The outcome parameters studied were length of hospital stay, timeline for wound healing, viability, and functional outcomes. Results: Our patients consisted of 18 men and three women, of which 14.3% were smokers and 85.7% were right-handed. There were 11 finger replantation/revascularizations (n = 11) versus 10 pulp replantation/revascularizations (n = 10). The average age of digit replantation/revascularization patients was 44.8 years compared with 26.4 years in pulp replantation/revascularization patients (Student t test, P = 0.04). Mean ischemia time in digital replants was 67 minutes versus 32.3 minutes in pulp replantation/revascularization (Student t test, P = 0.056). Digital replantation/revascularization was viable in 72% of cases versus a 90% viability in the pulp subcohort. Conclusions: In our patient cohort, pulp replantation/revascularizations produced better postoperative viability. Where supermicrosurgery expertise is available, pulp replantation/revascularization should be considered a worthwhile option when compared with digital replantation/revascularization.

Objective: There has been increasing interest in the physical health, mental wellbeing and burnout afflicting medical students over recent years. This paper describes the overall results from phase two of an international study including a further nine countries across the world. Methods: We sampled large groups of medical students in nine countries at the same time and with exactly the same method in order to aid direct comparison of demographics, burnout and mental wellbeing through validated instruments. Results: A total of 4,942 medical students from these countries participated in this study. Around 68% of respondents screened positive for mild psychiatric illness using the General Health Questionnaire-12. Around 81% and 78% of respondents were found to be disengaged or exhausted respectively using the Oldenburg Burnout Inventory. Around 10% were found to be CAGE positive and 14% reported cannabis use. The main source of stress reported by medical students was their academic studies, followed by relationships, financial difficulties and housing issues. Conclusion: Cultural, religious and socioeconomic factors within each country are important and understanding their effects is fundamental in developing successful local, regional and national initiatives. Further quantitative and qualitative research is required to confirm our results, clarify their causes and to develop appropriate preventative strategies.

High levels of stress, burnout, and symptoms of poor mental health have been well known among practicing doctors for a number of years. Indeed, many health systems have formal and informal mechanisms to offer support and treatment where needed, though this varies tremendously across cultures. There is increasing evidence that current medical students, our doctors of the future, also report very high levels of distress, burnout, and substance misuse. We sampled large groups of medical students in 12 countries at the same time and with exactly the same method in order to aid direct comparison. 3766 students responded to our survey across five continents in what we believe is a global first. Our results show that students in all 12 countries report very high levels of 'caseness' on validated measures of psychiatric symptoms and burnout. Rates of substance misuse, often a cause of or coping mechanism for this distress, and identified sources of stress also varied across cultures. Variations are strongly influenced by cultural factors. Further quantitative and qualitative research is required to confirm our results and further delineate the causes for high rates of psychiatric symptoms and burnout. Studies should also focus on the implementation of strategies to safeguard and identify those most at risk.

Background Upper limb arthroplasty is an increasingly used treatment modality for end-stage joint disease of the shoulder, elbow and wrist. Whilst complications have been reported, the risk of venous thromboembolism has received less attention when compared to the lower limb. Guidance to aid clinical decision-making remains limited. This review aims to ascertain whether venous thromboembolism prophylaxis is beneficial after upper limb major joint replacement surgery. Methods A systematic review was performed in April 2019, utilising EMBASE, MEDLINE, Cochrane and Google Scholar. All clinical studies reporting venous thromboembolism incidence and risk reduction (after prophylaxis) in upper limb joint replacement were included. Results Twenty-four observational studies were identified. The reported incidence of venous thromboembolism ranged from 0.2% to 16% (weighted mean 0.68%) and 0.2% to 0.8% (weighted mean 0.49%) in shoulder and elbow arthroplasty, respectively. No records for wrist arthroplasty were found. In the literature, baseline venous thromboembolism risk of patients without an operation is reported as 0.5%. Discussion There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery. We recommend further research, ideally formal randomised controlled trials to guide recommendations. Although venous thromboembolism is rare in upper limb surgery, surgeons should remain vigilant to this possibility.

