Improving morbidity and mortality in hip fragility fractures.

PURPOSE OF REVIEW: Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system. RECENT FINDINGS: There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality. SUMMARY: HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Aetiology of Type 2 diabetes in people with a 'normal' body mass index: testing the personal fat threshold hypothesis.

Weight loss in overweight or obese individuals with Type 2 diabetes (T2D) can normalize hepatic fat metabolism, decrease fatty acid oversupply to ß cells and restore normoglycaemia. One in six people has BMI <27 kg/m2 at diagnosis, and their T2D is assumed to have different aetiology. The Personal Fat Threshold hypothesis postulated differing individual thresholds for lipid overspill and adverse effects on ß-cell function. To test this hypothesis, people with Type 2 diabetes and body mass index <27kg/m2 (n = 20) underwent repeated 5% weight loss cycles. Metabolic assessments were carried out at stable weight after each cycle and after 12 months. To determine how closely metabolic features returned to normal, 20 matched normoglycemic controls were studied once. Between baseline and 12 months: BMI fell (mean ± SD), 24.8 ± 0.4 to 22.5 ± 0.4 kg/m2 (P<0.0001) (controls: 21.5 ± 0.5); total body fat, 32.1 ± 1.5 to 27.6 ± 1.8% (P<0.0001) (24.6 ± 1.5). Liver fat content and fat export fell to normal as did fasting plasma insulin. Post-meal insulin secretion increased but remained subnormal. Sustained diabetes remission (HbA1c < 48 mmol/mol off all glucose-lowering agents) was achieved by 70% (14/20) by initial weight loss of 6.5 (5.5-10.2)%. Correction of concealed excess intra-hepatic fat reduced hepatic fat export, with recovery of ß-cell function, glycaemic improvement in all and return to a non-diabetic metabolic state in the majority of this group with BMI <27 kg/m2 as previously demonstrated for overweight or obese groups. The data confirm the Personal Fat Threshold hypothesis: aetiology of Type 2 diabetes does not depend on BMI. This pathophysiological insight has major implications for management.

The Crisis of Deficiency in Emergency Coverage for Hand and Facial Trauma: Exploring the Discrepancy Between Availability of Elective and Emergency Surgical Coverage.

INTRODUCTION: Injuries are one of the most common reasons for emergency department visits, with approximately 40.2 million injury-related visits occurring in 2011. Facial, hand, and wrist injuries make up a large portion of these visits. Despite the high demand for specialists to attend to these injury-related emergency department visits, recent studies have suggested a discrepancy between elective surgical coverage and trauma care in general. The goal of this study was to determine if there was a difference between access to elective surgical procedures in comparison with on-call emergency care for facial and hand/wrist conditions in New York State. METHODS: Hospitals throughout New York State, excluding New York City, were selected from the Department of Health Web site, hospitals.nyhealth.gov. A phone survey was administered between May 2012 and October 2013, to quantify the availability of elective and emergent procedures for facial and hand/wrist conditions. We compared the availability of emergency facial and hand/wrist surgical care based on hospital characteristics such as bed size and access to a surgical intensive care unit. RESULTS: We selected 113 hospitals, and 52 hospitals participated for a response rate of 46%. A total of 88% of hospitals offered elective hand procedures, but only 27% had consistent coverage for emergency hand trauma. Furthermore, only 29 % of hospitals had a facial specialist consistently available whereas the availability for elective facial procedures was 79%. CONCLUSION: Our study results show a discrepancy between the availability of surgeons for elective procedures and on-call emergency care for facial and hand/wrist condition.

Risk factors for retained placenta.

