Total Knee Arthroplasty With and Without Schedule II Opioids: A Randomized, Double-Blinded, Placebo-Controlled Trial.

INTRODUCTION: Orthopedic surgeons are the third highest prescribers of narcotics. Previous work demonstrated that surgeons prescribe three times the narcotics required, and most patients do not properly dispose of leftover medication following surgery. This has prompted the creation of multimodal pain regimens to reduce reliance on narcotics. It is unknown if these pathways can effectively eliminate opioids following total knee arthroplasty (TKA). Our purpose was to evaluate a multimodal regimen without schedule II narcotics following TKA, in a randomized, blinded fashion. We hypothesized that there would be no difference in pain scores between groups. METHODS: A total of 43 narcotic-naïve patients participated in a randomized, double-blinded, placebo-controlled trial. Postoperative protocols were identical between cohorts, except for the study medication. The narcotic group received an encapsulated 5 mg oxycodone, whereas the control group received an encapsulated placebo. Perioperative outcomes were compared with routine statistical analysis. RESULTS: Four patients withdrew early secondary to pain: three in the placebo group and one in the narcotic group (p=1.00). We found no difference in hospital length of stay (p=0.09) or pain scores at all time points between cohorts (all p>0.05). There was a higher proportion of patients using a narcotic in the opioid treatment arm at day 30 (40% vs. 21.4%, p=0.29) and day 60 (20% vs. 7.1%, p=0.32), although this was not statistically significant. CONCLUSION: A multimodal regimen without schedule II narcotics demonstrates equivalent pain scores and may reduce the risk of long-term opioid dependence following TKA.

Lateralizing calcaneal osteotomy performed with a percutaneous burr results in a significantly lower increase in tarsal tunnel pressure.

PURPOSE: Tarsal tunnel syndrome is well documented following lateralizing calcaneal osteotomy to manage varus hindfoot deformity. Traditionally, calcaneal osteotomy is performed with an oscillating saw. No studies have investigated the effect of alternative surgical techniques on postoperative tarsal tunnel pressure. The purpose of this study was to investigate the difference in tarsal tunnel pressures following lateralizing calcaneal osteotomy performed using a high-torque, low-speed "minimally invasive surgery" (MIS) Shannon burr versus an oscillating saw. METHODS: Lateralizing calcaneal osteotomy was performed on 10 below-knee cadaveric specimens. This was conducted on 5 specimens each using an oscillating saw (Saw group) or MIS burr (Burr group). The calcaneal tuberosity was translated 1 cm laterally and transfixed using 2 Kirschner wires. Tarsal tunnel pressure was measured before and after osteotomy via ultrasound-guided percutaneous needle barometer. Mean pre/post-osteotomy pressures were compared between groups. Differences were analyzed using Student's t test. RESULTS: The mean pre-procedure tarsal tunnel pressure was 25.8 ± 5.1 mm Hg in the Saw group and 26.4 ± 4.3 mm Hg in the Burr group (p = 0.85). The mean post-procedure pressure was 63.4 ± 5.1 in the Saw group and 47.8 ± 4.3 in the Burr group (p = 0.01). Change in tarsal tunnel pressure was significantly lower in the Burr group (21.4 ± 4.5) compared to the Saw group (37.6 ± 12.5) (p = 0.03). The increase in tarsal tunnel pressure was 43% lower in the Burr group. CONCLUSION: In this cadaveric study, tarsal tunnel pressure increase after lateralizing calcaneal osteotomy was significantly lower when using a burr versus a saw. This is likely because the increased width ("kerf") of the 3 mm MIS burr, compared to the submillimeter saw blade width, causes calcaneal shortening. Given the smaller increase in tarsal tunnel pressure, using the MIS burr for lateralizing calcaneal osteotomy may decrease the risk of postoperative tarsal tunnel syndrome. Future research in vivo should explore this.

A massive galaxy that formed its stars at z ≈ 11.

