Anterior Displacement of a Posterior Malleolar Fragment Through the Syndesmosis: A Case Report.

Ankles are the most common site of injury in lower limb fractures. Despite this, the classification of the Maisonneuve fracture is still highly controversial, perhaps due to its low incidence. Typically described as a proximal fibular fracture with associated injury to the syndesmosis and medial structures secondary to an external rotation mechanism, the injury often necessitates surgical intervention to restore joint stability for good functional outcomes. A 32-year-old lady sustained a pronation external rotation injury resulting in a proximal fibula fracture with disruption of the distal tibiofibular syndesmosis as well as an associated posterior malleolar fracture with displacement of the fragment anteriorly through the syndesmosis to the ventral aspect of the ankle joint. The patient underwent surgical fixation of the posterior malleolar fracture as well as repair of the syndesmosis with a screw. This report aims to highlight the details of a Maisonneuve fracture with the rarer associated posterior malleolar fracture, and its anterior displacement through the syndesmosis, as well as provide a narrative review of the current literature.

A woman with a normal uterus and duplicated cervices: A case report and review of a Müllerian anomaly.

Müllerian duct anomalies (MDAs) are common and can lead to problems with menstrual flow, pregnancy, and fertility. This is a case report of a 21-year-old woman with an incidentally found bicollis uterus with vaginal septum, which challenges the previously held principles of embryology and further supports the current theories that explain these transitional forms of female reproductive anomalies. Due to the irregularity found during the physical examination, detailed imaging with magnetic resonance helped to delineate the anatomy of the reproductive system and genitourinary (GU) tract, uncovering and confirming the anatomical abnormality. Due to the concern for future implications, especially during pregnancy, surgical excision of the vaginal septum was performed. This unique anomaly bolsters a discussion on the outcomes and implications of these unknown rare anomalies in various settings.

The Incidence and Anatomic Variation of Os Naviculare in a Multiethinic Asian Population.

The incidence of asymptomatic os naviculare ranges from 4% to 21%, varying between different ethnicities, with majority of studies performed in Caucasians. The aim of this study was to document the incidence of asymptomatic os naviculare in an Asian population stratified by ethnicity, and to characterize the features of each type. The records of all patients who underwent dorsoplantar and oblique foot radiographs between July and December 2017 were reviewed. We excluded patients with medial-sided foot pain. The radiographs of the remaining patients were reviewed and the incidence and type of os naviculare according to Coughlin's classification were recorded. About 439 patients were included. The overall incidence of asymptomatic os naviculare was 46.0%, of which 76.7% were bilateral. The prevalence of type Ia, Ib, and Ic os was 7.5%, 6.2%, and 5.9%, respectively. The prevalence of type IIAa, IIAb, IIAc, IIBa, IIBb, and IIBc was 2.7%, 0.7%, 0.2%, 16.6%, 5.9%, and 2.1%, respectively. The prevalence of type IIIa, IIIb, and IIIc was 1.1%, 8.4%, and 0.2%. Type IIBa had the highest prevalence of 16.6% out of 439 patients. The highest incidence of os naviculare was in the Chinese population (n = 145, p = .034) at 50.2%. There was no significant gender difference in the incidence of asymptomatic os naviculare. The incidence of asymptomatic os naviculare in a multiethnic Asian population is higher than that reported in other populations, and particularly in the Chinese. Type IIBa was the most prevalent type, which differs from previous reports. When treating patients of Chinse ethnicity who present with pain over the medial aspect of the foot, the diagnosis of a symptomatic os naviculare should be considered.

Experienced hearing aid users' perspectives of assessment and communication within audiology: a qualitative study using digital methods.

OBJECTIVE: To explore experienced hearing aid users' perspectives of audiological assessments and the patient-audiologist communication dynamic during clinical interactions. DESIGN: A qualitative study was implemented incorporating both an online focus group and online semi-structured interviews. Sessions were audio-recorded and transcribed verbatim. Iterative-inductive thematic analysis was carried out to identify themes related to assessment and communication within audiology practice. STUDY SAMPLES: Seven experienced hearing aid users took part in an online focus group and 14 participated in online semi-structured interviews (age range: 22 - 86 years; 9 males, 11 females). RESULTS: Themes related to assessment included the unaided and aided testing procedure and relating tests to real world hearing difficulties. Themes related to communication included the importance of deaf aware communication strategies, explanation of test results and patient centred care in audiology. CONCLUSION: To ensure hearing aid services meet the needs of the service users, we should explore user perspectives and proactively adapt service delivery. This approach should be ongoing, in response to advances in hearing aid technology. Within audiology, experienced hearing aid users' value (1) comprehensive, relatable hearing assessment, (2) deaf aware patient-audiologist communication, (3) accessible services and (4) a personalised approach to recommend suitable technology and address patient specific aspects of hearing loss.