OBJECTIVE: Retained placenta complicates 2-3% of vaginal deliveries and is a known cause of postpartum hemorrhage. Treatment includes manual or operative placental extraction, potentially increasing risks of hemorrhage, infections, and prolonged hospital stays. We sought to evaluate risk factors for retained placenta, defined as more than 30 minutes between the delivery of the fetus and placenta, in a large US obstetrical cohort. STUDY DESIGN: We included singleton, vaginal deliveries ≥24 weeks (n = 91,291) from the Consortium of Safe Labor from 12 US institutions (2002-2008). Multivariable logistic regression analyses estimated the adjusted odds ratios (OR) and 95% confidence intervals (CI) for potential risk factors for retained placenta stratified by parity, adjusting for relevant confounding factors. Characteristics such as stillbirth, maternal age, race, and admission body mass index were examined. RESULTS: Retained placenta complicated 1047 vaginal deliveries (1.12%). Regardless of parity, significant predictors of retained placenta included stillbirth (nulliparous adjusted OR, 5.67; 95% CI, 3.10-10.37; multiparous adjusted OR, 4.56; 95% CI, 2.08-9.94), maternal age ≥30 years, delivery at 24 0/7 to 27 6/7 compared with 34 weeks or later and delivery in a teaching hospital. In nulliparous women, additional risk factors were identified: longer first- or second-stage labor duration, whereas non-Hispanic black compared with non-Hispanic white race was found to be protective. Body mass index was not associated with an increased risk. CONCLUSION: Multiple risk factors for retained placenta were identified, particularly the strong association with stillbirth. It is plausible that there could be something intrinsic about stillbirth that causes a retained placenta, or perhaps there are shared pathways of certain etiologies of stillbirth and a risk of retained placenta.

The PPARß/δ agonist GW0742 modulates signaling pathways associated with cardiac myocyte growth via a non-genomic redox mechanism.

Peroxisome proliferator-activated receptors (PPARs) are ligand-activated transcription factors that belong to the nuclear hormone receptor superfamily and appear to have beneficial effects in the cardiovascular system. PPARß/δ has been shown previously to exert an inhibitory effect on cardiac myocyte hypertrophy in vivo and in vitro although the exact mechanism is not fully clear yet. The principal signaling pathways that have been involved in triggering cardiac hypertrophic response are mitogen-activated protein kinases (MAPKs) and PI3K/Akt cascades. In this study, we sought to evaluate the potential effects evoked by PPARß/δ activation on signaling pathways that are implicated in cardiac myocyte growth responses. The selective PPARß/δ agonist GW0742 attenuated ERK1/2 and Akt phosphorylation that was stimulated by growth promoting agonists (phenylephrine, insulin or IGF-1). This effect was not reversed by the specific PPARß/δ antagonist, GSK0660, but was inhibited by vanadate, a potent protein tyrosine phosphatase inhibitor. In addition, GW0742 prevented the oxidation and inactivation of PTEN supporting further the notion that its inhibitory action on the agonist-induced kinase phosphorylation is mediated by the modulation of phosphatase activity. Furthermore, GW0742 abolished the agonist-induced intracellular generation of reactive oxygen species, independently of PPARß/δ activation. Our data reveals a new non-genomic mechanism of GW0742, which ameliorates the generation of reactive oxygen species and attenuates ERK1/2 and PI3K/Akt signaling, with implications in the regulation of cardiac hypertrophic response.

Food Insecurity, MyPlate Recognition, and Meal Preparation Confidence Among College Food Pantry Users.

OBJECTIVE: This study examined college students' food security status, Choose MyPlate familiarity, and confidence in preparing healthy meals using food pantry ingredients. METHODS: A sample of 354 student users of a college food pantry in the US southeastern region were surveyed before using the food pantry for the first time. RESULTS: Of the respondents, 81.3% were food insecure, and 47% of the overall sample experienced very low food security. About one-third (37.3%) recognized MyPlate; of those, 89.4% stated intention to use MyPlate knowledge making pantry selections. Students familiar with MyPlate (P = 0.003) and intending to use MyPlate when making food selections (P = 0.02) exhibited greater confidence. Differences were not observed on the basis of food security status. CONCLUSIONS AND IMPLICATIONS: These findings suggest that familiarity with simple nutritional guidelines such as MyPlate may improve students' intended food pantry selections and healthy meal selection confidence.

The effect of sociodemographic characteristics, academic factors, and individual health behaviors on psychological well-being among college students.