BACKGROUND National Institute for Health and Care Excellence (NICE) CG74 has set out evidence-based guidance on which types of surgery require antibiotic prophylaxis. Our aim was to establish what the current practice for antibiotic prophylaxis in Dupuytren's surgery is amongst hand surgeons in the United Kingdom, through the British Society for Surgery of the Hand (BSSH). METHODS Permission was granted for our online survey to be distributed to BSSH hand surgeons via consecutive BSSH e-bulletins. Hand surgeons who did not perform fasciectomy or dermofasciectomy were excluded from the study. RESULTS There were 64 respondents, represented an estimated 7.4-7.8% of membership. Eleven percent of respondents used antibiotics for fasciectomy, with an increasing trend towards revision surgery and dermofasciectomy. Over 30% prescribed them for revision dermofasciectomy. Dupuytren's surgery was classified as clean, non-prosthetic and uncomplicated which NICE CG74 suggestions did not require antibiotic prophylaxis. CONCLUSION This study highlighted variation in practice amongst hand surgeons in the United Kingdom. Further consultation to create guidelines for hand surgery may help guide members and reduce potentially unnecessary prophylactic antibiotic use.

Background:The psychological wellbeing and stresses on medical students are currently under a global spotlight. Under a wider initiative supported by the British Medical Association (BMA), international surveys have been conducted to understand and begin to tackle these issues.Method:This study aimed at describing the mental wellbeing and levels of burnout of Iranian medical students. A total of 179 medical students from 19 different cities participated voluntarily in the survey by answering an online questionnaire between April and August 2020. We detected a trend toward higher prevalence of psychiatric disorders (namely depressive disorders) and substance misuse when compared to previous national studies.Results:About 6% of students screened positive for alcohol problems with the CAGE questionnaire. About 77% of medical students screened positive for mental health problems with the GHQ12 questionnaire. Very high rates of burnout were also reported. These findings emphasize the urgent need to define methods to screen at risk medical students and implement local and national initiatives to curtain their potential detrimental effects.

The prevalence of osteoarthritis (OA) of the first carpometacarpal (CMC) joint and subsequent thumb disability is rising. Abductor pollicis longus tendon interposition arthroplasty (APLTIA) has gained popularity as a procedure to alleviate pain and restore thumb function.A systematic review was performed to assess the current reported outcomes of APLTIA. Inclusion criteria involved clinical studies with case-series as the minimal accepted level of evidence. Our primary outcome focussed on PROMs data, whilst secondary outcomes focussed on objective measures of function and complications. Papers investigating pathologies other than CMC OA or procedures other than APLTIA were excluded.Twelve studies were included (485 thumbs), all of which were observational in study design. APLTIA appears to be associated with a reduction in pain and functional improvement. APLTIA was not found to complicate further surgery.APLTIA may be associated with improvement in short-term pain relief and functional status. Further research is required to evaluate the benefits, duration of relief and long-term outcomes of APLTIA.

Medical students are tomorrow's healthcare professionals (HCPs), and their role in the design and delivery of healthcare in the future is crucial. Following an invitation to participate in a global call on mental health and wellbeing among medical students, it was decided to include Moroccan medical students based in the Faculty of Medicine and Pharmacy of Rabat between March 2019 and May 2019. Six hundred and thirty-seven medical students from the Faculty of Medicine and Pharmacy of Rabat responded to the BMA (British Medical Association) online survey, with females representing 66% of students. Medical studies were considered the main source of stress by 90% of respondents. The CAGE test screened 5% of students to be at risk of alcohol related health problems. Thirteen per cent of respondents reported substance misuse, 20% consumed alcohol, and 13% reported Illicit drug use. Almost half of Moroccan medical students had minor psychiatric disorder according to GHQ-12. Very high rates of burnout were found among undergraduate medical students, at 93%, and 68% reported, respectively, exhaustion and disengagement. This study showed very high levels of burnout among Moroccan undergraduate medical students. These results draw attention to the poor mental wellbeing of medical students. It is important that careful steps are put in place to support medical students who need this help.