The formation of galaxies by gradual hierarchical co-assembly of baryons and cold dark matter halos is a fundamental paradigm underpinning modern astrophysics1,2 and predicts a strong decline in the number of massive galaxies at early cosmic times3-5. Extremely massive quiescent galaxies (stellar masses of more than 1011 M⊙) have now been observed as early as 1-2 billion years after the Big Bang6-13. These galaxies are extremely constraining on theoretical models, as they had formed 300-500 Myr earlier, and only some models can form massive galaxies this early12,14. Here we report on the spectroscopic observations with the JWST of a massive quiescent galaxy ZF-UDS-7329 at redshift 3.205 ± 0.005. It has eluded deep ground-based spectroscopy8, it is significantly redder than is typical and its spectrum reveals features typical of much older stellar populations. Detailed modelling shows that its stellar population formed around 1.5 billion years earlier in time (z ≈ 11) at an epoch when dark matter halos of sufficient hosting mass had not yet assembled in the standard scenario4,5. This observation may indicate the presence of undetected populations of early galaxies and the possibility of significant gaps in our understanding of early stellar populations, galaxy formation and the nature of dark matter.

A population of faint, old, and massive quiescent galaxies at [Formula: see text] revealed by JWST NIRSpec Spectroscopy.

Here we present a sample of 12 massive quiescent galaxy candidates at [Formula: see text] observed with the James Webb Space Telescope (JWST) Near Infrared Spectrograph (NIRSpec). These galaxies were pre-selected from the Hubble Space Telescope imaging and 10 of our sources were unable to be spectroscopically confirmed by ground based spectroscopy. By combining spectroscopic data from NIRSpec with multi-wavelength imaging data from the JWST Near Infrared Camera (NIRCam), we analyse their stellar populations and their formation histories. We find that all of our galaxies classify as quiescent based on the reconstruction of their star formation histories but show a variety of quenching timescales and ages. All our galaxies are massive ([Formula: see text] M[Formula: see text]), with masses comparable to massive galaxies in the local Universe. We find that the oldest galaxy in our sample formed [Formula: see text] M[Formula: see text] of mass within the first few hundred million years of the Universe and has been quenched for more than a billion years by the time of observation at [Formula: see text] ([Formula: see text] billion years after the Big Bang). Our results point to very early formation of massive galaxies requiring a high conversion rate of baryons to stars in the early Universe.

Breast Magnetic Resonance Imaging for Preoperative Evaluation of Breast Cancer: A Systematic Review and Meta-Analysis.

Purpose: Preoperative breast magnetic resonance imaging (MRI) is known to detect additional cancers that are occult on mammography and ultrasound. There is debate as to whether these additional lesions affect clinical outcomes. The objective of this systematic review was to summarize the evidence on whether additional information on disease extent obtained with preoperative breast MRI in patients with newly diagnosed breast cancer affects surgical management, rates of recurrence, survival, re-excision, and early detection of bilateral cancer. Methods: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched until January 2021 (partial update July 2022) for studies comparing outcomes with versus without pre-operative MRI. Included were both randomized controlled trials and other comparative studies provided MRI and control groups had equivalent disease and patient characteristics or methods such as multivariable analysis or propensity score matching were used to control potential confounders. Results: The search resulted in 26,399 citations, of which 8 randomized control trials, 1 prospective cohort study, and 42 retrospective studies met the inclusion criteria. Use of MRI resulted in decreased rates of reoperations (OR = 0.73, 95% CI = 0.63 to 0.85), re-excisions (OR = 0.63, 95% CI = 0.45 to 0.89), and recurrence (HR = 0.77, 95% CI = 0.65 to 0.90). Increased detection of synchronous contralateral breast cancers led to a reduction in metachronous contralateral breast cancer (HR = 0.71, 95% CI = 0.59 to 0.85). Hazard ratios for recurrence-free and overall survival were 0.77 (95% CI = 0.53 to 1.12) and 0.89 (95% CI = 0.74 to 1.07). Conclusion: This systematic review indicates substantial benefits of pre-operative breast MRI in decreasing reoperations and recurrence.

Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline.

BACKGROUND: The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent. METHODS: After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic. RESULTS: Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

Patient Satisfaction and Pain Relief After Deep Peroneal Nerve Neurectomy for Midfoot Arthritis: A Preliminary Short Report.

