Distal radius malunion: outcomes following an ulnar shortening osteotomy.

PURPOSE: Positive ulnar variance following a distal radius malunion can lead to ulnar-sided wrist pain, loss of grip strength, and distal radioulnar joint impingement. The primary aim of this study is to describe upper limb-specific functional outcomes following ulnar shortening osteotomy (USO) for ulnar-sided wrist pain associated with malunion of the distal radius. METHODS: We retrospectively identified 40 adult patients from a single centre over a 9-year period that had undergone an USO for symptomatic malunion of the distal radius. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were the QuickDASH, EQ-5D-5L, complications, and net promoter score (NPS). RESULTS: Outcomes were available for 37 patients (93%). The mean age was 56 years and 25 patients were female (68%). At a mean follow-up of 6 years (range 1-10 years) the median PRWE was 11 (IQR 0-29.5), the median QuickDASH 6.8 (IQR 0-29.5), and the median EQ-5D-5L index was 0.88 (IQR 0.71-1). The NPS was 73. Complications occurred in nine patients (24%) and included non-union (n = 4), early loss of fixation requiring revision surgery (n = 1), superficial wound infection (n = 2), neurological injury (n = 1), and further surgery for symptomatic hardware removal (n = 1). CONCLUSIONS: For patients with a symptomatic distal radius malunion where the predominant deformity is ulnar positive variance, this study has demonstrated that despite 1 in 4 patients experiencing a complication, USO can result in excellent patient reported outcomes with high levels of satisfaction. LEVEL OF EVIDENCE: III (Cohort Study).

New Concepts of Chronic Pain and the Potential Role of Complementary Therapies.

CONTEXT: The mechanisms of chronic pain involve complex neuroplastic changes at all 3 orders of neurons involved in the transmission of pain as well as changes in the descending inhibitory pathway. Although traditional pharmaceutical therapies have some efficacy, substantial scope exists for a new model of individualized therapy, tailored to the specific response of each patient. Because changes occur at all levels of the pain pathway, successful treatment may require a combination of therapies with different mechanisms of action. OBJECTIVE: The research team intended to examine the potential changes within the peripheral nervous system (PNS) and central nervous system (CNS) of patients with chronic pain and to propose a model of chronic pain treatment involving multimodal, complementary therapies for individualized treatment targeting multiple sites along the pain pathway. DESIGN: The research team performed a review of the literature in the field. SETTING: The study took place in the School of Health and Human Sciences at Southern Cross University (Lismore, New South Wales, Australia). INTERVENTIONS: A growing body of evidence supports the use of a variety of complementary therapies to treat chronic pain, including curcumin, capsaicin, vitamin D, omega-3 fatty acids, lipoic acid, acupuncture, yoga, meditation, and mindfulness meditation. These therapies vary with respect to the mechanisms by which they act and the potential areas of effect along the pain pathway. RESULTS: The literature review showed a number of complementary therapies may be efficacious in reducing chronic pain and/or the need for analgesics, which may offer a reduced adverse effect profile. These therapies include curcumin, capsaicin, vitamin D, omega-3 fatty acids, lipoic acid, acupuncture, yoga, meditation, and mindfulness meditation. Response rates to treatment are likely to vary between people and within therapies. CONCLUSIONS: The available evidence suggests that efficacious complementary therapies exist that target all 3 orders of neurons and, therefore, the authors recommend multimodal individualized treatment for each patient. There is high interindividual variability between patients in responses to treatments.

Evaluation of the IAEA-TRS 483 protocol for the dosimetry of small fields (square and stereotactic cones) using multiple detectors.