Objective: This study aimed to measure the potential relationships between sociodemographic characteristics, academic factors, body mass index (BMI), financial challenges, individual health behaviors, impact of COVID-19, and psychological well-being (PWB) among students. Participants: Undergraduate college students. Methods: Data from the National College Health Assessment III (American College Health Association [ACHA]) were used (n = 1,439). Differences in absolute values among PWB groups were analyzed using analysis of variance (ANOVA). To measure the influence of all factors combined on PWB, multiple regression analyses were performed. Results: Significant differences were observed in age, GPA, financial challenges, and individual health behaviors by PWB groups (p < .05). Being older, being female, having a higher GPA, being a full-time student, having a higher intake of vegetables, taking less time to fall asleep, and having lower stress levels were significantly positively associated with higher PWB scores (p < .05). Conclusions: Multiple considerations related to the academic environment and individual behaviors seem to influence PWB among college students.

Comparison of Pericapsular Nerve Group and Lateral Quadratus Lumborum Blocks for Analgesia after Primary Total Hip Arthroplasty: A Randomized Controlled Trial.

Introduction: The quadratus lumborum block (QLB) and the pericapsular nerve group (PENG) block both provide effective postoperative analgesia after hip surgery while minimizing impact on motor function. This study aimed to compare QLB and PENG in patients undergoing primary total hip arthroplasty. Methods: This superiority trial randomized patients scheduled for elective total hip arthroplasty to receive a lateral QLB or PENG with lateral femoral cutaneous nerve blocks for postoperative analgesia. Perioperative analgesic protocols were standardized. The primary outcome was postoperative cumulative opioid consumption at 72 hours. Secondary outcome was postoperative pain scores. Additional outcomes of interest included time to first ambulation, length of stay, patient reported outcome measures, and opioid-related side effects. Results: This trial consented and randomized 106 subjects and 101 were included in analysis: PENG (n=50), QLB (n=51). Mean (95% CI) opioid consumption (IV MME) in the first 72 hours did not differ between PENG [109.6 (93.6, 125.6)] and QL [92.3 (76.6, 107.9)] groups (p=0.129) There were no significant differences between treatment arms in average pain score, time to ambulation, distance ambulated, rate of same day discharge, or hospital length of stay. There were also no differences in patient reported outcomes using HOOS-JR and PROMIS-10 scores. Conclusion: Patients undergoing primary THA receiving preoperative PENG vs QLB had similar opioid consumption, pain scores, time to ambulation, and hospital length of stay. Both QL and PENG blocks are analgesic options in patients undergoing primary THA. Clinical Trials Registration: NCT05710107; www.ClinicalTrial.gov IRB Protocol ID: Pro00124880. Key message: Pericapsular nerve group (PENG) block may provide analgesia after hip arthroplasty and improve early functional recovery. This study evaluated postoperative opioid consumption in patients randomized to PENG or lateral quadratus lumborum block (QLB).Opioid consumption, pain scores, motor recovery, and functional outcome measures did not differ in patients randomized to PENG vs lateral QLB.PENG and lateral QLBs are analgesic options following total hip arthroplasty with similar rates of same day discharge.

5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: an extension study.

