Comparison of Intraoperative Fluoroscopy to Postoperative Weight-Bearing Radiographs Obtained 4 to 6 Weeks After Bunion Repair With A Chevron Osteotomy

Background: During operative treatment of bunions, an attempt is made to correct the hallux valgus angle (HVA) and the intermetatarsal angle (IMA). In this study, the HVA and the IMA were measured using intraoperative C-arm fluoroscopic images obtained during surgical treatment of a bunion with chevron osteotomy. These angles were again measured using weight-bearing radiographs obtained 4 to 6 weeks postoperatively. Methods: At our institution, we reviewed medical records of patients who underwent a bunion repair with chevron osteotomy between January 2013 and October 2017. A total of 26 feet from 24 patients were included. Three authors (ALP, TMH, and RAM) measured the HVA and IMA using intraoperative fluoroscopic images and postoperative weight-bearing radiographs (4 measurements per foot; total, 104 measurements). The authors were blinded to their previous angular measurements and to measurements made by the others. An intraclass correlation coefficient was calculated for the HVA and IMA measurements between groups (ie, intraoperative fluoroscopic images and postoperative radiographs) to determine interobserver reliability. We compared the angles measured by the authors between groups and used a paired t test for statistical evaluation. Results: Interobserver difference of the HVA and IMA was low between intraoperative fluoroscopic images and postoperative weight-bearing radiographs (0.98 and 0.79; 0.78 and 0.95, respectively). The measured IMAs were relatively consistent between groups (6.21° and 6.37°, respectively); only two patients had a difference \u3e 3°. There was a greater difference in HVAs between groups (11.5° and 14.2°, respectively). In 11 feet, the HVA was \u3e 5° (range, 5.3-12.7°) in the postoperative radiograph compared to the fluoroscopic image. In one foot, we noted a 7° decrease of the HVA on the postoperative radiograph. The average difference of HVA between groups was 2.6° (P \u3c 0.0001), whereas the IMA was 0.16° (P = 0.002). Conclusions: Interobserver measurements of the HVA and IMA were reliable on both the intraoperative fluoroscopic images and the postoperative weightbearing radiographs. The IMA was similar between groups; however, the HVA was often greater on the postoperative weight-bearing radiographs

Leukocytoclastic Vasculitis in a 66-Year-Old Woman After Fusion of the Second Right Metatarsocuneiform Joint Using Titanium Plate and Screws: A Case Report

Metallic orthopaedic implants are known to instigate cutaneous reactions; however, the mechanism by which this occurs is not fully understood. Contact dermatitis after implantation of stainless steel fracture plates was first described in 1966, and similar reactions to various implants have been documented subsequently. Leukocytoclastic vasculitis (LCV) is an inflammatory condition of small dermal blood vessels resulting from neutrophil invasion, degranulation, and cell death caused by a type III hypersensitivity reaction. No studies have reported use of titanium orthopaedic implants resulting in LCV. We describe a 66-year-old woman who developed LCV after the fusion of her second right metatarsocuneiform joint with a titanium plate and screws. At 4 months after removal of the titanium plate and screws, the LCV symptoms had resolved without further intervention. Although this rash might be a rare complication associated with orthopaedic implants, it is an important differential diagnosis for orthopaedic surgeons to consider when assessing and treating postoperative rashes

Geriatric Hip Fracture Quality Initiative

Introduction: Multiple studies demonstrate increased morbidity, mortality, and loss of independence after hip fractures in geriatric patients. The 1-year mortality rate after a hip fracture has been estimated at anywhere from 14% to 58%. Hip fractures are one of the most common injuries evaluated by the UNM Orthopedic department. Geriatric hip fracture protocols have shown improved outcomes at many other centers with regard to improved functionality and decreased morbidity. The goal of this initiative is to improve outcomes with regard to length of hospital stay, functionality after surgery, and as a result, decreased morbidity and mortality. Materials/methods: All deaths in the orthopedic department were reviewed and analyzed from June 2009 to July 2019. Deaths were identified from morbidity and mortality submissions and NSQIP data. The geriatric hip fracture protocol was developed and implemented in Fall 2019, with non-critical care patients being primarily admitted to orthopedics, with hospitalist co-management. Specific post-operative and pain order sets were developed for efficiency and improved standard of care. Results: Early results of the newly developed geriatric hip fracture protocol demonstrate decreased length of stay in the hospital and earlier time to surgical intervention. It is too early to determine if morbidity and mortality has seen any decrease, however this can be anticipated with earlier time to surgery and decreased time in the hospital. Conclusions: We identified a need and successfully developed an initiative to improve care for geriatric patients with hip fractures. Implementation of this protocol decreased length of hospital stay as well as time to surgery. The analysis of the effect of this protocol on overall morbidity and mortality is ongoing