In studies around the world, medical students have been identified as being at high risk for poor mental wellbeing, burnout and mental ill health. This can lead on to poorer physical health, substance misuse and reduced academic performance. We surveyed Portuguese medical students to assess burnout (using the Oldenburg Burnout Inventory, OLBI), minor psychiatric illness (General Health Questionnaire 12, GHQ12) and alcohol misuse (CAGE questionnaire). A total of 622 medical students participated in the study. We found high levels of exhaustion (89%), disengagement (81%) and minor psychiatric illness (91%). The CAGE questionnaire was positive in 10% of students. Future research is required to confirm these results, assess and monitor local and global trends and investigate interventions at both local and national level to improve the mental wellbeing of medical students.

Medical students' wellbeing and mental health are of extreme importance. Studies from around the world have shown that the rates of burnout appear to be high. It is also well recognized that individuals with mental illnesses frequently avoid seeking help for fear of stigma, affecting their careers and being rejected or treated differently by their peers, or due to the perception that they will be deemed unfit for practice or rejected from their preferred specialty. Students who are open about their mental health conditions are often ostracized by their own peers and dismissed or even mistreated by teachers who consider mental 'toughness' to be a requirement for success in the medical arena. The impact of socioeconomic conditions cannot be under-estimated. We carried out a survey of mental health and wellbeing of medical students in the National University of Asuncion. A sample of 180 students across different years showed that 21% had sought help and 4% had been diagnosed with a mental condition before entering medical school; 3% had been previously diagnosed with Attention Deficit Hyperactivity Disorder or Autism Spectrum Disorders; 14% currently consult with a health professional specifically about their mental health; and 8% reported currently taking medication for their mental health. The most common medication was Escitalopram at 21%, followed by Sertraline with 11%. Various sources of stress were identified, all of which were noted to be concerning four specific domains: financial difficulties, familial issues, housing issues, and difficulties surrounding studies. Of these students, 20% were CAGE positive and 9.4% reported using substances to feel better. These findings indicate that medical students need better support to ensure that they function better. They require in-depth exploration of the potential causes of their illnesses.

Across the globe medical students are experiencing high levels of depression, anxiety, and psychological distress. This can ultimately lead to poor academic performance, substance misuse and/or concerns over clinical practice and fitness to practice. We surveyed Jordanian medical students to assess burnout (using the Oldenburg Burnout Inventory, OLBI), minor psychiatric illness (General Health Questionnaire 12, GHQ12) and alcohol/substance abuse (CAGE questionnaire). Results indicate a high level of exhaustion (91%), disengagement (87%) and 'minor' psychiatric illness (92%). OLBI and GHQ12 scores were found to correlate positively (

Background: The incidence of melanoma and nonmelanoma skin cancers is increasing in the United Kingdom. Surgical excision carries the highest cure rates for all skin cancers and is the first-line treatment for melanomas and high-risk nonmelanoma cancers. This is most commonly performed by general practitioners (GPs), dermatologists, and plastic surgeons. Objective: The aim of this study was to identify which health-care professionals achieve the best outcomes following surgical excision of skin cancer lesions. Materials and Methods: A comprehensive search of the Cochrane Library and PubMed databases was conducted. PRISMA guidelines were adhered to throughout. Results: Six studies were identified and reviewed. Dermatologists were most likely to excise lesions adequately, and GPs were the least likely. Dermatologists displayed the greatest diagnostic accuracy, and excisions led by them had the highest overall and disease-free survival rates. Plastic surgeons were most likely to excise complex lesions on difficult-to-treat areas. Conclusion: Dermatologists can excise many skin lesions adequately, but plastic surgeons should continue to take an active role in complex or anatomically challenging lesions. There is a need for more validated training for GPs in the management of skin cancers. Further studies incorporating a randomized control protocol are needed to definitely assess who is best placed to surgically excise these lesions.