BACKGROUND: In DiRECT, a randomised controlled effectiveness trial, weight management intervention after 2 years resulted in mean weight loss of 7·6 kg, with 36% of participants in remission of type 2 diabetes. Of 36 in the intervention group who maintained over 10 kg weight loss at 2 years, 29 (81%) were in remission. Continued low-intensity dietary support was then offered up to 5 years from baseline to intervention participants, aiming to maintain weight loss and gain clinical benefits. This extension study was designed to provide observed outcomes at 5 years. METHODS: The DiRECT trial took place in primary care practices in the UK. Participants were individuals aged 20-65 years who had less than 6 years' duration of type 2 diabetes, a BMI greater than 27 kg/m2, and were not on insulin. The intervention consisted of withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (825-853 kcal per day formula diet for 12-20 weeks), stepped food reintroduction (2-8 weeks), and then structured support for weight-loss maintenance. After sharing the 2-year results with all participants, UK National Health Service data were collected annually until year 5 from remaining intervention participants who received low-intensity dietary support, intervention withdrawals, and the original randomly allocated groups. The primary outcome was remission of type 2 diabetes; having established in the DiRECT trial that sustained weight loss was the dominant driver of remission, this was assumed for the Extension study. The trial is registered with the ISRCTN registry, number 03267836. FINDINGS: Between July 25, 2014, and Aug 5, 2016, 149 participants were randomly assigned to the intervention group and 149 were assigned to the control group in the original DiRECT study. After 2 years, all intervention participants still in the trial (101 [68%] of 149) were approached to receive low-intensity support for a further 3 years. 95 (94%) of 101 were able to continue and consented and were allocated to the DiRECT extension group. 54 participants were allocated to the non-extension group, where intervention was withdrawn. At 5 years, DiRECT extension participants (n=85) lost an average of 6·1 kg, with 11 (13%) of 85 in remission. Compared with the non-extension group, DiRECT extension participants had more visits with HbA1c <48 mmol/mol (<6·5%; 36% vs 17%, p=0·0004), without glucose-lowering medication (62% vs 30%, p<0·0001), and in remission (34% vs 12%, p<0·0001). Original control participants (n=149) had mean weight loss 4·6 kg (n=82), and 5 (5%) of 93 were in remission. Compared with control participants, original intervention participants had more visits with weight more than 5% below baseline (61% vs 29%, p<0·0001), HbA1c below 48 mmol/mol (29% vs 15%, p=0·0002), without antidiabetic medication (51% vs 16%, p<0·0001), and in remission (27% vs 4%, p<0·0001). Of those in remission at year 2, 26% remained in remission at 5 years. Serious adverse events in the original intervention group (4·8 events per 100 patient-years) were under half those in the control group (10·2 per 100 patient-years, p=0·0080). INTERPRETATION: The extended DiRECT intervention was associated with greater aggregated and absolute weight loss, and suggested improved health status over 5 years. FUNDING: Diabetes UK.

Underreporting of viral encephalitis and viral meningitis, Ireland, 2005-2008.

Viral encephalitis (VE) and viral meningitis (VM) have been notifiable infectious diseases under surveillance in the Republic of Ireland since 1981. Laboratories have reported confirmed cases by detection of viral nucleic acid in cerebrospinal fluid since 2004. To determine the prevalence of these diseases in Ireland during 2005-2008, we analyzed 3 data sources: Hospital In-patient Enquiry data (from hospitalized following patients discharge) accessed through Health Intelligence Ireland, laboratory confirmations from the National Virus Reference Laboratory, and events from the Computerised Infectious Disease Reporting surveillance system. We found that the national surveillance system underestimates the incidence of these diseases in Ireland with a 10-fold higher VE hospitalization rate and 3-fold higher VM hospitalization rate than the reporting rate. Herpesviruses were responsible for most specified VE and enteroviruses for most specified VM from all 3 sources. Recommendations from this study have been implemented to improve the surveillance of these diseases in Ireland.

Tropical rock lobster (Panulirus ornatus) uses chemoreception via the antennular lateral flagellum to identify conspecific ecdysis.

The tropical rock lobster, Panulirus ornatus, is a commercially important aquaculture species exhibiting complex social interactions in laboratory culture, including cannibalism of moulting conspecifics. Cannibalism of soft-shelled post-moult stage individuals is a major limitation during the juvenile stage of culture. Not limited to P. ornatus, cannibalism is widespread across farmed decapods, limiting stocking densities in crab, freshwater crayfish, and prawn species. To understand the mechanisms driving this behaviour and reduce its prevalence, we have investigated the role of chemoreception via the aesthetasc-bearing region of the lateral antennular flagellum, in the recognition of conspecific moulting cues. Differential expression analysis of several tissues in P. ornatus shows an upregulation of 70 ionotropic receptor isoforms, including co-receptors (IR25a and IR93a) and divergent receptors (IR4, IR7, and IR21a) in the aesthetasc-bearing region of the antennules. Deafferentation of the aesthetascs via deionised water exposure prevents juveniles from responding to conspecific moulting cues in a two-current choice flume, suggesting chemoreception, possibly olfaction, plays a role in identifying moulting juveniles. This is the first step in understanding the mechanisms via which cannibalism is triggered in juvenile P. ornatus culture. Further work in this area will help discover means to limit cannibalism in laboratory and commercial culture.

Parasternal intercostal plane block catheters for cardiac surgery: a retrospective, propensity weighted, cohort study.