BACKGROUND: The deep peroneal nerve (DPN) plays a role in afferent nociceptive dorsal midfoot joint pain perception. DPN neurectomy for treatment of symptomatic dorsal midfoot osteoarthritis allows early mobilization and weightbearing. The purpose of our study was to evaluate the patient satisfaction and pain relief after DPN neurectomy for treatment of chronic dorsal midfoot pain due to osteoarthritis. METHODS: In this retrospective, IRB-approved, questionnaire-based study, we evaluated 48 patients (55 feet) with an average follow-up of 35.1 (range, 16-51) months who underwent DPN neurectomy at our institution between September 2017 and February 2021. There were 38 women and 10 men, 41 unilateral (22 right, 19 left) and 7 bilateral procedures, with an average age of 67.8 (range, 35-88) years at the time of surgery. A questionnaire that included questions regarding postsurgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded. RESULTS: Of the 48 patients, 80.8% were satisfied with the result of the surgery in relieving their dorsal midfoot pain, 84.6% would repeat the surgery under the same circumstances, 83.8% would recommend the surgery to a friend, 10.4% reported they wish they had undergone arthrodesis, 91.7% reported pain relief in the first 6 months, and 55.6% reported current activity limitations. Six feet (10.9%) underwent a second procedure with an average postoperative time of 20.5 (range, 1-36) months. Complications included 1 hematoma and deep wound infection, 1 DPN neuroma and superficial peroneal nerve entrapment, and 4 patients with inadequate pain relief. CONCLUSION: In this cohort, DPN neurectomy appeared to be a reasonable surgical alternative to arthrodesis for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Contemporary Review: Autograft Bone Use in Foot and Ankle Surgery.

Bone autografts are frequently harvested for use in foot and ankle surgery. A commonly used harvest site is the iliac crest; however, because of known morbidity with this site, the tibia and calcaneus are attractive alternatives. There remains limited understanding regarding the osteogenic potential of autografts from each of these locations. In this review, we provided an update of the known data on bone autografts from the iliac crest, tibia, and calcaneus, focusing on the total cells harvested from each site as well as the presence of osteogenic osteoprogenitor cells. Level of Evidence: Level V, expert opinion.

Effectiveness of an Electronic Medical Record-Based Recognition Tool for the Identification of Incidental Pulmonary Nodules.

BACKGROUND: Incidental pulmonary nodules (IPNs) are lung nodules detected on imaging studies performed for an unrelated reason. Approximately 1.6 million IPNs are detected in the United States every year. Unfortunately, close to 1.1 million (69%) of these IPNs are not managed with appropriate follow-up care. The goal of this study was to assess the utility of a noncommercial electronic medical record (EMR)-based IPN keyword recognition program in identifying IPNs and the ability of lung navigators to communicate these findings to patients. METHODS: This is a observational, implementation study aimed identify IPNs using an EMR-based protocol and to relay results of findings to patients. The patient population included patients 16 and older undergoing computed tomography (CT) chest, CT chest/abdomen, CT angiogram chest, CT chest/abdomen/pelvis, and chest radiography through the radiology department within a large community tertiary medical campus between June 2019 and August 2020. EPIC EMR were queried using criteria designed to find IPNs. A lung navigator reviewed these cases and sorted them into categories based on their size and risk status. After identification of risk factors, actions were taken to directly communicate results to patients. RESULTS: Seven hundred and fifty-three patients were found to have true IPNs without a history of active malignancy involving the lung. On the basis of radiographic measurements, 60% of the nodules identified were <6 mm, 17% were between 6 and 8 mm, 22% were >8 mm, and 12% were deemed nodular opacities. Lung navigators were able to contact a total of 637 (87%) individuals with IPNs and results were directly communicated. Of the 637 patients identified to have an IPN, a total of 12 (2%) cancers were diagnosed. CONCLUSION: We have here demonstrated that the development of an EMR-based keyword recognition platform for the identification of IPNs is a useful and successful tool for communication of IPN findings to patients using lung navigators.

Measuring Deltoid Insufficiency After Supination-External Rotation Ankle Fracture With Lateral Talar Subluxation on Gravity Stress View.