ObjectivesTo estimate COVID-19 infections and deaths in healthcare workers (HCWs) from a global perspective during the early phases of the pandemic.DesignSystematic review.MethodsTwo parallel searches of academic bibliographic databases and grey literature were undertaken until 8 May 2020. Governments were also contacted for further information where possible. There were no restrictions on language, information sources used, publication status and types of sources of evidence. The AACODS checklist or the National Institutes of Health study quality assessment tools were used to appraise each source of evidence.Outcome measuresPublication characteristics, country-specific data points, COVID-19-specific data, demographics of affected HCWs and public health measures employed.ResultsA total of 152 888 infections and 1413 deaths were reported. Infections were mainly in women (71.6%, n=14 058) and nurses (38.6%, n=10 706), but deaths were mainly in men (70.8%, n=550) and doctors (51.4%, n=525). Limited data suggested that general practitioners and mental health nurses were the highest risk specialities for deaths. There were 37.2 deaths reported per 100 infections for HCWs aged over 70 years. Europe had the highest absolute numbers of reported infections (119 628) and deaths (712), but the Eastern Mediterranean region had the highest number of reported deaths per 100 infections (5.7).ConclusionsCOVID-19 infections and deaths among HCWs follow that of the general population around the world. The reasons for gender and specialty differences require further exploration, as do the low rates reported in Africa and India. Although physicians working in certain specialities may be considered high risk due to exposure to oronasal secretions, the risk to other specialities must not be underestimated. Elderly HCWs may require assigning to less risky settings such as telemedicine or administrative positions. Our pragmatic approach provides general trends, and highlights the need for universal guidelines for testing and reporting of infections in HCWs.

Summary Background The prevalence of chronic wrist pain and subsequent functional decline is increasing. Diagnosis is challenging, with non-surgical treatment frequently failing. Recently, partial wrist denervation (PWD) has gained popularity as a procedure to alleviate chronic pain. Methods A systematic review was performed in April 2019. Inclusion criteria involved clinical studies with a minimum of ten wrists, focusing on PROMs, objective measures of function and complications. Papers investigating complete or mixed denervation procedures were excluded. Results Nine studies were included (292 wrists), all of which were observational in study design and limited in patient numbers, evaluation techniques and follow-up length. PWD appears to be associated with a reduction in pain, and functional improvement. Further surgery was required in 54 (24%) wrists at an average follow-up of 18 months. PWD was not found to complicate further surgery. Conclusion PWD is associated with improvement in short-term pain relief and functional status, yet carries a high re-operation rate without contraindicating further salvage surgery. Further research is required to evaluate the benefits, duration of relief and long-term complications of PWD.

