Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience.

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome. The mean DASH score improved from 42.3 (SD 9.6) at six weeks post-injury, to 19.5 (SD 14.3) at one-year follow-up (p < 0.001), but outcomes were mixed, with 30 patients having a DASH score > 30 at one year. MRI revealed a range of associated injuries, with a full-thickness rotator cuff tear present in 19 patients (19%). Overall, 11 patients (11%) developed complications requiring further operative intervention; 20 patients (21%) developed post-traumatic secondary shoulder stiffness. Multivariate analysis revealed a high-energy mechanism (p = 0.009), tobacco consumption (p = 0.033), use of mobility aids (p = 0.047), a full-thickness rotator cuff tear (p = 0.002), and the development of post-traumatic secondary shoulder stiffness (p = 0.035) were independent predictors of poorer outcome. The results of nonoperative management of minimally displaced GT fractures are heterogeneous. While many patients have satisfactory early outcomes, a substantial subgroup fare much worse. There is a high prevalence of rotator cuff injuries and post-traumatic shoulder stiffness, and their presence is associated with poorer patient experience. Furthermore, patients who have a high-energy injury, smoke, or use walking aids, have worse outcomes.

Human-black bear conflict: crop raiding by Asiatic black bear (Ursus thibetanus) in Azad Jammu and Kashmir, Pakistan.

Asiatic black bear has long been in conflict with human beings crop raiding is a major cause of this conflict frequently noted in South Asia. Crops raided by black bears affected by temporal, spatial and anthropogenic attributes. Insight in this conflict and its mitigation is vital for the conservation of this threatened species. Present study aimed to evaluate crop raiding by black bears in the mountainous region of Azad Jammu and Kashmir. Field surveys were carried out to observe spatial and temporal crop raiding features between 2015-2020 and data gathered using designed questionnaires randomly tailored in villages nearby the forests. Results revealed that maize was the sole crop raided by black bears. A total of 28-acre area was raided by black bear in the fall season (Aug-November) resulting in a damage of 51 metric tons, whole raiding was carried out at night. Each respondent received crop damage on 0.09 acre with a loss of 0.17 metric ton yield. Crop quantity and area were significantly correlated to each other. District Neelum shared 49% of the total crop loss, while 47% of the maize was raided at the altitudinal range of 2100-2500 m. crop raiding was highly significantly ( χ 2 = 1174.64 ; d f = 308 ;   p < 0.01 ) dependent upon distance to the forest. Linear regression revealed that maize quantity was determined by area, time and the total field area. Farmers faced 3.8 million PKRs loss due to crop damage by black bears. Despite the huge loss, the majority (23%) of the respondents did not respond to the query on mitigation measures indicating a poor adaptation of preventive measures. Preferred strategy to avoid crop damage was making noise (27.8%) when bears attacked their crops. A start of compensation scheme to the farmers is recommended that will have turned their negative attitude into a positive one toward the wildlife and black bear particularly. Study provides a new insight in human-bear conflict, particularly in spatial and temporal context of crop raiding in AJ&K.

The human-wildlife conflict in Musk Deer National Park, Neelum Gureze Valley, Azad Jammu & Kashmir, Pakistan.

Growing human population is a solemn risk to biodiversity at a global level. Massive anthropogenic pressure and invasion in the natural habitats initiated the human-wildlife conflict in rural areas. Present study aimed to assess human-wildlife conflict in Musk Deer National Park (MDNP) from 2013 to 2018. Results revealed an estimated 241784 nomadic and 5589 residential livestock heads grazed in different areas of MDNP during the summer season. A total of 126 heads were depredated by carnivores during the study period. Majority (n=39) of livestock heads were killed in May (n=29). Livestock depredation resulted in economic losses worth 3.115 million PKRs (25744 US$) to the herder community while farmers received 1.629 million PKRs (13466 US$) losses due to crop raiding. Most (64%) of the respondents believed human-wildlife conflict heightened due to scarcity of food or prey in the natural habitats of carnivores. Majority (92%) of the respondents did not like the presence of predators in MDNP. Loss compensation schemes could turn this negative attitude into the positive one and increase tolerance about the presence of carnivores in their vicinity. This study provides an insight into the human-wildlife conflict in MDNP and paves a way for understanding the conflict and conservation of carnivore species in the study area.