BACKGROUND: Stress-view radiographs are frequently obtained to evaluate supination-external rotation (SER) variant ankle fractures. Measurement of the ankle medial clear space (MCS) is a surrogate of medial structure integrity as part of overall ankle stability. Measurement of the lateral talus displacement with respect to the incisura may be a sensitive and specific method to assess joint subluxation. METHODS: Retrospective review of acute SER-variant isolated lateral malleolar fractures with gravity stress views (GSVs) were performed for 103 patients. GSV analysis was performed with standardized measurements of the MCS, superior clear space (SCS), and 2 new novel measurements of lateral talus subluxation (LTS). Decision for surgery was obtained by surgeons who reviewed masked injury radiographs for predictive performance analysis of the LTS vs MCS. RESULTS: MCS, SCS, and LTS measurements were performed on 103 patients. Mean MCS, SCS, and LTS within the operative group was increased. MCS ≥5 mm and LTS >4 mm had equal sensitivity (95%), with higher specificity for LTS (75% vs 60%). Receiver operating characteristic analysis demonstrates an area under the curve of 0.786 for MCS ≥5 mm vs 0.918 for LTS >4 mm. CONCLUSION: We found LTS to be superior to MCS for medial ankle structure stability on gravity stress views of SER-variant ankle fractures. We propose this as a useful tool for clinicians to consider when evaluating SER-variant ankle fractures. LEVEL OF EVIDENCE: Level II, prospective comparative study of radiographs.

A retrospective case series of prophylactic neurectomy during total knee arthroplasty.

INTRODUCTION: Total knee arthroplasty is a common operation performed to relieve pain and restore functional activity. While overall widely successful, a subset of patients has continued pain postoperatively with no identifiable cause. Neuroma formation has been identified as a possible contributor to this unexplained pain, often necessitating an additional procedure for neuroma removal. The purpose of our study was to evaluate if prophylactic neurectomy could reduce the occurrence of postoperative pain. METHODS: A total of 112 patients were compared, 44 control patients and 68 neurectomy patients. Demographic information, Numerical rating pain scale (NRS) and Knee Society Scores (KSS) were collected pre- and post-operatively. Patients were additional asked if they were overall satisfied with the operation. RESULTS: There were no differences between groups with respect to age (Median: 71 vs 69 years, p = 0.28), male sex (41% vs 44%, p = 0.85), or body mass index (Median: 32.2 vs 31.3, p = 0.80). When comparing the degree of change following surgery there were no statistically significant differences observed in NRS pain scores (Median change: -7 vs -6, p = 0.89) or KSS scores (Median change: +44 vs +40, p = 0.14). Similarly, there was no statistically significant difference in overall patient-reported satisfaction with the knee replacement (82.5% vs 86.6%, p = 0.59). CONCLUSION: We did not find a statistically significant difference in NRS, KSS, or overall patient satisfaction between the prophylactic neurectomy and control patient groups. Larger studies with evaluation of the nerve diameter will be needed to determine which patients are at risk for symptomatic neuroma development following total knee arthroplasty.

A Retrospective Study Characterizing the Radiographic Progression of Hallux Valgus.

