Giant cerebral hydatid cyst with intraventricular extension: A rare case report with imaging findings.

Hydatid cyst is the condition caused by larvae of the parasite Echinococcus granulosus, usually involving the liver, lung, and spleen. Involvement of the cerebrum with a hydatid cyst is a rare entity, comprising 2%-3% of all cases of hydatidosis. Intraventricular extension of cerebral hydatid cysts occurs in only a limited percentage of cases. Cerebral hydatid cysts can present with nonspecific symptoms, usually with features of raised intracranial pressure. Therefore, it is crucial to consider cerebral hydatid cysts as a potential diagnosis, especially in pediatric patients with nonspecific neurological symptoms, particularly those from areas endemic to the parasite. We report a case of a 9-year-old girl who presented with progressive headache and vomiting, with imaging findings suggestive of a giant hydatid cyst in the brain. She was managed surgically with a good outcome.

Customized therapeutic deep anterior lamellar keratoplasty in perforated Mooren's ulcer: A novel technique.

We describe customized therapeutic deep anterior lamellar keratoplasty (DALK) for treating a perforated Mooren's ulcer. Slit-lamp biomicroscopy revealed corneal perforation (3.5 mm × 3.0 mm) with iris prolapse. The corneal melt extended from 9.0 o'clock to 4.0 o'clock. The peripheral edge of the ulcer was sloping, whereas the medial edge showed undermining. Immunological tests did not reveal any evidence of systemic autoimmune disease. In view of extensive peripheral corneal melt with large corneal perforation, the patient needed tectonic keratoplasty. The penetrating graft is not only technically demanding but also results in a poor visual outcome. We advised customized tectonic DALK. We used two different-sized trephines to obtain appropriate-sized donor tissue and avoided manual dissection. The post-surgery period was uneventful. He was prescribed topical steroids and oral methotrexate. He achieved 6/9 aided visual acuity at 4 months and maintained it until the last follow-up at 36 months.

Manual schism and intracameral air injection for impacted Descemet's membrane detachment.

A woman in her 60s was referred to us for management of poor vision following cataract surgery in the right eye. She had undergone manual small incision cataract surgery 12 weeks earlier. Slit-lamp biomicroscopy revealed corneal oedema, a horizontal line at the upper border and the adhered inferior border of detached Descemet's membrane (DM). Clinical diagnosis of impacted Descemet's membrane detachment (DMD) was considered.Surgical intervention with manual schisis and intracameral injection of air was planned. Using the 'push technique,' we tried to place the tip of the 27 gauge cannula between the back of the cornea and detached DM. The tip of the 27 gauge cannula was behind the impacted DM, and air injection was unsuccessful. Using the back-up the 'pull technique,' bent tip of the 27 gauge cannula was used to pull the impacted DMD. This manoeuvre, disimpacted the inferior border and the air bubble, was injected using the 27 gauge cannula. The air bubble unfolded and reattached the DM successfully.

Double bubble pneumo-descemetopexy for the management of Descemet membrane detachment: An innovative technique.

A 62-year-old woman was referred with poor vision following manual small incision cataract surgery. On presentation, the uncorrected distance visual acuity in the involved eye was 3/60, whereas slit-lamp examination revealed a central corneal edema with the peripheral cornea relatively clear. Direct focal examination with a narrow slit upper border and lower margin of detached rolled up Descemet's membrane (DM) could be visualized. We performed a novel surgical approach, "double-bubble pneumo-descemetopexy." The surgical procedure included unrolling of DM with "small air bubble" and descemetopexy with "big bubble." No postoperative complications were observed, and best corrected distance visual acuity improved to 6/9 at 6 weeks. The patient had a clear cornea and maintained BCVA 6/9 during 18 months at follow-up. Double-bubble pneumo-descemetopexy, a more controlled technique, provides a satisfactory anatomical and visual outcome in DMD without the need for endothelial keratoplasty (Descemet's stripping endothelial keratoplasty or DMEK) or penetrating keratoplasty.

In vitro antimicrobial efficacy of riboflavin, ultraviolet-A radiation, and combined riboflavin/ultraviolet-A radiation on ocular pathogens.