Rethinking Global Health Education in Plastic Surgery Residency

Surgical disease is now among the most common, preventable, and growing contributors to the global burden of disease. The attitudes of trainees toward global surgery and the viability of a global surgery as an academic track have blossomed. More optimized experiences within residency education are necessary, however, to prepare the next generation of global surgeons. The field of plastic surgery is thus at an important crossroads in the effort to incorporate global surgery into training programs in a uniform fashion across the country. The recent American Council of Academic Plastic Surgeons meeting in February 2020 was dedicated to identifying strategies that will enhance the adoption of global surgery practices within plastic surgery. In this article, we discuss the principles, themes, and ideas that emerged from this session, and further develop concrete initiatives believed to be potentially fruitful. Some have been discussed in other surgical disciplines or presented in isolation to the plastic surgery community, but never as a cohesive set of recommendations that take into account the background and shortfalls of the current model for global health education in the 21st century. We then introduce five recommendations to optimize learner education: (1) clarification of learner expectations and roles; (2) domestic teaching for optimization of field experiences; (3) expansion of longitudinal, formal rotations; (4) strengthening of the role of research; and (5) integration of program financing

Impact of Adopting Population Pharmacokinetics for Tailoring Prophylaxis in Haemophilia A Patients: A Historically Controlled Observational Study

Background Performing individual pharmacokinetics (PK) studies in clinical practice can be simplified by adopting population PK-based profiling on limited post-infusion samples. The objective of this study was to assess the impact of population PK in tailoring prophylaxis in patients with haemophilia A. Patients and Methods Individual weekly treatment plans were developed considering predicted plasma factor activity levels and patients' lifestyle. Patients were trained using a visual traffic-light scheme to help modulate their level of physical activity with respect to factor infusions timing. Annualized joint bleeding rate (ABJR), haemophilia-specific quality of life questionnaire for adults (Haemo-QoL-A) and factor utilization were measured for 12 months before and after tailoring, compared within patients and analysed separately for those previously on prophylaxis (P), situational prophylaxis (SP) or on-demand (OD). Results Sixteen patients previously on P, 10 on SP and 10 on OD were enrolled in the study. The median (lower, upper quartile) ABJR changed from 2.0 (0, 4.0) to 0 (0, 1.6) for P (p = 0.003), from 2.0 (2.0, 13.6) to 3.0 (1.4, 7.2) for SP (p = 0.183) and from 16.0 (13.0, 25.0) to 2.3 (0, 5.0) for OD (p = 0.003). The Haemo-QoL-A total score improved for 58% of P, 50% of SP and 29% of OD patients. Factor utilization (IU/kg/patient/year) increased by 2,400 (121; 2,586) for P, 1,052 (308; 1,578) for SP and 2,086 (1,498; 2,576) for OD. One of 138 measurements demonstrated a factor activity level below the critical threshold of 0.03 IU/mL while the predicted level was above the threshold. Conclusion Implementing tailored prophylaxis using a Bayesian forecasting approach in a routine clinical practice setting may improve haemophilia clinical outcomes

Garlic extract induces intestinal P-glycoprotein, but exhibits no effect on intestinal and hepatic CYP3A4 in humans

Garlic extracts have been shown to decrease drug exposure for saquinavir, a P-glycoprotein and cytochrome P450 3A4 substrate. In order to explore the underlying mechanisms and to study the effects of garlic on pre-systemic drug elimination, healthy volunteers were administered garlic extract for 21 days. Prior to and at the end of this period, expression of duodenal P-glycoprotein and cytochrome P450 3A4 protein were assayed and normalized to villin, while hepatic cytochrome P450 3A4 function and simvastatin, pravastatin and saquinavir pharmacokinetics were also evaluated. Ingestion of garlic extract increased expression of duodenal P-glycoprotein to 131% (95% CI, 105-163%), without increasing the expression of cytochrome P450 3A4 which amounted to 87% (95% CI, 67-112%), relative to baseline in both cases. For the erythromycin breath test performed, the average result was 96% (95% CI, 83-112%). Ingestion of garlic extract had no effect on drug and metabolite AUCs following a single dose of simvastatin or pravastatin, although the average area under the plasma concentration curve (AUC) of saquinavir decreased to 85% (95% CI, 66-109%), and changes in intestinal P-glycoprotein expression negatively correlated with this change. In conclusion, garlic extract induces intestinal expression of P-glycoprotein independent of cytochrome P450 3A4 in human intestine and liver