BACKGROUND: Hallux valgus deformity is the lateral deviation of the metatarsophalangeal (MTP) joint and is the most common pathology of the great toe, affecting 2%-4% of the population. It is commonly believed that the condition progresses over time both in the magnitude of deformity and development of arthritic changes. To our knowledge, there are rare studies describing the rate of deformity progression and the development of arthritic changes. Our aim is to quantify the progression of hallux valgus and associated arthritic changes in an adult population using radiographs. METHODS: Patients who are 18 years of age and older (mean age: 61.7 years and range: 18.6-94.2) who presented to our institutions between January 1, 2004, and December 1, 2019, were included. Patients were included in the study if they had hallux valgus on weight-bearing radiographs and two such radiographs at least six months apart. Hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsophalangeal (MTP) arthritis, tarsometatarsal (TMT) osteoarthritis, Hardy-Clapham sesamoid position, and round sign were collected per patient in the initial and final radiographs. Included cases were first studied together in a whole group. Then, cases were separated into three groups based on the time between initial and final radiographs. RESULTS: A total of 52 radiographic records for 43 patients were included. HVA and IMA progress with time; however, progression does not follow a direct relationship with the time elapsed between initial and final radiographs (p = 0.92 and p = 0.35, respectively). The progression of TMT osteoarthritis, sesamoid position, and round sign do not show a dependence on the time elapsed (p = 0.20, p = 0.11, and p = 0.42, respectively). An increase of one sesamoid unit position over baseline is associated with a 0.85-degree increase in IMA. A one-unit progression of sesamoid position at baseline raises the odds of MTP osteoarthritis progression at the follow-up visit by 2.14 (OR = 2.14, p = 0.0007, CI = [1.35, 3.83]). A HVA increase of one degree increases the odds of TMT osteoarthritis progression at follow-up by a factor of 1.17 (OR = 1.17, p = 0.0005, CI = [1.07, 1.34]). Patients with MTP arthritis at the initial visit have 3.77 times higher odds of round sign progression on their follow-up visit (OR = 3.77, p = 0.027, CI = [1.16, 13.13]). DISCUSSION: Hallux valgus progression can be quantified. Upon their first visit, a patient's hallux valgus parameters can be utilized to demonstrate expected progression. Progression of the deformity and arthritic changes is slow. Nonetheless, the results should be considered by surgeons and patients when developing a treatment plan with patients.

Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Breast Cancer: ASCO-OH (CCO) Guideline Update.

PURPOSE: To update recommendations of the American Society of Clinical Oncology (ASCO)-Ontario Health (Cancer Care Ontario [CCO]) adjuvant bone-modifying agents in breast cancer guideline. METHODS: An Expert Panel conducted a systematic review to identify new, potentially practice-changing data. RESULTS: Four articles met eligibility criteria and form the evidentiary basis for revision of the previous recommendations. RECOMMENDATIONS: Adjuvant bisphosphonate therapy should be discussed with all postmenopausal patients (natural or therapy-induced) with primary breast cancer, irrespective of hormone receptor status and human epidermal growth factor receptor 2 status, who are candidates to receive adjuvant systemic therapy. Adjuvant bisphosphonates, if used, are not substitutes for standard anticancer modalities. The benefit of adjuvant bisphosphonate therapy will vary depending on the underlying risk of recurrence and is associated with a modest improvement in overall survival. The NHS PREDICT tool provides estimates of the benefit of adjuvant bisphosphonate therapy and may aid in decision making. Factors influencing the decision to recommend adjuvant bisphosphonate use should include patients' risk of recurrence, risk of side effects, financial toxicity, drug availability, patient preferences, comorbidities, and life expectancy. When an adjuvant bisphosphonate is used to prevent breast cancer recurrence, the therapeutic options recommended by the Panel include oral clodronate, oral ibandronate, and intravenous zoledronic acid. The Panel supports starting bisphosphonate therapy early, consistent with the points outlined in the parent CCO-ASCO guideline; this is a consensus recommendation. The Panel does not recommend adjuvant denosumab to prevent breast cancer recurrence, because studies did not show a consistent reduction of breast cancer recurrence in any subset of those with early-stage breast cancer.Additional information can be found at www.asco.org/breast-cancer-guideline.

Intertrochanteric fracture fixation in solid organ transplant patients: outcomes and survivorship.

BACKGROUND: Solid organ transplantation (SOT) recipients have complex medical and surgical risk factors; however, the outcomes of these patients undergoing surgical fixation of hip fractures are unknown. This study sought to evaluate SOT patients' outcomes and survivorship after intertrochanteric (IT) fracture fixation. METHODS: A retrospective review identified 12 SOT patients who underwent cephalomedullary (CMN) nail fixation for IT fractures and were matched (1:2) to a cohort of 24 non-SOT IT fracture patients. Perioperative results and complications, mortality/patient survivorship, and clinical outcomes were compared between the cohorts. RESULTS: The time from presentation to surgical fixation was within 48 h of presentation for the non-SOT patients, while only 75% of SOT patients underwent surgery within 48 h of presentation (p = 0.034). The 90-day readmission rate for SOT patients was 25% versus 13% in the non-SOT group (p = 0.38). Similarly, the SOT cohort experienced a higher rate of major medical complication (25% vs. 13%, p = 0.38). There were two (16%) reoperations in the SOT group and three (13%) in the non-SOT matched group (p = 0.99). Respectively, the 90-day and 1-year estimated patient survivorship was similar between the two cohorts: SOT patients with 92% (95% CI 54-99%) and 73% (95% CI 24-93%) versus 86% (95% CI 62-95%) and 72% (95% CI 47-86%, HR 0.92, 95% CI 0.18-4.62, p = 0.92) in non-SOT patients. CONCLUSION: SOT patients who underwent CMN fixation for IT fractures required more time from hospital presentation to surgical management than non-SOT patients. Although not statistically significant, SOT patients demonstrated more acute complications and readmissions, but similar mortality compared to those without transplant.