Clinicians' views of using cortical auditory evoked potentials (CAEP) in the permanent childhood hearing impairment patient pathway.

Objective: To obtain clinicians' views on the use of cortical auditory evoked potentials (CAEP) in the clinical pathway.Design: A questionnaire aimed at clinicians who use the HEARLab system with the Aided Cortical Assessment (ACA) Module. Results compared for Australians (where HEARLab produced) to other countries.Sample: The questionnaire was completed by 49 clinicians; 33 from Australia and 13 clinicians outside of Australia and 3 clinicians, destination unknown.Results: The findings of this research demonstrated that clinicians using CAEPs found them valuable for clinical practice. CAEPs were used to verify or modify hearing aid fittings and were used for counselling parents to reinforce the need for hearing aids. With the use of speech token as the stimulus clinicians had more relevant information to increase confidence in decision-making on paediatric hearing management.Conclusions: The main benefit from the use of CAEPs (using speech token stimuli) was for infant hearing aid fitting programmes, to facilitate earlier decisions relating to hearing aid fitting, for fine-tuning the aids and as an additional measure for cochlear implant referrals.

L445P mutation on heavy chain stabilizes IgG4 under acidic conditions.

IgG4, a common type of therapeutic antibody, is less stable during manufacturing processes compared with IgG1. Aggregation and fragmentation are the two main challenges. Here, we report instability of the heavy chain (HC) C-terminal region under acidic conditions, which leads to cleavage and aggregation. Leu445, at the C-terminal region of the HC in IgG4, plays a critical role in its acid-induced fragmentation and subsequent aggregation. We found that mutating HC C-terminal Leu445 to Pro (the corresponding residue in IgG1) in IgG4_CDR-X significantly reduces fragmentation and aggregation, while mutating Pro445 to Leu in IgG1_CDR-X promotes fragmentation and aggregation. HC C-terminal Gly446 cleavage was observed in low pH citrate buffer and resulted in further fragmentation and aggregation, whereas, glycine buffer can completely inhibit the cleavage and aggregation. It is proposed that cleavages occur through acid-induced hydrolysis under acidic conditions and glycine stabilizes IgG4 via two main mechanisms: 1) product feedback inhibition of the hydrolysis reaction, and 2) stabilization of protein conformation by direct interaction with the peptide backbone and charged side chains. Experiments using IgG4 molecules IgG4_CDR-Y and IgG4_CDR-Z with the same CH domains as IgG4_CDR-X, but different complementarity-determining regions (CDRs), indicate that the stability of the HC C-terminal region is also closely related to the sequence of the CDRs. The stability of IgG4_CDR-X is significantly improved when binding to its target. Both observations suggest that there are potential interactions between Fab and CH2-CH3 domains, which could be the key factor affecting the stability of IgG antibodies.

A qualitative review of parents' perspectives on the value of CAEP recording in influencing their acceptance of hearing devices for their child.

Objective: To obtain a parental perspective on how audiological tests, including recording cortical auditory-evoked potentials (CAEP) to speech sounds, influenced their uptake of hearing devices for their infant. Design: A focus group was established by parents of hearing-impaired children. A facilitator explored how audiology tests influenced their understanding and management of hearing loss in their child and their acceptance of hearing aids or cochlear implant referral. The views were transcribed and thematic analysis was used to understand key topics. Study samples: Eight sets of parents participated. Their children had been enrolled in an audiology pathway that included CAEP testing. The sample included six children who were aided, one child who was going through the implant assessment and one child who was implanted. Results: Parents reported that it was important for them to understand the test results because this influenced acceptance of hearing aids and cochlear implant assessments. Seven sets of parents had not understood ABR results, while six reported that CAEPs had helped them to understand their child's hearing and need for intervention. Conclusion: Compliance with early hearing aid use and referral for cochlear implant depends upon parents' understanding of their infant's hearing loss by including CAEPs in the audiology pathway.