The IAEA TRS 483 protocol1 for the dosimetry of small static fields in radiotherapy was used to calculate output factors for the Elekta Synergy linac at the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). Small field output factors for both square and circular fields were measured using nine different detectors. The "corrected" output factors (ratio of detector readings multiplied by the appropriate correction factor from the protocol) showed better consistency compared to the "uncorrected" output factors (ratio of detector readings only), with the relative standard deviation decreasing by approximately 1% after the application of the relevant correction factors. Comparisons relative to an arbitrarily chosen PTW 60019 microDiamond detector showed a reduction of maximal variation for the corrected values of approximately 3%. A full uncertainty budget was prepared to analyze the consistency of the output factors. Agreement within uncertainties between all detectors and field sizes was found, except for the 15 mm circular field. The results of this study show that the application of IAEA TRS 4831 when measuring small fields will improve the consistency of small field measurements when using multiple detectors contained within the protocol.

Systematic review of musculoskeletal injuries in professional golfers.

OBJECTIVE: The distribution of injuries affecting professional golfers is yet to be fully understood. We performed a systematic review of the clinical literature to establish the epidemiology of musculoskeletal injuries affecting professional golfers. DESIGN: Systematic review. DATA SOURCES: Searched databases in July 2018 were PubMed, SPORTDiscus and Embase. ELIGIBILITY CRITERIA: Published observational research articles relating to the incidence or prevalence of musculoskeletal injuries in professional golfers, which were written in the English language and not restricted by age or gender. RESULTS: Of the 1863 studies identified on the initial search, 5 studies were found to satisfy the inclusion criteria for analysis. The mean age of the golfers in these studies was 34.8 (±3.6) years. The gender of patients in included studies compromised 72% males and 28% females. Four studies reported that lumbar spine injuries were the most common (range 22%-34%). Excluding injuries to the spine (lumbar, thoracic and cervical), the hand/wrist was the next most common region of injury (range 6%-37%). The quality of the studies was relatively poor with no study satisfying >50% of the quality assessment tool questions and only one study giving a clear definition of how they defined injury. CONCLUSION: There is a paucity of well-designed epidemiological studies evaluating musculoskeletal injuries affecting professional golfers. Injuries to the spine are the most frequently affected region, followed by the hand/wrist. This study has identified targeted areas of future research that aims to improve the management of injuries among professional golfers.

Survey of 5 mm small-field output factor measurements in Australia.

The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) held a comparison exercise in April 2016 where participants came to ARPANSA and measured the output factor of a nominal 5 mm cone attached to the ARPANSA Elekta Synergy (Elekta, Crawley, UK) linear accelerator. The goal of the exercise was to compare the consistency and methods used by independent medical physicists in measuring small-field output factors. ARPANSA provided a three-dimensional scanning tank for detector setup and positioning, but the participants were required to measure the output factor with their own detectors. No information regarding output factors previously measured was supplied to participants to make each result as independent as possible. Fifteen groups travelled to ARPANSA bringing a wide range of detectors and methods. A total of 30 measurements of the output factor were made. The standard deviation of the measurements (excluding one expected outlier from an uncorrected ionization chamber measurement) was 3.6%. The results provide an insight into the consistency of small-field dosimetry being performed in Australia and New Zealand at the present time.

Validity of a Cochrane Systematic Review and meta-analysis for determining the safety of vitamin E.

The public safety of α-tocopherol has been called in question by several meta-analyses which have raised concern among regulatory authorities. The objective of this study was to evaluate the Cochrane Database Systematic Review 2012 (CD007176) which concludes that α-tocopherol forms of vitamin E have a statistically significant effect on mortality, by assessing the trials and datasets used and determining their effect upon the primary outcome.The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC), a factorial design study of Finnish smokers was a pivotal paper in the Cochrane Review owing to the high mortality rate observed which resulted in a substantial weighting (42.6%) in the meta-analysis. The Cochrane meta-analysis used a 3 cell analytical method comparing all vitamin E cells (vitamin E alone plus vitamin E + ß-carotene) to the placebo only cell. This had the unfortunate effect of incorrectly inflating the mortality risk attributed to vitamin E by not balancing the contribution to mortality of the ß-carotene intervention. Re-analysis of the ATBC trial using data derived from the more generally accepted 'inside the table' (2 cell - vitamin E versus placebo) or 'at the margins' (4 cell - all vitamin E versus all non-vitamin E) analytical methods demonstrates a statistically non-significant result.The data from the ATBC study has been given in 5 datasets (the trial alone and four extended post-trial follow-up time periods). Using the 3 cell analysis method only the 6 and 8-year (used in the meta-analysis) follow-up periods were statistically significant. Using the 2 or 4 cell method the outcome remains non-significant over all time periods.The impartiality of excluding trials with zero mortality is also examined and questioned.This paper raises concerns overall as to the appropriateness of datasets chosen, the validity of methods and generalisability of results when using meta-analysis as a tool to determine safety. Issues raised in this paper are not unique to the Cochrane study in question. Until we have new tools, there may be a need to rely on conventional narrative systematic literature synthesis in the assessment of safety or contain our results to specific sub-populations where more conclusive results can be determined.