ObjectivesTo estimate COVID-19 infections and deaths in healthcare workers (HCWs) from a global perspective.DesignScoping review.MethodsTwo parallel searches of academic bibliographic databases and grey literature were undertaken. Governments were also contacted for further information where possible. Due to the time-sensitive nature of the review and the need to report the most up-to-date information for an ever-evolving situation, there were no restrictions on language, information sources utilised, publication status, and types of sources of evidence. The AACODS checklist was used to appraise each source of evidence.Outcome measuresPublication characteristics, country-specific data points, COVID-19 specific data, demographics of affected HCWs, and public health measures employedResultsA total of 152,888 infections and 1413 deaths were reported. Infections were mainly in women (71.6%) and nurses (38.6%), but deaths were mainly in men (70.8%) and doctors (51.4%). Limited data suggested that general practitioners and mental health nurses were the highest risk specialities for deaths. There were 37.17 deaths reported per 100 infections for healthcare workers aged over 70. Europe had the highest absolute numbers of reported infections (119628) and deaths (712), but the Eastern Mediterranean region had the highest number of reported deaths per 100 infections (5.7).ConclusionsHCW COVID-19 infections and deaths follow that of the general world population. The reasons for gender and speciality differences require further exploration, as do the low rates reported from Africa and India. Although physicians working in certain specialities may be considered high-risk due to exposure to oronasal secretions, the risk to other specialities must not be underestimated. Elderly HCWs may require assigning to less risky settings such as telemedicine, or administrative positions. Our pragmatic approach provides general trends, and highlights the need for universal guidelines for testing and reporting of infections in HCWs.Summary BoxWhat is already known on this topicIn China, studies documented over 3,300 confirmed cases of infected healthcare workers in early March. In the United States, as high as 19% of patients had been identified as healthcare workers. There are no studies that perform a global examination of COVID-19 infections and deaths in the health workforce.What this study addsTo our knowledge, this is the first study assessing the number of healthcare workers who have been infected with or died from COVID-19 globally. The data from our study suggest that although infections were mainly in women and nurses, COVID-19 related deaths were mainly in men and doctors; in addition, our study found that Europe had the highest numbers of infection and death, but the lowest case-fatality-rate, while the Eastern Mediterranean had the highest case-fatality-rate.

Foundation forums have been adopted over the last few years to provide representation for newly qualified doctors, but they do not develop essential leadership, management and quality improvement skills for those recruited – key attributes that have been formally identified by General Medical Council (2012) guidance. A foundation forum was set up across three Oxford deanery hospitals. Forum members were assigned classical forum roles, but were also tasked to complete quality improvement projects, organize a national quality improvement conference, and undergo formal leadership and management training. Members were surveyed before and after completion of training, revealing statistically significant increases in confidence in leadership, management and quality improvement skills. All members revealed an eagerness to continue formal leadership and management training. The foundation forum proved a successful initiative to improve overall trainee experience and involvement, while providing a platform for leadership and management training to satisfy key domains within the Medical Leadership Competency Framework.

The wellbeing of doctors in training is currently under the spotlight. The British Medical Association (BMA) has committed to understanding issues of wellbeing amongst medical students. Medical students from England were asked to complete an online survey pertaining to wellbeing. 84 students responded. Results show 29% of respondents were given a mental health diagnosis whilst at medical school, and 82% could be classified as 'disengaged' and 85% 'exhausted' using the Oldenburg Burnout Scale. This demonstrates the need for further surveys with an increased number of respondents in order to gather more evidence surrounding these high rates of mental health issues. Support and preventative measures for medical students are required.

Background: Injuries remain an important public health concern, resulting in considerable annual morbidity and mortality. In low- and middle-income countries (LMICs), the lack of appropriate infrastructure, equipment and skilled personnel compound the burden of injury, leading to higher mortality rates. As Advanced Trauma Life Support (ATLS) courses remain uneconomical and inappropriate in LMICs, the Primary Trauma Care (PTC) course was introduced to provide an alternative that is both sustainable and appropriate to local resources. Methods: A systematic review was performed in May 2019, utilising MEDLINE, EMBASE, Cochrane Library and Google Scholar. All studies reporting patient related outcomes (mortality and morbidity rates) and course participant related outcomes (knowledge, confidence and skills) in LMICs were included. PRISMA guidelines were adhered to throughout. Results: Nine observational studies were identified (Level 3 evidence). Six studies reported improved knowledge in injury management post-PTC course ( p < 0.05). Two studies reported improvements in confidence ( p < 0.05) and one on skill attainment ( p < 0.0001). One study reported a reduction in mortality rates post-PTC course ( p < 0.01). Conclusion: Departmental, institutional and personal improvements may occur in clinical practice as a result of formal PTC training of trauma team members in LMICs. Further high-quality research is needed to evaluate this course's effects on observed change in clinical practice and patient outcomes. This may require long-term observational and epidemiological studies to assess improvements in morbidity and mortality. PROSPERO Registration Number: CRD42019133986

