A 69-year-old woman presented with a cortical hand syndrome progressing over several weeks. MRI brain showed characteristic appearances of progressive multifocal leukoencephalopathy (PML), confirmed by detection of the JC virus in CSF, despite the absence of any evidence of immunosuppression. Treatment with mirtazapine, mefloquine and cidofovir did not affect the progression of the disease, which was fatal within 7 months of presentation. This report adds to the small case literature that suggests that PML can occur in immunocompetent people, albeit extremely rarely.

Background High bone mass (HBM, BMD Z-score ≥  + 3.2) and cam morphology (bulging of lateral femoral head) are associated with greater odds of prevalent radiographic hip osteoarthritis (rHOA). As cam morphology is itself a manifestation of increased bone deposition around the femoral head, it is conceivable that cam morphology may mediate the relationship between HBM and rHOA. We therefore aimed to determine if individuals with HBM have increased odds of prevalent cam morphology. In addition, we investigated whether the relationship between cam and prevalent and incident osteoarthritis was preserved in a HBM population. Methods In the HBM study, a UK based cohort of adults with unexplained HBM and their relatives and spouses (controls), we determined the presence of cam morphology using semi-automatic methods of alpha angle derivation from pelvic radiographs. Associations between HBM status and presence of cam morphology, and between cam morphology and presence of rHOA (or its subphenotypes: osteophytes, joint space narrowing, cysts, and subchondral sclerosis) were determined using multivariable logistic regression, adjusting for age, sex, height, weight, and adolescent physical activity levels. The association between cam at baseline and incidence of rHOA after an average of 8 years was determined. Generalised estimating equations accounted for individual-level clustering. Results The study included 352 individuals, of whom 235 (66.7%) were female and 234 (66.5%) had HBM. Included individuals contributed 694 hips, of which 143 had a cam deformity (20.6%). There was no evidence of an association between HBM and cam morphology (OR = 0.97 [95% CI: 0.63–1.51], p = 0.90) but a strong relationship was observed between cam morphology and rHOA (OR = 3.96 [2.63–5.98], p = 5.46 × 10–11) and rHOA subphenotypes joint space narrowing (OR = 3.70 [2.48–5.54], p = 1.76 × 10–10), subchondral sclerosis (OR = 3.28 [1.60–6.60], p = 9.57 × 10–4) and osteophytes (OR = 3.01 [1.87–4.87], p = 6.37 × 10–6). Cam morphology was not associated with incident osteoarthritis (OR = 0.76 [0.16–3.49], p = 0.72). Conclusions The relationship between cam morphology and rHOA seen in other studies is preserved in a HBM population. This study suggests that the risk of OA conferred by high BMD and by cam morphology are mediated via distinct pathways.

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries.

The ubiquitous nature of social media has meant that its effects on fields outside of social communication have begun to be felt. The generation undergoing medical education are of the generation referred to as “digital natives”, and as such routinely incorporate social media into their education. Social media’s incorporation into medical education includes its use as a platform to distribute information to the public (“distributive education”) and as a platform to provide information to a specific audience (“push education”). These functions have proved beneficial in many regards, such as enabling constant access to the subject matter, other learners, and educators. However, the usefulness of using social media as part of medical education is limited by the vast quantities of poor quality information and the time required to find information of sufficient quality and relevance, a problem confounded by many student’s preoccupation with “efficient” learning. In this Perspective, the authors discuss whether social media has proved useful as a tool for medical education. The current growth in the use of social media as a tool for medical education seems to be principally supported by students’ desire for efficient learning rather than by the efficacy of social media as a resource for medical education. Therefore, improvements in the quality of information required to maximize the impact of social media as a tool for medical education are required. Suggested improvements include an increase in the amount of educational content distributed on social media produced by academic institutions, such as universities and journals.