Midterm clinical and radiologic survivorship of a stemless total shoulder arthroplasty.

AIM: The aim of this study was to evaluate the clinical and radiologic outcomes of stemless total shoulder arthroplasty (TSA) in patients with glenohumeral arthritis. PATIENTS AND METHODS: This is a retrospective case series of all patients who underwent a TSA with Affinis Short prosthesis during the period 2010-2017. Seventy-two TSAs were performed within our unit, in 62 patients (45 females and 17 males), with 10 patients having bilateral TSAs with this prosthesis. The mean follow-up was 3.9 years (2-8.7 years). Patients were evaluated clinically with the Oxford Shoulder Score, range of movement assessment, and a numerical patient satisfaction score. Follow-up radiographs were evaluated by 2 reviewers assessing for lucency and assigned a Lazarus grade. RESULTS: Six patients were lost to follow-up prior to their 2-year review. At last follow-up, the mean forward elevation was 157° (80°-180°), abduction was 150° (60°-180°), and external rotation was 39° (20°-60°). The mode internal rotation was to the lumbar spine, with 95% of patients achieving internal rotation to L5 or higher. The mean Oxford Shoulder Score was 45 (18-48). The mean patient satisfaction score was 4.93/5. No humeral lucencies were observed. Sixty-four percent (n=47) of the glenoids were Lazarus grade 0, showing no evidence of radiolucency. The remaining patients were Lazarus grade 1-3, although none were progressive and all patients were asymptomatic. No patients were revised for aseptic loosening. Four patients underwent revision: 1 for infection, 1 for heterotrophic ossification and stiffness, and 2 for rotator cuff failure. CONCLUSION: Midterm follow-up results indicate good clinical and radiologic survivorship for this stemless TSA. Our findings suggest good patient function and satisfaction, and no patients have required revision for aseptic loosening. Further follow-up is required to determine long-term survivorship.

Vanillin confers antifungal drug synergism in Candida albicans by impeding CaCdr2p driven efflux.

AIM: Among the most common mechanisms of multidrug resistance (MDR) in prevalent human fungal pathogen, Candida albicans, overexpression of drug efflux pumps remains the predominant mechanism. Hence to inhibit efflux pumps and chemosensitize C. albicans against traditional antifungal drugs still represents an attractive approach. The present study aimed to analyze the effect of Vanillin (Van), a natural food flavoring agent, on drug efflux pump activity of Candida albicans. METHODS AND RESULTS: We observed that Van specifically inhibits Candida drug resistance protein 2 (CaCdr2p) activity belonging to ATP Binding Cassette (ABC) superfamily as revealed by abrogated rhodamine 6G efflux and nile red accumulation assay with CaCdr2p over expressing strain. Insight studies into the mechanisms suggested that abrogated efflux by CaCdr2p is due to competitive mode of inhibition by Van as depicted by Lineweaver-Burk plot. RT-PCR, western blot and confocal microscopy further unraveled that Van leads to reduced expression of CDR2 and CaCdr2p mislocalization respectively. Furthermore, Van sensitizes the azole sensitive and resistant clinical matched pair of isolates Gu4/Gu5 and led to abrogated rhodamine 6G efflux and depleted ergosterol. Furthermore, Van synergizes with membrane targeting drugs fluconazole and amphotericin B as their fractional inhibitory coefficient index was less than 0.5. CONCLUSION: Van being a potent inhibitor of CaCdr2p and chemosensitizing of drug resistant C. albicans warrants further studies to be exploited as effective antifungal agent.

Anti-Candida activity of geraniol involves disruption of cell membrane integrity and function.

Candidiasis is a major problem in immunocompromised patients. Candida, an opportunistic fungal pathogen, is a major health concern today as conventional drugs are highly toxic with undesirable side effects. Their fungistatic nature is responsible for drug resistance in continuously evolving strains. Geraniol, an acyclic monoterpene alcohol, is a component of several plant essential oils. In the present study, an attempt has been made to understand the antifungal activity of geraniol at the cell membrane level in three Candida species. With an MIC of 30-130µg/mL, this natural compound was fungicidal at concentrations 2×MIC. There was complete suppression of fungal growth at MIC values (growth curves) and encouragingly geraniol is non-toxic even at the concentrations approaching 5×MIC (hemolysis assay). Exposed cells showed altered morphology, wherein the cells appeared either broken or shrivelled up (SEM studies). Significant reduction was seen in ergosterol levels at sub-MIC and glucose-induced H(+) efflux at concentrations>MIC values. Our results suggest that geraniol disrupts cell membrane integrity by interfering with ergosterol biosynthesis and inhibiting the very crucial PM-ATPase. It may hence be used in the management and treatment of both superficial and invasive candidiasis but further studies are required to elaborate its mode of action.