Curcumin encapsulation in nanostructures for cancer therapy: a 10-year overview

Journal pre-proofsCurcumin (CUR) is a phenolic compound present in some herbs, including Curcuma longa Linn. (turmeric rhizome), with a high bioactive capacity and characteristic yellow color. It is mainly used as a spice, although it has been found that CUR has interesting pharmaceutical properties, acting as a natural antioxidant, anti-inflammatory, antimicrobial, and antitumoral agent. Nonetheless, CUR is a hydrophobic compound with low water solubility, poor chemical stability, and fast metabolism, limiting its use as a pharmacological compound. Smart drug delivery systems (DDS) have been used to overcome its low bioavailability and improve its stability. The current work overviews the literature from the past 10 years on the encapsulation of CUR in nanostructured systems, such as micelles, liposomes, niosomes, nanoemulsions, hydrogels, and nanocomplexes, emphasizing its use and ability in cancer therapy. The studies highlighted in this review have shown that these nanoformulations achieved higher solubility, improved tumor cytotoxicity, prolonged CUR release, and reduced side effects, among other interesting advantages.This study was funded by the Coordination for Higher Level Graduate Improvements (CAPES/Brazil, finance code 001), National Council for Scientific and Technological Development (CNPq/Brazil, PIBIC process #123483/2020-4), State of São Paulo Research Foundation (FAPESP/Brazil, processes #2017/10789-1, #2018/10799-0, #2018/06475-4, #2018/07707-6, #2019/08549-8, and #2020/03727-2). This work was also supported by the Portuguese Foundation for Science and Technology (FCT) under the scope of the strategic funding of UIDB/04469/2020 unit and the project AgriFood XXI (NORTE-01-0145-FEDER-000041) funded by the European Regional Development Fund under the scope of Norte2020 - Programa Operacional Regional do Norte. Our Figures were created with BioRenderinfo:eu-repo/semantics/publishedVersio

Exploring hydro-meteorological drought patterns over the Greater Horn of Africa (1979-2014) using remote sensing and reanalysis products

Spatio-temporal patterns of hydrological droughts over the Greater Horn of Africa (GHA) are explored based on total water storage (TWS) changes derived from time-variable gravity field solutions of Gravity Recovery And Climate Experiment (GRACE, 2002-2014), together with those simulated by Modern Retrospective Analysis for Research Application (MERRA, 1980-2014). These hydrological extremes are then related to meteorological drought events estimated from observed monthly precipitation products of Global Precipitation Climatology Center (GPCC, 1979-2010) and Tropical Rainfall Measuring Mission (TRMM, 1998-2014). The major focus of this contribution lies on the application of spatial Independent Component Analysis (sICA) to extract distinguished regions with similar rainfall and TWS with similar overall trend and seasonality. Rainfall and TWS are used to estimate Standard Precipitation Indices (SPIs) and Total Storage Deficit Indices (TSDIs), respectively that are employed to characterize frequency and intensity of hydro-meteorological droughts over GHA. Significant positive (negative) changes in monthly rainfall over Ethiopia (Sudan) between 2002 and 2010 leading to a significant increase in TWS over the central GHA region were noted in both MERRA and GRACE TWS (2002-2014). However, these trends were completely reversed in the long-term (1980-2010) records of rainfall (GPCC) and TWS (MERRA). The four independent hydrological sub-regions extracted based on the sICA (i.e., Lake Victoria Basin, Ethiopia-Sudanese border, South Sudan, and Tanzania) indicated fairly distinct temporal patterns that matched reasonably well between precipitation and TWS changes. While meteorological droughts were found to be consistent with most previous studies in all sub-regions, their impacts are clearly observed in the TWS changes resulting in multiple years of extreme hydrological droughts. Correlations between SPI and TSDI were found to be significant over Lake Victoria Basin, South Sudan, and Tanzania. The low correlations between SPI and TSDI over Ethiopia are likely related to inconsistency between TWS and precipitation signals. Further, we found that hydrological droughts in these regions were significantly associated with Indian Ocean Dipole (IOD) events while El Niño Southern Oscillation (ENSO) plays a secondary role

MAP Kinase Phosphatase-2 Plays a Critical Role in Response to Infection by Leishmania mexicana

In this study we generated a novel dual specific phosphatase 4 (DUSP4) deletion mouse using a targeted deletion strategy in order to examine the role of MAP kinase phosphatase-2 (MKP-2) in immune responses. Lipopolysaccharide (LPS) induced a rapid, time and concentration-dependent increase in MKP-2 protein expression in bone marrow-derived macrophages from MKP-2+/+ but not from MKP-2−/− mice. LPS-induced JNK and p38 MAP kinase phosphorylation was significantly increased and prolonged in MKP-2−/− macrophages whilst ERK phosphorylation was unaffected. MKP-2 deletion also potentiated LPS-stimulated induction of the inflammatory cytokines, IL-6, IL-12p40, TNF-α, and also COX-2 derived PGE2 production. However surprisingly, in MKP-2−/− macrophages, there was a marked reduction in LPS or IFNγ-induced iNOS and nitric oxide release and enhanced basal expression of arginase-1, suggesting that MKP-2 may have an additional regulatory function significant in pathogen-mediated immunity. Indeed, following infection with the intracellular parasite Leishmania mexicana, MKP-2−/− mice displayed increased lesion size and parasite burden, and a significantly modified Th1/Th2 bias compared with wild-type counterparts. However, there was no intrinsic defect in MKP-2−/− T cell function as measured by anti-CD3 induced IFN-γ production. Rather, MKP-2−/− bone marrow-derived macrophages were found to be inherently more susceptible to infection with Leishmania mexicana, an effect reversed following treatment with the arginase inhibitor nor-NOHA. These findings show for the first time a role for MKP-2 in vivo and demonstrate that MKP-2 may be essential in orchestrating protection against intracellular infection at the level of the macrophage