PURPOSE: There is a lack of studies evaluating the antimicrobial effect of riboflavin and ultraviolet-A (UVA) radiation using an epithelium-off cross-linking technique (Dresden protocol) in the literature. This study aimed to demonstrate the antimicrobial properties of riboflavin and UVA radiation and combined riboflavin/UVA radiation on various ocular pathogens Dresden protocol. MATERIALS AND METHODS: This was a prospective and comparative study. This study included four groups: Staphylococcus aureus, Pseudomonas aeruginosa, Candida albicans, and Acanthamoeba. All the groups were tested 12 different times with riboflavin alone, UVA light alone, and combined riboflavin with UVA. The growth inhibition zones were measured. Descriptive statistics were expressed as mean and standard deviation. The main outcome was measurement and analysis of growth inhibition zones. RESULTS: The mean growth inhibition zones following riboflavin and UVA exposure were 9.70 ± 1.63 mm for P. aeruginosa and 7.70 ± 1.08 mm for S. aureus. The mean growth inhibition zones for P. aeruginosa were greater than for S. aureus (t = 2.395, P = 0.038). The mean growth inhibition zones for C. albicans and Acanthamoeba were 0. The mean growth inhibition zones following UVA exposure alone and riboflavin alone for all organisms were also 0. CONCLUSION: Combined riboflavin and UVA in the clinical dose was effective against P. aeruginosa and S. aureus but ineffective against C. albicans and Acanthamoeba. Our study shows the potential of combined riboflavin and UVA in the treatment of bacterial keratitis.

Histopathologically Validated Diagnostic Accuracy of PSMA-PET/CT in the Primary and Secondary Staging of Prostate Cancer and the Impact of PSMA-PET/CT on Clinical Management: A Systematic Review and Meta-analysis.

Prostate-specific membrane antigen (PSMA) is a highly expressed protein in prostate cancer (PCa) and has become an increasingly popular target for molecular imaging in recent years. PSMA based positron-emission-tomography/computed tomography (PET/CT) is a well characterised hybrid imaging modality that combines the high sensitivity of PET with the high spatial resolution of CT imaging. The combination of these two imaging modalities provides an accurate tool for detecting and managing PCa. Several diagnostic accuracy and clinical management studies investigating the role of PSMA PET/CT in PCa have been published recently. This study aimed to perform an updated systematic review and meta-analysis to evaluate the diagnostic performance of PSMA PET/CT in localised, lymph node metastatic (LNM) and recurrent PCa patients and assess its impact on the clinical management of primary and recurrent PCa. Using Medline, Embase, PubMed and Cochrane Library databases, studies reporting the diagnostic accuracy and clinical management of PSMA PET/CT were analysed based on the PRISMA guidelines. Statistical analyses were conducted using random-effects models, and meta-regression explored observed heterogeneity. Results indicate that the sensitivity and specificity of PSMA PET/CT for localised PCa were 71.0% (95% confidence interval (CI): 58.0, 81.0) and 92.0% (95% CI: 86.0, 96.0), respectively (N = 10; n = 404 patients). Sensitivity and specificity in LNM were 57.0% (95% CI: 49.0, 64.0) and 96.0% (95% CI: 95.0, 97.0) (N = 36; n = 3,659 patients). For patients with biochemical recurrence (BCR), sensitivity was 84.0% (95% CI: 74.0, 90.0), and specificity was 97.0% (95% CI: 88.0, 99.0) (N = 9; n = 818 patients). The pooled proportion of management changes in primary (N = 16; n = 1,099 patients) and recurrent (N = 40; n = 5,398 patients) PCa was 28.0% (95% CI: 23.0, 34.0) and 54.0% (95% CI: 50.0, 58.0), respectively. In conclusion, PSMA PET/CT shows moderate sensitivity and high specificity in localised and LNM disease, while the accuracy in BCR patients was high. PSMA PET/CT also had a large impact on the clinical management of PCa patients. This is the most extensive and first systematic review to include three subgroups of PCa with histologically verified diagnostic accuracy and clinical management change reported separately in primary and recurrent disease settings.

Retrocorneal Scleral Patch Supported Glue: A Technique for Management of Corneal Perforation and Corneoscleral Melt following Pterygium Surgery.