The effect of 1 mg folic acid supplementation on clinical outcomes in female migraine with aura patients.

BACKGROUND: Migraine is a common neurovascular condition that may be linked to hyperhomocysteinemia. We have previously provided evidence that reduction of homocysteine with a vitamin supplementation can reduce the occurrence of migraine in women. The current study examined the occurrence of migraine in response to vitamin supplementation with a lower dose of folic acid. METHODS: This was a 6 month randomised, double blinded placebo controlled trial of daily vitamin supplementation containing 1 mg of folic acid, 25 mg of Vitamin B6 and Vitamin B12, on reduction of homocysteine and the occurrence of migraine in 300 female patients diagnosed with migraine with aura. RESULTS: Vitamin supplementation with 1 mg of folic acid, did not significantly decrease homocysteine levels (P = 0.2). The treatment group did not show a significant decrease in the percentage of participants with high migraine disability, severity or frequency at the end of the 6 month intervention (P > 0.1). CONCLUSION: 1 mg of folic acid in combination with vitamin B6 and B12 is less effective in reducing migraine associated symptoms compared to the previously tested dosage of 2 mg folic acid in combination with 25 mg of vitamin B6 and 400 µg of vitamin B12.

The 2013 Australian dietary guidelines and recommendations for older Australians.

BACKGROUND: Dietary guidelines are designed to assist people to make appropriate food choices to reduce their risk of diet-related diseases. In 2013, the Australian Dietary Guidelines were updated and now includes food group recommendations for two groups of older Australians (51-70 years and 70+ years), where previously only one older age group existed (60+ years). OBJECTIVE: The aim of this article is to raise awareness among general practitioners (GPs) about the latest Australian Dietary Guidelines and to identify relevant resources that will help GPs provide up-to-date dietary advice for older patients. DISCUSSION: The 2013 Australian Guide to Healthy Eating visually represents the proportions of the five food groups recommended for daily consumption. The Recommended Dietary Intake for some nutrients is higher for older people, compared with the general adult population. Older people often turn to their GP for nutritional advice.

Conjunctivodacryocystorhinostomy and lacrimal sinus diversion via sinopsys surgical lacrimal stent: cadaveric proof of concept.

PURPOSE: To determine the viability of lacrimal sinus diversion by using a novel Sinopsys Surgical Lacrimal Stent. METHODS: Two disarticulated cadaveric heads were used in the laboratory. First, bilateral conjunctivodacryocystorhinostomies (CDCR) were performed by using a traditional Pyrex Jones tube and the Sinopsys Surgical Lacrimal Stent. The fluiditics were then evaluated by using contrast agent and fluroscopy. Subsequently, conjunctivoethmoidectomies (CE) and conjunctivomaxillectomies (CM) were performed by using the Sinopsys Surgical Lacrimal Stent, of which the fluiditics were also studied. RESULTS: The conjunctivodacryocystorhinostomy (CDCR) placement experience of the Jones tube and the Sinopsys Surgical Lacrimal Stent were similar. The CDCR fluiditics as measured by using contrast agent and fluoroscopy were identical with each draining 0.5 mL over 5 to 10 seconds. Placement of the Sinopsys Surgical Lacrimal Stent in the 4 ethmoid (CE) and 4 maxillary (CM) sinuses was similar to the CDCR experience. Fluiditics of lacrimal sinus diversion were similar to CDCR with drainage of 0.5 mL over 5 seconds. CONCLUSIONS: The Sinopsys Surgical Lacrimal Stent has flow characteristics that are similar to a Pyrex Jones tube. Drainage in the nose via a CDCR procedure is similar to drainage in the ethmoid and maxillary sinuses via a CE and CM, respectively.