Aim: Anesthesia for cardiac surgery has evolved toward fast-track recovery strategies incorporating non opioid analgesics and regional anesthesia. Materials & methods: This retrospective cohort study compared opioid consumption, pain scores and length of stay in patients who underwent cardiac surgery via median sternotomy and did or did not receive preoperative parasternal intercostal plane block catheters with postoperative ropivacaine infusions. Results: Postoperative opioid consumption and postoperative pain scores did not differ. Blocks were associated with decreased intraoperative opioids and reduced length of stay in the intensive care unit and hospital. Conclusion: Parasternal intercostal plane block catheters were not associated with decreased postoperative opioid consumption or pain scores, but were associated with reduced intraoperative opioids and length of stay.

Creation of a Novel Child Simulator and Curriculum to Optimize Administration of Seizure Rescue Medication.

INTRODUCTION: Although most cases of pediatric convulsive status epilepticus start in the prehospital setting, many patients do not receive treatment. The use of prehospital seizure rescue medications by caregivers is crucial, but studies suggest a lack of proper training on medication use. METHODS: We created a novel proof of principle mannequin and simulation for training proper administration of rectal diazepam, with a scoring paradigm to standardize and assess the educational process. RESULTS: Twenty-three health care providers (nurses and nurse practitioners, residents/fellows, and attending physicians) and 5 patient guardians/parents were included in the study. The rectal diazepam simulator displayed a high degree of physical and emotional realism (mean ≥ 4/5 on Likert scale survey) that effectively decreased time to treatment (-12.3 seconds; SD, 16.3) and improved the accuracy of medication delivery in a simulation setting (-4.2 points; SD, 3.1). The scoring technique had appropriate interrater reliability (≥86% on all but 2 prompts) and was a feasible instrument to assess the effectiveness of the educational intervention. CONCLUSIONS: A unique procedure-focused child simulator and rescue medication score offer an innovative and effective means to train caregivers on the use of lifesaving seizure rescue medications.

PPAR-alpha activation as a preconditioning-like intervention in rats in vivo confers myocardial protection against acute ischaemia-reperfusion injury: involvement of PI3K-Akt.

Peroxisome proliferator-activated receptors (PPAR) regulate the expression of genes involved in lipid metabolism, energy production, and inflammation. Their role in ischaemia-reperfusion (I/R) is less clear, although research indicates involvement of PPARs in some forms of preconditioning. This study aimed to explore the effects of PPAR-α activation on the I/R injury and potential cardioprotective downstream mechanisms involved. Langendorff-perfused hearts of rats pretreated with the selective PPAR-α agonist WY-14643 (WY, pirinixic acid; 3 mg·(kg body mass)·day(-1); 5 days) were subjected to 30 min ischaemia - 2 h reperfusion with or without the phosphatidylinositol 3-kinase (PI3K)-Akt inhibitor wortmannin for the evaluation of functional (left ventricular developed pressure, LVDP) recovery, infarct size (IS), and reperfusion-induced arrhythmias. A 2-fold increase in baseline PPAR-α mRNA levels (qPCR) in the WY-treated group and higher post-I/R PPAR-α levels compared with those in untreated controls were accompanied by similar changes in the expression of PPAR-α target genes PDK4 and mCPT-1, regulating glucose and fatty acid metabolism, and by enhanced Akt phosphorylation. Post-ischaemic LVDP restoration in WY-treated hearts reached 60% ± 9% of the pre-ischaemic values compared with 24% ± 3% in the control hearts (P < 0.05), coupled with reduced IS and incidence of ventricular fibrillation that was blunted by wortmannin. Results indicate that PPAR-α up-regulation may confer preconditioning-like protection via metabolic effects. Downstream mechanisms of PPAR-α-mediated cardioprotection may involve PI3K-Akt activation.

Active Rehabilitation in a Patient During and After Venovenous Extracorporeal Membrane Oxygenation With a Diagnosis of COVID-19: A Case Report.