Purpose: To describe a new method of treatment of corneal perforation with extensive corneoscleral melt. Case Report: A 42-year-old man presented with moderate-sized (3.5 mm) corneal perforation with extensive corneo-limbo-scleral ulceration following bare sclera excision of pterygium. No prior use of antimetabolites or postoperative beta radiation noted. We considered retrocorneal sclera patch supported cyanoacrylate application. The sclera was thinned to one-third thickness and a patch (4.5 × 4.5 mm) was punched. The sclera patch was placed on the iris, behind the corneal perforation, adequately covering it from inside. A minimal amount of adhesive was applied on the retrocorneal sclera patch and margin of corneal perforation. The ulcerating sclera was covered with double layered amniotic membrane. Topical antibiotic, steroid, and cycloplegic drops were instilled thrice daily. Corneal perforation healed and no recurrence occurred during the 18 months' follow-up. Conclusion: Retrocorneal scleral patch supported cyanoacrylate is effective for corneal perforation with corneo-scleral melt.

Effect of mydriatic eye drops (combined 0.8% tropicamide and 5% phenylephrine) on the measurements of corneal parameters using Pentacam.

Purpose: The purpose of the study is to investigate the effects of combined 0.8% tropicamide and 5% phenylephrine on the corneal parameters using Pentacam. Methods: The study was performed on 200 eyes of 100 adult patients visiting the ophthalmology clinic for evaluation of refractive errors or cataract screening. Mydriatic drops (Tropifirin; Java, India) containing tropicamide 0.8%, phenylephrine hydrochloride 5%, and chlorbutol 0.5% (as a preservative) were instilled into the eyes of the patients three times every 10 minutes. The Pentacam was repeated after 30 minutes. The measurement data of various corneal parameters from different Pentacam displays (keratometry, pachymetry, densitometry, and Zernike analysis) was manually compiled on an Excel spreadsheet and analyzed using Statistical Package for the Social Sciences (SPSS) 20 software. Results: Analysis of Pentacam refractive maps revealed a statistically significant increase (P < 0.05) in the values of radius peripheral (cornea front), pupil center Pachymetry, pachymetry apex, thinnest location Pachymetry, and cornea volume. However, pupil dilation did not affect the Q-value (asphericity). Analysis of the densitometry values revealed significant increase in all zones. Aberrations maps revealed statistically significant increase in the value of spherical aberration after the induction of mydriasis, but the values of Trefoil 0º, Trefoil 30º, Koma 90º, and Koma 0º were not affected significantly. We did not observe any untoward effect of the drug, except transient blurring of vision. Conclusion: The current study showed that routine mydriasis in the eye clinics leads to a significant increase in various corneal parameters including corneal pachymetry, cornea densitometry, and spherical aberration as measured by Pentacam, which can influence the decision-making in the management of various corneal diseases. The ophthalmologists should be aware of these issues and make adjustments in their surgical planning accordingly.

Interaction study of aflatoxin M1 with milk proteins using ATR-FTIR.

Aflatoxin M1 (AFM1) is a metabolite of carcinogenic aflatoxin B1 (AFB1) and appears in milk of dairy animals on ingestion of feed contaminated with AFB1. It has been reported to have affinity towards milk proteins, the exact mechanism of which is still unknown. In the present study, ATR-FTIR coupled with chemometrics is utilized to understand AFM1 interaction with milk proteins. The second order derivative spectra of the spectral window 1700-1600 cm-1 confirms the affinity of AFM1 towards milk proteins. The results of principal component analysis suggested that spectral window of 1700-1600 cm-1 is informative and provides an indication of the conformational changes brought by AFM1 in the secondary structure of milk proteins. Supplementary Information: The online version contains supplementary material available at 10.1007/s13197-022-05587-x.

Tissue Adhesives for the Management of Corneal Perforations and Challenging Corneal Conditions.