Isolation of bacteria in semen and evaluation of antibiotics in extender for cryopreservation of buffalo (Bubalus bubalis) bull spermatozoa.

This study was designed to investigate the occurrence of bacterial species in water buffalo semen at the time of collection/processing and to assess the efficacy of some selected antibiotics (GTLS; gentamycin, tylosin and linco-spectin or SP; streptomycin and penicillin) in cryodiluent on bacterial control and quality including in vivo fertility of buffalo spermatozoa. For this purpose, four experiments were conducted. In experiment 1, a total of 11 bacterial species were isolated from buffalo ejaculates. In experiment 2, total aerobic bacterial counts at post dilution and thawing were lower (P < 0.05) in GTLS than in SP or control. The majority of the bacterial isolates from ejaculates were more susceptible to GTLS than SP. In experiment 3, sperm acrosome integrity was higher (P < 0.05) in GTLS and SP compared to control. In experiment 4, the in vivo fertility results for GTLS were higher (P < 0.05) than that for SP. In conclusion, a number of bacterial species were isolated from the bubaline semen, which requires an efficient control before its use in artificial insemination program. The GTLS combination of antibiotics may be incorporated into a freezing extender/protocol without compromising the post-thaw quality and in vivo fertility of buffalo bull spermatozoa.

Fungicidal activity of thymol and carvacrol by disrupting ergosterol biosynthesis and membrane integrity against Candida.

Natural isopropyl cresols have been reported to have antifungal activity. This work is an attempt to examine thymol and carvacrol against 111 fluconazole-sensitive and -resistant Candida isolates. Insight into the mechanism of action was elucidated by flow cytometric analysis, confocal imaging and ergosterol biosynthesis studies. The susceptibility tests for the test compounds were carried out in terms of minimum inhibitory concentrations (MICs), disc diffusion assays and time-kill curves against all Candida isolates by employing standard protocols. Propidium iodide (PI) cell sorting has been investigated by flow cytometric analysis and confocal imaging. Haemolytic activity on human erythrocytes was studied to exclude the possibility of further associated cytotoxicity. Both compounds were found to be effective to varying extents against all isolates, including the resistant strains. In contrast to the fungistatic nature of fluconazole, our compounds were found to exhibit fungicidal nature. Significant impairment of ergosterol biosynthesis was pronouncedly induced by the test entities. Negligible cytoxicity was observed for the same compounds. Furthermore, it was observed that the positional difference of the hydroxyl group in carvacrol slightly changes its antifungal activity. Carvacrol and thymol show strong fungicidal effect against all of the Candida isolates. The mechanisms of action of these natural isopropyl cresols appear to originate from the inhibition of ergosterol biosynthesis and the disruption of membrane integrity.

The complication rate and medium-term functional outcome after total hip replacement in smokers.

We aimed to study the effect of smoking on the complication rate and medium-term functional outcome after total hip replacement. 1767 patients undergoing a cemented THR in one hospital were followed up prospectively at 6, 18, 36, and 60 months. Harris Hip Scores, SF-36 scores and complications were recorded. There was no statistically significant difference in early complications and length of hospital stay between smokers and those patients who had never smoked. Smokers were less likely to require a blood transfusion and showed a statistically lower Harris Hip Score at six months but there was no difference seen at the subsequent time-points to five years after surgery. Smoking did not influence the complication rate or medium-term functional outcome at five years after total hip replacement.

Fractures of the clavicle.

Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union, and the functional outcomes are good after nonoperative treatment. Nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits than previously reported. However, it remains difficult to predict which patients will have these complications. Since a satisfactory functional outcome may be obtained after operative treatment of a clavicular nonunion or malunion, there is currently considerable debate about the benefits of primary operative treatment of these injuries. Displaced lateral-end fractures have a higher risk of nonunion after nonoperative treatment than do shaft fractures. However, nonunion is difficult to predict and may be asymptomatic in elderly individuals. The results of operative treatment are more unpredictable than they are for shaft fractures.

Osteoporotic periprosthetic fractures of the femur in elderly patients: outcome after fixation with the LISS plate.

Longer patient survival and the extension of joint arthroplasty to older patients means that osteoporotic fractures of the femur are often associated with joint implants. This poses a significant trauma work load. This problem is likely to increase over time. The management of these periprosthetic fractures may be difficult and strategies are not universally agreed. Revision arthroplasty, single or double plate fixation with or without augmentation with methylmethacrylate or bone grafting, are all variously advocated in the literature for different indications. We retrospectively identified 28 elderly patients consecutively treated in our institution with Less Invasive Stabilisation System (LISS) plate fixation for osteoporotic and periprosthetic fractures of the femur. We present prospectively collected data for clinical and radiographic follow-up and patient outcomes. Patients had a mean age of 86.7 years. A fall from a standing height was the most common mechanism of injury. No cases of non-union were seen in survivors. Mortality in the first year was a major complication (5 patients). Rates of revision surgery were low (2 patients). Most patients required a formal period of rehabilitation, however, only half of the patients were successfully discharged to their own homes. The LISS plate provides good fixation in osteoporotic periprosthetic fractures of the femur. It restores a stable limb allowing early weight bearing as well as achieving clinical and radiographic union. Patients return to mobility levels approaching their pre-injury status although most benefit from a formal period of rehabilitation. In this patient group, the LISS plate often outlives the patient.

Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation.

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury). Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries. A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated.

Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma.

BACKGROUND: Subtrochanteric fractures of the femur that are caused by low-energy trauma are less common than other proximal femoral fractures, but they occur in a similar population of elderly individuals, who are often socially dependent and medically frail. Although a wide range of operative techniques have been used, cephalomedullary nailing theoretically provides the most minimally invasive and biomechanically stable means of treating these complex fractures. The purpose of the present review was to evaluate the functional outcome and perioperative complications associated with the use of a trochanteric-entry cephalomedullary nail to treat all low-energy subtrochanteric fractures that were seen at a single institution. METHODS: Over an eight-year period, we used the long Gamma nail to treat a consecutive series of 302 local patients who had sustained a subtrochanteric fracture during low-energy trauma. The mortality, prevalence of complications, and functional outcome were prospectively assessed during the first year after the injury. Survival analysis was used to assess the rates of reoperation and implant revision during the first year after surgery. RESULTS: At one year, seventy-four (24.5%) of the original 302 patients had died and seventeen (5.6%) had been lost to follow-up. The remaining 211 patients (69.9%) were evaluated with regard to the functional outcome and postoperative complications during the first year after the injury. As with other proximal femoral fractures in the elderly, there was an increased level of social dependence, an increase in the use of walking aids, and a reduction in mobility among survivors. Although eighty-eight (41.7%) of the 211 patients who were evaluated at one year after the injury had some degree of hip discomfort, only two described the pain as severe and disabling. Reoperation for the treatment of implant or fracture-related complications was required in twenty-seven (8.9%) of the 302 patients; however, only eighteen of these patients required nail revision, corresponding with a one-year nail-revision rate of 7.1% (95% confidence interval, 4.0% to 10.2%) on survival analysis. Of the 250 patients who survived for six months after the injury, five (2%) had a nonunion that was confirmed at the time of surgical exploration. Complications related to the proximal lag screw were seen in twelve of the original 302 patients, and a fracture distal to the tip of the nail occurred in five. Although superficial wound infection was relatively common, deep infection occurred in only five of the 302 patients. CONCLUSIONS: Subtrochanteric fractures caused by low-energy trauma are similar to other proximal femoral fractures, with a high mortality rate during the first year after the injury. Trochanteric-entry cephalomedullary nails are associated with an acceptable rate of perioperative complications and favorable functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV.

Hydrogen peroxide production by Mycoplasma bovis and Mycoplasma agalactiae and effect of in vitro passage on a Mycoplasma bovis strain producing high levels of H2O2.