Infrapatellar Saphenous Nerve Is at Risk During Tibial Nailing: An Anatomic Study.

OBJECTIVES: To determine the location and stage of the tibial nailing procedure where infrapatellar saphenous nerve (IPSN) injury may occur. METHODS: Fourteen fresh-frozen right cadaveric knees underwent tibial nailing. Six knees underwent a suprapatellar approach and 8 a medial parapatellar approach. Two proximal medial-to-lateral screws were placed using the aiming guide. The incisions were then closed. After the procedure, medial retinacular and saphenous nerves were dissected under surgical 2.5× loupe magnification from a proximal to distal direction. The branch of the IPSN closest to the locking screws was measured, as was the distance between the IPSN branch and the inferior pole of the patella. RESULTS: Twelve of 14 cadavers had prominent IPSN (main branch from the saphenous proper) with an average of 2.5 sub-branches. The mean (SD) distance from the main branch of the IPSN to the inferior pole of the patella was 40.9 (24.4) mm. Four medial retinacular nerve branches, branching from the femoral nerve and not IPSN, were identified proximal to the patella during the medial parapatellar approach. All were cut after the medial parapatellar arthrotomy. The mean (SD) distance from the IPSN to the nearest locking screw was 10.2 (14.1) mm. Seven of 14 had IPSN injuries, and one had hamstring injury. Two direct screw entrapments occurred, whereas two IPSNs were lacerated by the incision. Suture closure entrapped three nerve branches, and one specimen had injured fibers of the hamstring tendinous insertion. CONCLUSIONS: Injury to the IPSN can occur at different locations and stages of tibial nailing, including approach, proximal locking screw insertion, and closure.

Virtual Care in Patients with Cancer: A Systematic Review.

Virtual care in cancer care existed in a limited fashion globally before the COVID-19 pandemic, mostly driven by geographic constraints. The pandemic has required dramatic shifts in health care delivery, including cancer care. We conducted a systematic review of comparative studies evaluating virtual versus in-person care in patients with cancer. Embase, APA PsycInfo, Ovid MEDLINE, and the Cochrane Library were searched for literature from January 2015 to 6 August 2020. We adhered to PRISMA guidelines and used the modified GRADE approach to evaluate the data. We included 34 full-text publications of 10 randomized controlled trials, 13 non-randomized comparative studies, and 5 ongoing randomized controlled trials. Evidence was divided into studies that provide psychosocial or genetic counselling and those that provide or assess medical and supportive care. The limited data in this review support that in the general field of psychological counselling, virtual or remote counselling can be equivalent to in-person counselling. In the area of genetic counselling, telephone counselling was more convenient and noninferior to usual care for all outcomes (knowledge, decision conflict, cancer distress, perceived stress, genetic counseling satisfaction). There are few data for clinical outcomes and supportive care. Future research should assess the role of virtual care in these areas. Protocol registration: PROSPERO CRD42020202871.

Quorum quenching activity of Andrographis paniculata (Burm f.) Nees andrographolide compounds on metallo-ß-lactamase-producing clinical isolates of Pseudomonas aeruginosa PA22 and PA247 and their effect on lasR gene expression.