Exploring an objective measure of overactivity in children with rare genetic syndromes.

BACKGROUND: Overactivity is prevalent in several rare genetic neurodevelopmental syndromes, including Smith-Magenis syndrome, Angelman syndrome, and tuberous sclerosis complex, although has been predominantly assessed using questionnaire techniques. Threats to the precision and validity of questionnaire data may undermine existing insights into this behaviour. Previous research indicates objective measures, namely actigraphy, can effectively differentiate non-overactive children from those with attention-deficit hyperactivity disorder. This study is the first to examine the sensitivity of actigraphy to overactivity across rare genetic syndromes associated with intellectual disability, through comparisons with typically-developing peers and questionnaire overactivity estimates. METHODS: A secondary analysis of actigraphy data and overactivity estimates from The Activity Questionnaire (TAQ) was conducted for children aged 4-15 years with Smith-Magenis syndrome (N=20), Angelman syndrome (N=26), tuberous sclerosis complex (N=16), and typically-developing children (N=61). Actigraphy data were summarized using the M10 non-parametric circadian rhythm variable, and 24-hour activity profiles were modelled via functional linear modelling. Associations between actigraphy data and TAQ overactivity estimates were explored. Differences in actigraphy-defined activity were also examined between syndrome and typically-developing groups, and between children with high and low TAQ overactivity scores within syndromes. RESULTS: M10 and TAQ overactivity scores were strongly positively correlated for children with Angelman syndrome and Smith-Magenis syndrome. M10 did not substantially differ between the syndrome and typically-developing groups. Higher early morning activity and lower evening activity was observed across all syndrome groups relative to typically-developing peers. High and low TAQ group comparisons revealed syndrome-specific profiles of overactivity, persisting throughout the day in Angelman syndrome, occurring during the early morning and early afternoon in Smith-Magenis syndrome, and manifesting briefly in the evening in tuberous sclerosis complex. DISCUSSION: These findings provide some support for the sensitivity of actigraphy to overactivity in children with rare genetic syndromes, and offer syndrome-specific temporal descriptions of overactivity. The findings advance existing descriptions of overactivity, provided by questionnaire techniques, in children with rare genetic syndromes and have implications for the measurement of overactivity. Future studies should examine the impact of syndrome-related characteristics on actigraphy-defined activity and overactivity estimates from actigraphy and questionnaire techniques.

Surgical training 2.0: How contemporary developments in information technology can augment surgical training.

BACKGROUND: The current surgical trainee is faced with reduced training time compared to predecessors as a result of changes in working practices. The past decade has seen marked developments in the information technology sector. This editorial will review how modern technological innovations could augment current surgical training. METHODS: We review the literature and summarize important developments in information technology that could assist the modern surgical trainee. We also look at some of the challenges faced by use of this technology. FINDINGS: Developments in mobile internet connectivity will improve access to online resources for the surgical trainee. Web 2.0 will revolutionise the way trainees interact with textbooks, journals, webpages and each other. Simulators could help to fill gaps created by reduced operating hours. To maximize the effectiveness of these resources they need to be accessible and incorporated into training in a structured way, ensuring patient safety and accuracy of information. CONCLUSION: Contemporary developments in technology offer benefits to the surgical trainee and could fill gaps left by reduced operating times. In order to ensure efficient use of technology and patient safety, bodies such as the Royal Colleges and Training Programmes must embrace these developments.

Artificial gauge fields in the t-z mapping for optical pulses: Spatiotemporal wave packet control and quantum Hall physics.