Corneal perforations are ophthalmological emergencies which can have serious and detrimental consequences, if not managed timely and appropriately. These are a significant cause of ocular morbidity and can result in decreased vision, blindness, and even loss of the eye. Corneal perforations can be managed using a range of treatment approaches, including temporary solutions such as the application of corneal glue and bandage contact lens, as well as definitive treatment such as corneal transplantation. Tissue glues/adhesives were developed as substitutes for sutures in ophthalmic surgery. Unlike sutures, these glues are associated with shorter overall surgical times and reduced inflammation, thus improving postoperative comfort without compromising wound strength. The available tissue adhesives can be broadly classified into two types: synthetic (eg, cyanoacrylate derivatives) and biological (eg, fibrin glue). Cyanoacrylate glue is chiefly used as a corneal patch to manage acute corneal perforations and improve visual outcomes. Fibrin glue can be used instead of cyanoacrylate glue in many conditions with the benefits of reduced conjunctival and corneal inflammation and reaction. Apart from this, each type of adhesive is distinct in terms of its benefits as well as limitations and is accordingly used for different indications. The present review focuses on the two main types of tissue adhesives, their applications in the management of corneal perforations, the associated complications, safety and efficacy data related to their use available in the literature and the need for newer adhesives in this field.

Methods to differentiate between cotton tract area ghee and cotton seed oil adulterated ghee.

Ghee, the clarified butter fat is one of the principal dairy products in India. In some places of India, cotton seed is fed extensively to dairy animals which changes the physico-chemical constants and fatty acid profile of the milk fat. Ghee is often adulterated with cotton seed oil and is marketed as cotton tract area ghee. Physico-chemical constants like RM value, Polenske value, BR reading, saponification value, iodine value and colorimetric tests i.e., Halphen and DPPH radical test were employed to differentiate ghee adulterated with cotton seed oil and that from cotton tract area. Chromatographic techniques like HPLC and GC-MS were also explored. Physico-chemical constants were not useful to differentiate the two types of ghee. Cyclopropenoic acids were observed only in ghee adulterated with cotton seed oil and not in cotton tract ghee. The RP-HPLC could able to distinguish the cotton tract area ghee from ghee adulterated with cotton seed oil on the basis of presence of ß-sitosterol in the latter. Halphen test was positive for cotton tract ghee, but not for the cotton seed oil adulterated ghee. Methylene blue reduction and DPPH radical test were also found to be useful to distinguish both types of ghee.

Utilization and characterization of flaxseed oil in ultrasonically emulsified mango beverage.

The present study described the formation of stable emulsion of flaxseed oil (0%, 0.25%, 0.50%, 0.75% v/v) in ready to serve Mango beverages using 20 kHz ultrasound of power input 21 W, 32 W, 43 W for varying times 3, 5, 7 min to create emulsion droplets size 100-800 nm. Oil was extracted by ultrasound-assisted extraction and solvent extraction method by varying solvents, time, ultrasonic intensity etc. and physio-chemical characterization was conducted. Fatty acid profiling revealed that linolenic acid and linoleic acid are major fatty acids present in extracted oil. Effect of flaxseed oil in fruit-based beverage was evaluated in terms of turbidity, pH, acidity, color, antioxidant activity and carotenoids content. Pectin stabilizes emulsion droplets by generating electrostatic repulsion (ζ potential - 25 mV) and the emulsions were stable upto 18 days at (4 ± 2) °C. The rheological behaviour in terms of viscosity of the emulsion stayed unaffected with sonication time upon storage. The carotenoids and antioxidant activity significantly increased from 151.37 to 292.24 µg/mL and 26.99% to 61.43% respectively at 0 to 0.75% added oil in the beverage and enhanced stability by preventing lipid oxidation. Organoleptic score of 0.25% and 0.50% of the flaxseed oil in the beverage was found to be acceptable.

Microcosting Study of Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography in Prostate Cancer.

OBJECTIVES: Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) has emerged as a promising imaging tool in prostate cancer diagnosis. PSMA PET/CT radiotracers are produced in-house (gallium-68, eg, 68Ga-PSMA-11) or provided by commercial entities (fluorine-18, eg, 18F-DCFPyL). Nevertheless, the cost per procedure is not well established given that current estimates have several limitations. This study aimed to establish the cost of PSMA PET/CT in Australia. METHODS: Hospitals and diagnostic facilities currently conducting PSMA PET/CT in Australia in metropolitan and regional areas completed a survey of PSMA PET/CT throughput, radiotracers involved, and the cost of assets, departmental staffing, consumables, and occupancy. Total costs were estimated using a top-down microcosting approach, involving identifying all relevant cost components and valuing each component for the average patient, and a gross costing approach, involving apportioning cost components at an aggregated level. RESULTS: Data were collected from 8 facilities. The most common radiotracer used was 18F-DCFPyL (7 facilities, 87%), followed by 68Ga-PSMA-11 (4 facilities, 50%). The average cost of PSMA PET/CT was A$1554.77 and A$1306.00 based on the microcosting and gross costing approaches, respectively. CONCLUSIONS: This study provides a detailed and accurate estimation of the cost of PSMA PET/CT in Australia. These costs can be used as a benchmark to identify potential efficiencies and help policy makers set the appropriate reimbursement rate for this procedure. The use of data from facilities using different radiotracers in metropolitan and regional areas and with different throughput increases the generalizability of the results, especially in countries with similar health systems.