Foundation forums have been adopted over the last few years to provide representation for newly qualified doctors. These forums, however, do not develop essential leadership, management and quality improvement skills for those recruited, key attributes that have been formally identified by recent GMC guidance. A foundation forum was set up across three Oxford deanery hospitals. Forum members were assigned classical forum roles, but were also tasked to complete quality improvement projects, organise a national quality improvement conference and undergo formal leadership and management training. Members were surveyed before and after training completion, revealing statistically significant confidence increases in leadership, management and quality improvement skills. All members revealed an eagerness to continue formal leadership and management training. The foundation forum proved a successful initiative to improve overall trainee experience and involvement, whilst providing a platform for leadership and management training to satisfy key domains within the Medical Leadership Competency Framework.

Medical students' wellbeing and mental health requires nurturing in order for them to build success in their careers, help people while doing so, and to be happy. To better characterise the current state of wellbeing in medical schools in Wales, medical students from Cardiff and Swansea Universities were asked to complete an online survey as part of a larger international survey regarding their mental health and wellbeing. 266 students responded out of approximately 2150, a rate of 12%. 44 students received a mental health diagnosis whilst at medical school (predominantly depression or anxiety), 65 scored threshold for concerning alcohol consumption using the CAGE questionnaire, and 224 and 230 students reached threshold for the disengagement and exhaustion components of the Oldenburg Burnout Scale, respectively.

In line with studies from around the world, several studies have shown equal or higher rates of anxiety, depression, alcohol and other drug use, and burnout in medical students in Brazil. The aim of the present study was to identify difficulties Brazilian medical students face regarding stressors, psychological distress, and psychiatric morbidity using standardized reliable and valid instruments. In addition, this study also investigated differences associated with sex. Students (

Congenital clubfoot is a complex pediatric foot deformity, occurring in approximately 1 in 1000 live births and resulting in significant disability, deformity, and pain if left untreated. The Ponseti method of manipulation is widely recognized as the gold standard treatment for congenital clubfoot; however, its mechanical aspects have not yet been fully explored. During the multiple manipulation-casting cycles, the tendons and ligaments on the medial and posterior aspect of the foot and ankle, which are identified as the rate-limiting tissues, usually undergo weekly sequential stretches, with a plaster of Paris cast applied after the stretch to maintain the length gained. This triggers extracellular matrix remodeling and tissue growth, but due to the viscoelastic properties of tendons and ligaments, the initial strain size, rate, and loading history will affect the relaxation behavior and mechanical strength of the tissue. To increase the efficiency of the Ponseti treatment, we discuss the theoretical possibilities of decreasing the size of the strain step and interval of casting and/or increasing the overall number of casts. This modification may provide more tensile stimuli, allow more time for remodeling, and preserve the mechanical integrity of the soft tissues.

Medical students are tomorrow's healthcare professionals (HCPs), and their role in the design and delivery of healthcare in the future is crucial. Following an invitation to participate in a global call on mental health and wellbeing among medical students, it was decided to include Moroccan medical students based in the Faculty of Medicine and Pharmacy of Rabat between March 2019 and May 2019. Six hundred and thirty-seven medical students from the Faculty of Medicine and Pharmacy of Rabat responded to the BMA (British Medical Association) online survey, with females representing 66% of students. Medical studies were considered the main source of stress by 90% of respondents. The CAGE test screened 5% of students to be at risk of alcohol related health problems. Thirteen per cent of respondents reported substance misuse, 20% consumed alcohol, and 13% reported Illicit drug use. Almost half of Moroccan medical students had minor psychiatric disorder according to GHQ-12. Very high rates of burnout were found among undergraduate medical students, at 93%, and 68% reported, respectively, exhaustion and disengagement. This study showed very high levels of burnout among Moroccan undergraduate medical students. These results draw attention to the poor mental wellbeing of medical students. It is important that careful steps are put in place to support medical students who need this help.