PURPOSE: The coronavirus disease-2019 (COVID-19) pandemic has resulted in an influx of critically ill patients requiring mechanical ventilation, some receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). The benefits of early mobility while undergoing ECMO have been previously documented. However, the COVID-19 pandemic has presented physical therapists with novel challenges, balancing the risk of a widespread shortage of personal protective equipment (PPE) with the benefits of early mobility for patients on ECMO. The purpose of this case study is to report the successful rehabilitation of a critically ill patient with COVID-19 undergoing VV ECMO. METHODS: This is a case description of a 38-year-old man who presented to the hospital with COVID-19 and subsequent intubation and cannulation for VV ECMO. Physical therapy was initiated while the patient remained critically ill on VV ECMO. Focused coordination and education were employed to limit PPE usage by limiting the number of essential staff/therapists that entered the room as well as changing the frequency of therapy sessions dependent on how the patient was progressing functionally. RESULTS: On VV ECMO day 11, he was able to sit up and perform a sit-to-stand. ECMO decannulation occurred on hospital day 14 with extubation on hospital day 18. The patient progressed functionally while quarantined in the room until he was discharged home with supplemental oxygen after spending 29 days in the hospital. CONCLUSION: This case study demonstrates the clinical decision-making used to provide physical therapy services for a critically ill patient with COVID-19. High-level team coordination resulted in limiting the use of PPE as well as reducing staff exposure frequency during rehabilitation. Despite his severe critical illness, the patient was successfully discharged home within 30 days.

Development of a two-current choice flume behavioural bioassay for juvenile Panulirus ornatus response to moulting cues.

Characterising crustacean behaviour in response to conspecific chemical cues contributes to our evolving knowledge of the drivers of their social behaviour. There is particular interest in understanding the chemical and behavioural mechanisms contributing to cannibalism at ecdysis, as this behaviour substantially limits culture productivity of several commercially important crustaceans. Before investigating the role of chemoreception in cannibalism of moulting crustaceans, we must investigate its role in detecting moulting conspecifics. Here we use a two-current choice flume to observe juvenile tropical rock lobster (Panulirus ornatus) behavioural response to conspecific moulting cues and identifying attracted and avoidant behaviours correlating to moult stage and social relationship. Observed cue preferences show inter-moult juveniles are attracted to the moulting cues of lobsters to which they are socially naïve. In contrast, post-moult and inter-moult juveniles avoid the moulting cues of individuals whom they are socially familiar with. Average speed and total distance travelled by lobsters increases in response to conspecific moulting cues. This study demonstrates the suitability of a two-current choice flume for behavioural assays in P. ornatus and characterises clear behavioural patterns in juveniles exposed to conspecific moulting cues. This provides important framework for understanding the role of chemical communication in eliciting cannibalism.

Comparison of lateral quadratus lumborum and lumbar plexus blocks for postoperative analgesia following total hip arthroplasty: a randomized clinical trial.

INTRODUCTION: Effective analgesia after total hip arthroplasty must minimize pain and optimize early ambulation. Lumbar plexus blocks (LPBs) provide analgesia but may cause motor weakness. Quadratus lumborum blocks (QLBs) may provide analgesia with preserved motor strength. METHODS: This trial randomized subjects scheduled for elective hip arthroplasty to receive an LPB or lateral QLB for postoperative analgesia. The primary outcome was opioid consumption at 12-hour postoperative. Non-inferiority of lateral QLBs compared with LPBs was conducted using a one-sided two-sample t-test. Secondary outcomes included pain scores, cumulative opioid consumption, quadriceps strength, time to ambulation, and distance ambulated. Differences in pain scores and opioid consumption over time between groups were evaluated using a linear mixed model. RESULTS: The trial consented and randomized 111 subjects and 103 completed the study: LPB (n=50) and lateral QLB (n=53). Mean (95% CI) cumulative opioid consumption (mg) at 12-hour postoperative was not found to be non-inferior in the lateral QLB (15.9 (12.7 to 19.2)) vs the LPB (12.7 (10.2 to 15.1)) group (p=0.625). Pain scores in postoperative anesthetic care unit (PACU) and 24-hour postoperative did not differ. The maximum distance ambulated did not differ, but lateral QLB patients were 2.4 times more likely to ambulate in the first 12 hours (p=0.024) and had significantly greater quadriceps strength in PACU (p<0.001). DISCUSSION: Although we were unable to demonstrate non-inferiority for opioid consumption at 12-hour postoperative, strength and mobilization were improved in lateral QLB subjects. TRIAL REGISTRATION NUMBER: NCT04402437.

The role of PPAR in myocardial response to ischemia in normal and diseased heart.