Andrographis paniculata (Burm f.) Nees is a tropical plant native to Southeast Asia that has been used as an effective remedy for a wide variety of illnesses in traditional Chinese and Ayurvedic medicine. The antimicrobial activity of its crude extract had been shown to be due to its quorum quenching activity. The study determined the effect of purified extracted compounds from the leaf of A. paniculata, namely: andrographolide, 14-deoxyandrographolide, 14-deoxy-12-hydroxyandrographolide and neoandrographolide on quorum sensing-mediated virulence mechanisms in clinical isolates of metallo-ß-lactamase (MßL)-producing Pseudomonas aeruginosa. Their effect on the expression of the lasR gene, which codes for LasR, a transcription activator protein of the quorum sensing system in P. aeruginosa was also determined using RT-qPCR. All the pure compounds significantly decreased the biofilm formation, protease production and swarming motility of the P. aeruginosa isolates compared to the untreated controls (p < 0.05). Results of the RT-qPCR assay showed that all compounds significantly downregulated the expression of lasR compared to the untreated control (p < 0.05), supporting the position that the lower virulence activities of the treated group were due to quorum quenching activity of the pure compounds. Multiple comparisons using Tukey's HSD analysis revealed that the means of the relative expression of lasR of the isolates treated with the different compounds were not significantly different from each other (p > 0.05), suggesting equal potencies. Results show the potential of the isolated pure compounds from A. paniculata for use as antimicrobial agents as a result of their quorum quenching activities.

Allograft Interposition Bone Graft for First Metatarsal Phalangeal Arthrodesis: Salvage After Bone Loss and Shortening of the First Ray.

BACKGROUND: Previous studies have demonstrated success in using autogenous bone graft for arthrodesis in patients with failed surgeries of the hallux. These patients have several causes for pain and dysfunction preoperatively, including a shortened first ray, nonunion, and poor hallux alignment. METHODS: In this study, a consecutive series of 36 patients (38 procedures) were treated with a patellar wedge interposition structural allograft to salvage bone loss from great toe arthrodesis malunion, painful joint replacement, failed osteotomy, or infection of the great toe metatarsophalangeal (MP) joint with shortening of the first ray. The goals of the surgery were to restore length to the first ray and provide a stable MP joint fusion to relieve pain. The 38 treated toes were evaluated for preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) MP scores, subjective patient outcome scores, and clinically successful fusion of the hallux. RESULTS: At a minimum 1-year follow-up (mean, 3.2 years), all but 2 feet healed with a solid fusion, and all healed patients reported good or excellent outcomes. AOFAS MP scores averaged 43.5 preoperatively and 77.2 postoperatively. Three patients with infection as cause for nonunion of the initial procedure were treated with staged procedures, including the use of a temporary antibiotic spacer and mini external fixator; all 3 healed without recurrent infection. One patient had a fracture of her allograft following her interposition arthrodesis, but it fused successfully after a second interposition arthrodesis surgery. Two patients developed a nonunion of the revision arthrodesis. CONCLUSION: The use of an interposition patellar wedge allograft can restore length to the first ray and provide successful salvage of arthrodesis nonunions and bone loss from failed hemiarthroplasty and total joint implants of the great toe MP joint. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Revisiting metal fluorides as lithium-ion battery cathodes.

Metal fluorides, promising lithium-ion battery cathode materials, have been classified as conversion materials due to the reconstructive phase transitions widely presumed to occur upon lithiation. We challenge this view by studying FeF3 using X-ray total scattering and electron diffraction techniques that measure structure over multiple length scales coupled with density functional theory calculations, and by revisiting prior experimental studies of FeF2 and CuF2. Metal fluoride lithiation is instead dominated by diffusion-controlled displacement mechanisms, and a clear topological relationship between the metal fluoride F- sublattices and that of LiF is established. Initial lithiation of FeF3 forms FeF2 on the particle's surface, along with a cation-ordered and stacking-disordered phase, A-LixFeyF3, which is structurally related to α-/ß-LiMn2+Fe3+F6 and which topotactically transforms to B- and then C-LixFeyF3, before forming LiF and Fe. Lithiation of FeF2 and CuF2 results in a buffer phase between FeF2/CuF2 and LiF. The resulting principles will aid future developments of a wider range of isomorphic metal fluorides.