Much attention has been focused on the well-being of health-care staff and more recently medical students. This small-scale study formed a part of a major international initiative and used standardized measures of health, substance misuse, and burnout. We found high levels of stress from several key sources alongside the rates of 80% and 83% for the disengagement and exhaustion subscales of the Oldenburg burnout scale. The rates of mental health problems as measured by the General Health Questionnaire-12 short version were 68%.

A 4 year old boy presented with pain in his right elbow after a fall from a bicycle onto his outstretched hand. His father had noticed him lying on his arm after the fall. The patient was guarding his right elbow in a flexed and adducted position. On examination, this was a closed injury with no obvious clinical deformity, swelling, or skin changes to the elbow; distally, the radial pulse was present and the median (including anterior interosseus), radial, and ulnar nerves were intact. No other injuries were identified. Observations were normal. Lateral and anteroposterior plain radiographs were taken (fig1, fig 2). Fig 1 Anteroposterior plain radiograph of right elbow Fig 2 Lateral plain radiograph of right elbow What is the diagnosis? Supracondylar fracture of the …

There is emerging evidence, although at early stages, of various detrimental health effects after smoking shisha. With regard to the cardiovascular system, there is a significant acute rise in cardiovascular markers, such as heart rate and blood pressure. The long-term effects on the cardiovascular system are yet to be established. Shisha smoking has also been significantly associated with lung cancer. Various other forms of cancer have also been documented, but have not reached statistical significance and require further research. Finally, shisha smoking increases the risk of infection and has been associated with outbreaks in the Middle East. Therefore, with the increasing consumption of shisha in Europe, especially in the UK, more research is required to tackle this potential public health threat.

Femoral fractures represent a substantial orthopaedic injury. In the developed world, closed reduction and locked intramedullary nailing is recognized as the optimal treatment. In the less developed world, the use of skeletal traction remains limited by cost and availability of traction pins, which are obtained from orthopaedic companies in the UK or Indian subcontinent. This study aimed to establish whether traction pins may be manufactured locally in resource-limited countries from cut down stainless steel rods. The overall costs for traction pins were obtained from five UK, Indian subcontinent-based companies and metal fabrication shops in Africa. Strict design specifications were provided. The mean price for 100 Steinmann pins was$428 in the Indian subcontinent,$96 in Malawi,$105 in Kenya and$244 in Tanzania. Our results indicate that Steinmann pins may be manufactured locally in resource-limited countries at a significantly cheaper price, which may increase the access to skeletal traction.

Objectives To investigate the acute cardiovascular effects of smoking shisha. Design A cross-sectional study was carried out in six shisha cafes. Participants smoked shisha for a period between 45 min (minimum) and 90 min (maximum). The same brand of tobacco and coal was used. Setting London, UK. Participants Participants were those who had ordered a shisha to smoke and consented to have their blood pressure, heart rate and carbon monoxide levels measured. Excluded subjects were those who had smoked shisha in the previous 24 h, who smoke cigarettes or who suffered from cardiorespiratory problems. Main outcome measures Blood pressure was measured using a sphygmomanometer. Pulse was measured by palpation of the radial artery. Carbon monoxide levels were obtained via a carbon monoxide monitor. These indices were measured before the participants began to smoke shisha and after they finished or when the maximum 90 min time period was reached. Results Mean arterial blood pressure increased from 96 mmHg to 108 mmHg ( p Conclusion The acute heart rate, blood pressure and carbon monoxide levels were seen to rise significantly after smoking shisha. The weak correlation between carbon monoxide levels and the other variables suggests that carbon monoxide levels had not contributed to their significant increase.