Characterization of Four New Compounds from Protea cynaroides Leaves and Their Tyrosinase Inhibitory Potential.

Protea cynaroides (king protea) is a flowering plant that belongs to the Proteaceae family. This multi-stemmed shrub is the national flower of South Africa and has important economic and medicinal values. Traditionally, the main therapeutic benefits of this plant species include the treatment of cancer, bladder, and kidney ailments. There are very limited reports on the isolation of phytochemicals and their biological evaluation from P. cynaroides. In this study, the leaves of P. cynaroides were air-dried at room temperature, powdered, and extracted with 80% methanol followed by solvent fractionation (hexane, dichloromethane, ethyl acetate, and butanol). The ethyl acetate and butanol extracts were chromatographed and afforded four new (1-4) and four known (5-8) compounds, whose structures were characterized accordingly as 3,4-bis(4-hydroxybenzoyl)-1,5-anhydro-D-glucitol (1), 4-hydroxybenzoyl-1,5-anhydro-D-glucitol (2), 2-(hydroxymethyl)-4-oxo-4H-pyran-3-yl-6-O-benzoate-ß-D-glucopyranoside (3), 3-hydroxy-7,8-dihydro-ß-ionone 3-O-ß-D-glucopyranoside (4), 4-hydroxybenzoic acid (5), 1,5-anhydro-D-glucitol (6), 3,4-dihydroxybenzoic acid (7), and 3-hydroxykojic acid (8). The structural elucidation of the isolated compounds was determined based on 1D and 2D NMR, FTIR, and HRMS spectroscopy, as well as compared with the available literature data. The tyrosinase inhibitory activities of the extracts and isolated compounds were also determined. According to the results, compounds 7 and 8 exhibited potent competitive tyrosinase inhibitory activity against L-tyrosine substrates with IC50 values of 0.8776 ± 0.012 and 0.7215 ± 0.090 µg/mL compared to the control (kojic acid, IC50 = 0.8347 ± 0.093), respectively. This study is the first chemical investigation of compounds 1-4 from a natural source and the first report of the biological evaluation of compounds 1-5 against the tyrosinase enzyme. The potent anti-tyrosinase activity exhibited by P. cynaroides constituents will support future exploration of the plant in the cosmetic field upon further biological and clinical investigations.

Cost-Effectiveness Analysis of Prostate-Specific Membrane Antigen (PSMA) Positron Emission Tomography/Computed Tomography (PET/CT) for the Primary Staging of Prostate Cancer in Australia.

BACKGROUND AND OBJECTIVES: Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) combined with computed tomography (CT) is a new imaging modality to detect the extra-prostatic spread of prostate cancer. PSMA PET/CT has a higher sensitivity and specificity than conventional imaging (CT ± whole body bone scan [WBBS]). This study conducted a cost-utility analysis of PSMA PET/CT compared with conventional imaging for patients with newly diagnosed, intermediate-risk or high-risk primary prostate cancer. PERSPECTIVE: Australian healthcare perspective. SETTING: Tertiary. METHODS: A decision-analytic Markov model combined data from a variety of sources. The time horizon was 35 years. The sensitivity and specificity of PSMA PET/CT and CT alone were based on meta-analyses and the test accuracy of CT+WBBS was based on a single randomised controlled trial. Health outcomes included cases detected, life-years, and quality-adjusted life-years. Costs related to other diagnostic tests, initial treatment, adverse events, and post-disease progression were included. All costs were reported in 2021 Australian Dollars (A$). RESULTS: The deterministic incremental cost-effectiveness ratio of PSMA PET/CT was estimated to be A $21,147/quality-adjusted life-year gained versus CT+WBBS, and A$36,231/quality-adjusted life-year gained versus CT alone. The results were most sensitive to the time horizon, and the initial treatments received by patients diagnosed with metastatic cancer. The probability of PSMA PET/CT being cost effective was estimated to be 91% versus CT+WBBS and 89% versus CT alone, using a threshold of AU$50,000/quality-adjusted life-year gained. CONCLUSIONS: PSMA PET/CT is likely to be more costly than CT+WBBS or CT alone in Australia; however, it is still likely to be considered cost effective compared with conventional imaging.