Peroxisome proliferator-activated receptors (PPAR), ligand-activated transcription factors, belong to the nuclear hormone receptor superfamily regulating expression of genes involved in different aspects of lipid metabolism, inflammation and cardiac energy production. Activation of PPAR-α isoform by its natural ligands, fatty acids (FA) and eicosanoids, promotes mitochondrial FA oxidation as the primary ATP-generating pathway. On the other hand, PPAR-γ regulates lipid anabolism or storage, while, until recently, the function of PPAR-ß/δ has been less explored. Under conditions associated with acute or chronic oxygen deprivation, PPAR-α modulates expression of genes that determine substrate switch (FA vs. glucose) aimed at maintenance of basic cardiac function. Although PPAR-α and PPAR-γ synthetic agonists, hypolipidemic and antidiabetic drugs, have been reported to protect the heart against ischemia/reperfusion injury, it is still a matter of debate whether PPAR activation plays a beneficial or detrimental role in myocardial response to ischemia, in particular, in pathological conditions. This article reviews some findings demonstrating the impact of PPAR activation on cardiac resistance to ischemia in normal and pathologically altered heart. Specifically, it addresses the issue of susceptibility to ischemia in the diabetic myocardium, with particular regards to the role of PPAR. Finally, involvement of PPAR in the mechanisms of lipid-independent cardioprotective effects of some hypolipidemic drugs is also discussed.

Low-Carbohydrate Diets in the Management of Obesity and Type 2 Diabetes: A Review from Clinicians Using the Approach in Practice.

Low-carbohydrate diets are increasingly used to help patients with obesity and type 2 diabetes. We sought to provide an overview of the evidence for this treatment approach, considering the epidemiology and pathophysiology of obesity and diabetes in terms of carbohydrate excess. We describe the mechanistic basis for the clinical benefits associated with nutritional ketosis and identify areas of practice where the evidence base could be improved. We summarize the key principles which inform our approach to treating patients with low-carbohydrate diets. The scientific controversy relating to these diets is real but is consistent with the known challenges of any dietary interventions and also the limitations of nutritional epidemiology. Secondly, notwithstanding any controversy, international guidelines now recognize the validity and endorse the use of these diets as a therapeutic nutritional approach, in appropriate patients. Thirdly, we have found that early de-prescription of diabetes medications is essential, in particular insulin, sulphonylureas, and sodium-glucose cotransporter (SGLT2) inhibitors. Fourthly, we encourage patients to eat ad libitum to satiety, rather than calorie counting per se. Furthermore, we monitor cardiovascular risk factors frequently, as with all patients with obesity or diabetes, but we do not necessarily consider an increase in low-density lipoprotein (LDL)-cholesterol as an absolute indication to stop these diets, as this is usually related to large LDL particles, which are not associated with increased cardiovascular risk. In the absence of large randomized controlled trials with cardiovascular and other hard endpoints, adopting a low-carbohydrate diet is a legitimate and potentially effective treatment option for patients with diabetes or obesity.

Low Oxygen Stress During Early Development Influences Regulation of Hypoxia-Response Genes in Farmed Atlantic Salmon (Salmo salar).

Survival and growth of developing salmonids are negatively affected by low oxygen levels within gravel nests in natural streams, and hypoxic stress is often experienced by farmed Atlantic salmon (Salmo salar) within hatcheries. Exposure to hypoxia during early development may have long-lasting effects by altering epigenetic marks and gene expression in oxygen regulatory pathways. Here, we examine the transcriptomic response to low dissolved oxygen (DO) in post-hatch salmon reared continuously in 30%, 60% or 100% DO from fertilization until start of feeding. RNA sequencing revealed multiple differentially expressed genes, including oxygen transporting hemoglobin embryonic α subunit (hbae) and EGLN3 family hypoxia-inducible factor 3 (egln3) which regulates the stability of hypoxia inducible factor 1α (HIF-1α). Both hbae and egln3 displayed expression levels inversely correlated to oxygen concentration, and DNA methylation patterns within the egln3 promoter were negatively associated with the transcript levels. These results suggest that epigenetic processes are influenced by low oxygen levels during early development in Atlantic salmon to upregulate hypoxia-response genes.