We extend the t-z mapping of time-dependent paraxial optics by engineering a synthetic magnetic vector potential, leading to a nontrivial band topology. We consider an inhomogeneous 1D array of coupled optical waveguides and show that the wave equation describing paraxial propagation of optical pulses can be recast as a Schrödinger equation, including a synthetic magnetic field whose strength can be controlled via the spatial gradient of the waveguide properties across the array. We use an experimentally motivated model of a laser-written array to demonstrate that this synthetic magnetic field can be engineered in realistic setups and can produce interesting physics such as cyclotron motion, a controllable Hall drift of the pulse in space or time, and propagation in chiral edge states. These results substantially extend the physics that can be explored within propagating geometries and pave the way for higher-dimensional topological physics and strongly correlated fluids of light.

Profiles of autism characteristics in thirteen genetic syndromes: a machine learning approach.

BACKGROUND: Phenotypic studies have identified distinct patterns of autistic characteristics in genetic syndromes associated with intellectual disability (ID), leading to diagnostic uncertainty and compromised access to autism-related support. Previous research has tended to include small samples and diverse measures, which limits the generalisability of findings. In this study, we generated detailed profiles of autistic characteristics in a large sample of > 1500 individuals with rare genetic syndromes. METHODS: Profiles of autistic characteristics based on the Social Communication Questionnaire (SCQ) scores were generated for thirteen genetic syndrome groups (Angelman n = 154, Cri du Chat n = 75, Cornelia de Lange n = 199, fragile X n = 297, Prader-Willi n = 278, Lowe n = 89, Smith-Magenis n = 54, Down n = 135, Sotos n = 40, Rubinstein-Taybi n = 102, 1p36 deletion n = 41, tuberous sclerosis complex n = 83 and Phelan-McDermid n = 35 syndromes). It was hypothesised that each syndrome group would evidence a degree of specificity in autistic characteristics. To test this hypothesis, a classification algorithm via support vector machine (SVM) learning was applied to scores from over 1500 individuals diagnosed with one of the thirteen genetic syndromes and autistic individuals who did not have a known genetic syndrome (ASD; n = 254). Self-help skills were included as an additional predictor. RESULTS: Genetic syndromes were associated with different but overlapping autism-related profiles, indicated by the substantial accuracy of the entire, multiclass SVM model (55% correctly classified individuals). Syndrome groups such as Angelman, fragile X, Prader-Willi, Rubinstein-Taybi and Cornelia de Lange showed greater phenotypic specificity than groups such as Cri du Chat, Lowe, Smith-Magenis, tuberous sclerosis complex, Sotos and Phelan-McDermid. The inclusion of the ASD reference group and self-help skills did not change the model accuracy. LIMITATIONS: The key limitations of our study include a cross-sectional design, reliance on a screening tool which focuses primarily on social communication skills and imbalanced sample size across syndrome groups. CONCLUSIONS: These findings replicate and extend previous work, demonstrating syndrome-specific profiles of autistic characteristics in people with genetic syndromes compared to autistic individuals without a genetic syndrome. This work calls for greater precision of assessment of autistic characteristics in individuals with genetic syndromes associated with ID.

Blood-brain barrier remodeling in an organ-on-a-chip device shows Dkk1 to be a regulator of early metastasis.

Brain metastases are the most lethal progression event, in part because the biological processes underpinning brain metastases are poorly understood. There is a paucity of realistic models of metastasis, as current in vivo murine models are slow to manifest metastasis. We set out to delineate metabolic and secretory modulators of brain metastases by utilizing two models consisting of in vitro microfluidic devices: 1) a blood brain niche (BBN) chip that recapitulates the blood-brain-barrier and niche; and 2) a migration chip that assesses cell migration. We report secretory cues provided by the brain niche that attract metastatic cancer cells to colonize the brain niche region. Astrocytic Dkk-1 is increased in response to brain-seeking breast cancer cells and stimulates cancer cell migration. Brain-metastatic cancer cells under Dkk-1 stimulation increase gene expression of FGF-13 and PLCB1. Further, extracellular Dkk-1 modulates cancer cell migration upon entering the brain niche.