Physico-chemical characterization of ultrasound assisted clove oil-loaded nanoemulsion: As enhanced antimicrobial potential.

Clove oil has a high eugenol content, making it an effective antimicrobial essential oil; nevertheless, its low water solubility, high volatility, and organoleptic qualities limit its use in food systems. As a result, we created an antibacterial system using clove oil-in-water nanoemulsion. Clove oil nanoemulsions were produced using whey protein concentrate (0.1-1%) as an emulsifier by ultrasonication and various physico-chemical characteristics (stability, particle size, zeta-potential, and poly dispersity index) were investigated. Mean particle size, zeta potential and polydispersity index of the most stable nanoemulsion were 279.0 ± 8.43 nm, -34.5 ± 0.12 mV, and 0.179 ± 0.012, respectively. Most stable nanoemulsion was fairly stable at different processing parameters such as various pH (3.0 - 7.0), temperature ranges (63 - 121 °C), and ionic strengths (0.1 - 1.0 M NaCl). Finally, antimicrobial activities, such as minimum inhibitory concentration was found with 50 µL, whereas minimum bactericidal concentration was observed to be 90 µL after 8 h contact time, against E. coli and B. subtilis strains.

Effect of incorporation of iron-whey protein concentrate (Fe-WPC) conjugate on physicochemical characteristics of dahi (curd).

Dahi samples were prepared from milk incorporated with spray-dried iron-whey protein concentrate (Fe-WPC) conjugate and ferrous sulfate (FeSO4) with three different concentrations of iron i.e. 15, 20 and 25 mg/L and their quality characteristics were determined. Fe-WPC conjugate incorporated dahi showed better sensory, textural and physical attributes as compared with those of FeSO4 fortified and control dahi. Non-significant (p > 0.05) changes were observed in attributes like acidity and flavor, color and appearance, body and texture scores of dahi fortified with Fe-WPC conjugate with upto 20 mg/L iron as compared to those of control. In contrast, definite metallic flavor was perceptible in case of FeSO4 incorporated dahi even at 15 mg/L level. Water holding capacity, viscosity and firmness were significantly (p < 0.05) higher in 20 mg/L Fe-WPC conjugate incorporated dahi samples as compared with those of 20 mg/L FeSO4 incorporated dahi samples. In vitro bio accessibility of iron from Fe-WPC conjugate incorporated dahi was found to be significantly (p < 0.05) higher than that from FeSO4 incorporated dahi. Therefore, the results indicated that Fe-WPC conjugate can be fortified in dahi with upto 20 mg/L without significantly altering its physicochemical properties and with a higher bioaccessibillity of iron.

Valvular Heart Disease in Patients with Chronic Kidney Disease.

Valvular heart disease (VHD) is highly prevalent in patients with chronic kidney disease (CKD) from the early stages to end-stage renal disease (ESRD). Aortic and mitral valves are the most frequently affected, leading to aortic valve and/or mitral annular calcification, which, in turn, causes either valve stenosis or regurgitation at an accelerated rate compared with the general population. Tricuspid regurgitation is also prevalent in CKD and ESRD, and haemodialysis patients are at an increasingly high risk of infective endocarditis. As for pathophysiology, several mechanisms causing VHD in CKD have been proposed, highlighting the complexity of the process. Echocardiography constitutes the gold standard for the assessment of VHD in CKD/ESRD patients, despite the progress of other imaging modalities. With regard to treatment, the existing 2017 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on the management of VHD addressing patients with normal kidney function are also applied to patients with CKD/ESRD.

Can the implementation of the Opioid Start Talking form impact the amount of opioid use in patients after ankle fracture repair?