Hydrogen peroxide (H2O2) production and oxygen uptake during the oxidation of NADH and L-alpha-glycerophosphate (GP) by lysed cells was determined for the type and field strains of Mycoplasma bovis and M. agalactiae. NADH oxidation by all the strains showed variable production of H2O2 ranging from 0 to 1.21 mol/mol O2 taken up. All strains were unable to oxidize GP, showing absence of GP oxidase activity. Some strains were identified that produced relatively high levels of H2O2 (> 1.0 mol/ mol O2 taken up). In vitro passage of M. bovis strain 119B96 showed reduced H2O2 production: 0.52, 0.16, and 0.07 mol/mol O2 taken up after the 50th, 100th and 200th passages, respectively. SDS-PAGE analysis showed the loss of a protein band of 32 kDa after 50 passages. These preliminary studies show that not only does H2O2 production by potentially pathogenic Mycoplasma spp. vary in the field but also that similar alterations can be induced by passage in culture. In the latter case, at least in one M. bovis strain, this alteration has been shown by SDS-PAGE to be associated with a loss of specific protein production. Further study of these phenomena is essential background for the production of more efficient vaccines for mycoplasmas.

Serum profiles of luteinizing hormone, oestradiol and cholesterol and ovarian functions in layer poultry birds (Gallus domesticus) fed diets containing furazolidone.

This study was carried out to assess the serum profiles of luteinizing hormone (LH), oestradiol, cholesterol and ovarian functions in layer poultry birds (Rhode Island Red: Gallus domesticus) fed a diet containing various concentrations of furazolidone (FZ). A total of 40 birds were randomly assigned to receive FZ 0, 200, 400 or 800 mg/kg feed (ppm) daily during the pre-laying age, i.e. 13-18 weeks (for 5 weeks). Blood samples were collected at weekly intervals. Concentrations of LH and oestradiol in serum were estimated at alternate weeks using radioimmunoassays. Serum cholesterol levels were analysed by an enzymatic calorimetric method. Furazolidone administration was terminated at the 18th week of age. The birds were sacrificed at 22nd week of age and ovarian tissues were processed for morphometric studies. Serum LH, oestradiol and cholesterol levels were affected by age (p < 0.001) and FZ dose (p < 0.001). Serum LH and oestradiol levels were lower (p < 0.05) in birds receiving FZ 800 mg/kg feed daily compared with the controls, whereas serum cholesterol profiles were lower (p < 0.05) in all FZ-administered groups than in the control group. The mean weight of ovaries having no yolky follicles observed in the group receiving FZ 400 or 800 mg/kg feed per day was reduced (p < 0.05) compared with the control group. Dosing FZ at 800 mg/kg feed per day reduced (p < 0.05) the mean volume of ovaries having no yolky follicles compared with the control group. In birds receiving FZ 800 mg/kg feed per day, the mean length of the oviduct was reduced (p < 0.05) as compared with the control group. Morphometric studies revealed that the mean number of oocytes with diameter in the range 401-800 microm decreased (p < 0.05) in birds fed FZ 400 or 800 mg/kg feed per day. Initial egg production was affected by age (p < 0.001) and dose (p < 0.001) of FZ. The mean number of eggs laid by different groups revealed that egg production was reduced (p < 0.05) in birds receiving FZ 800 mg/kg feed per day as compared with the controls. The present data suggest that FZ causes suppression in serum profiles of LH, oestradiol, cholesterol and ovarian functions in Rhode Island Red layer poultry birds. Therefore, great care must be taken with use of FZ in layer poultry birds (Gallius domesticus) with regard to dosage and duration of administration.

Medical surfing.

The Internet has revolutionized information technology. Vast amounts of latest information are available on the Internet to medical professionals. Medical surfing is fast becoming part of a doctor's profession. But the way to approach the Internet and retrieve useful information from myriads of medical websites seems a daunting task to many. This review aims to help the newcomer, the medical students and doctors in obtaining fruitful medical information while surfing. It will prevent them from the feeling of getting drowned in the ocean of medical information. As medical information is not restricted to books and journals, providing Internet addresses of different medical bodies with few salient features, will go a long way in helping attain the required information without wasting time. The Internet will soon become a universal library. Medical surfing should be included in the curriculum of all medical schools and universities.