OBJECTIVE: As part of 2018 legislation aimed at fighting the opioid epidemic, the Michigan Department of Health and Human Services (MDHHS) published the "Opioid Start Talking" (OST) Form on June 1, 2018. We examined if the implementation of the OST form led to an identifiable decrease in patient opioid use. Specifically, we examined the opioid prescription quantities in patients who sustained ankle fractures that required open reduction internal fixation (ORIF). DESIGN: Retrospective. Hospital medical records and Michigan Automated Prescription Database (MAPS) were analyzed for similar ankle fracture patients operated on by two surgeons prior to and after the initiation of the OST form. Records allowed us to track opioid filling through MAPS for 120 days after surgery in two groups: preimplementation (PRE) and post-implementation (POST) OST groups. The gathered data were analyzed by the investigators along with a staff statistician. SETTING: Single-institution orthopedic practice. PATIENTS, PARTICIPANTS: Seventy eight patients Main outcome measure: Average morphine milligram equivalent (MME) per patient encounter. RESULTS: Seventy eight patients were included in the final analysis after applying the exclusion criteria. There were 38 patients in the pre-OST form period and 40 in the post-OST form period groups. The pre-OST and post-OST groups were well matched between the two surgeons. There was no evidence of a statistically significant difference found in the median MME between patients from the pre-period group to the post-period group (median 59 vs 50, P = 0.61). In regard to the injury pattern, the bimalleolar MME median was 50 (38 = 25th percentile, 67 = 75th percentile; min-max 0-175) and the trimalleolar median MME was 63 (39 =25% percentile, 81 = 75th percentile; min-max 0-249) with a P value of 0.20. CONCLUSIONS: Overall, the administration of the OST form to patients with ankle fractures did not result in a decrease in MMEs prescribed within 120 days of surgery. Although it is a start in the battle against the opioid epidemic, further evaluation of the effectiveness of the OST form is necessary.

Comparing Postoperative Leg Length Discrepancy and Femoral Offset Using Two Different Surgical Approaches for Hemiarthroplasty of the Hip.

INTRODUCTION: The direct anterior approach (DAA) and anterolateral approach (ALA) may be used for hip hemiarthroplasty (HHA) as a treatment for femoral neck fractures. The DAA often utilizes intraoperative fluoroscopy to determine leg length and offset, while the ALA traditionally utilizes an intraoperative clinical exam to determine offset and leg length. This study will evaluate two techniques: the "grid fluoroscopy [GF] technique" and the "intraoperative exam [IE] technique," each performed by one of two separate surgeons, and compare each technique's accuracy to restore leg length and femoral offset in a patient population that underwent HHA. METHODS: Two investigators retrospectively reviewed charts of 208 randomly selected patients who had an HHA from either a DAA or ALA performed by two different surgeons for the treatment of femoral neck fractures. Postoperative AP pelvis radiographs were measured to determine offset and leg length compared with the non-operative extremity. Non-normal continuous variables were provided by median and interquartile range. Data were analyzed with the Mann-Whitney U test and Student's t-test. RESULTS: After inclusion and exclusion criteria, data were reviewed on 173 hemiarthroplasties. The mean age was 80.3 years (± 11.2 years). Of the surgical patients, 65.9% were female, and 70.9% identified their ethnicity as white. The DAA was used in 93 patients and ALA in 80 patients. Analysis comparing the two techniques demonstrated no statistically significant differences in median leg length between GF technique (1.02 IQR -0.1, 2.0 mm) and IE technique (1.25 IQR -2.4, 1.3 mm,) (p=0.67). There was also no statistically significant difference in offset between GF technique (1.3 IQR 0.2, 2.1 mm) and IE technique (0.6 IQR -2.7 mm, 3.2 mm) (p=0.13). However, a difference was found in mean length of surgery that was statistically significant. We found that the mean length of surgery for the IE technique was 74.8 ± 24.7 minutes versus the GF technique, which was 95.1 ± 23.0 minutes, (p<0.0001). DISCUSSION: There was no significant difference between leg length and offset with the use of intraoperative fluoroscopy with DAA compared to no intraoperative imaging with ALA. Our study suggests that DAA and ALA are equally effective approaches for re-establishing symmetric leg length and offset in HHA for femoral neck fractures. In this study, the ALA had a shorter surgical time compared to DAA, potentially due to the utilization of intraoperative fluoroscopy for this particular technique during the DAA.