Rectal prolapse and urinary retention: A case report of an "anal cystocele".

BACKGROUND: Concomitant rectal and vaginal prolapse is diagnosed in 14-55% of patients who present for pelvic floor evaluation.Case: A patient was referred for pelvic floor evaluation in the setting of rectal prolapse and urinary retention. Preoperative magnetic resonance (MR) imaging revealed the presence of a posterior cystocele prolapsing through the full-thickness rectal prolapse. CONCLUSION: Rectal prolapse with concomitant urinary retention should raise suspicion for posterior bladder prolapse. Here we propose the new term "anal cystocele". MR imaging aids in the diagnosis and treatment planning for this condition.

Rare Bosworth Fracture-Dislocation Variant of an Irreducible Distal Fibula Dislocation of the Ankle Without Fibula Fracture.

BACKGROUND: Irreducible fracture-dislocations of the ankle are rare orthopedic emergencies that should not be missed. The Bosworth fracture-dislocation is a rare fracture where an incarcerated fibula fragment remains locked behind the posterior lateral tubercle of the tibia. We present a case describing a variation of a Bosworth injury, with a dislocation of an intact distal fibula with an associated medial malleolus fracture. METHODS: Our patient is a 55-year old male who presented to the emergency department with a left ankle injury after being involved in a road traffic accident. Radiographs show a posterior dislocation of an intact distal fibula associated with a fracture of the medial malleolus and disruption of the ankle mortise. RESULTS: An attempt to reduce the dislocation at the emergency department under sedation was unsuccessful. The patient was subsequently taken to the operating theatre for manipulation and reduction and application of an external fixator. Definitive fixation was performed successfully a week later. CONCLUSION: A high index of suspicion is critical for diagnosing a Bosworth fracture-dislocation, as this diagnosis is commonly missed. Early diagnosis and proper surgical anatomic reduction are important to prevent chronic ankle instability and evolution towards ankle arthritis. LEVEL OF EVIDENCE: Level IV, case study.

Role of Cortical Auditory Evoked Potentials in Reducing the Age at Hearing Aid Fitting in Children With Hearing Loss Identified by Newborn Hearing Screening.

Recording of free-field cortical auditory evoked potential (CAEP) responses to speech tokens was introduced into the audiology management for infants with a permanent childhood hearing impairment (PCHI) during 2011-2015 at a U.K. service. Children with bilateral PCHI were studied from two sequential cohorts. Thirty-four children had followed an audiology pathway prior to CAEP introduction, and 44 children followed a pathway after the introduction of CAEP and were tested with unaided and aided CAEP responses. Data analysis explored the age of diagnosis, hearing aid fitting, and referral for cochlear implant (CI) assessment for each of these groups. CAEP offered a novel educative process for the parents and audiologists supporting decision-making for hearing aid fitting and CI referral. Delays in hearing aid fitting and CI referral were categorized as being due to the audiologist's recommendation or parental choice. Results showed that the median age of hearing aid fitting prior to CAEP introduction was 9.2 months. After the inclusion of CAEP recording in the infant pathways, it was 3.9 months. This reduction was attributable to earlier fitting of hearing aids for children with mild and moderate hearing losses, for which the median age fell from 19 to 5 months. Children with profound hearing loss were referred for CI assessment at a significantly earlier age following the introduction of CAEP. Although there has also been a national trend for earlier hearing aid fitting in children, the current study demonstrates that the inclusion of CAEP recording in the pathway facilitated earlier hearing aid fitting for milder impairments.

Evidence based review of literature on detriments to healing of diabetic foot ulcers.

BACKGROUND: Diabetes mellitus places a substantial burden on society worldwide. Diabetic foot ulcers are a challenging problem for clinicians. Seven generally accepted detriments to healing of diabetic foot ulcers were identified: infection, glycaemic control, vascular supply, smoking, nutrition, deformity and offloading. The aim of this paper is to present a comprehensive evidence based review of the literature available on detriments to healing of diabetic foot ulcers. METHOD: A research question was generated for each of the detriments to healing and a comprehensive review of the literature was performed using the Pubmed database in July 2014. All articles were assessed for relevancy and a level of evidence was assigned. An analysis of the total body of literature was used to assign a grade of recommendation to each detriment. RESULTS: Grade A recommendation was assigned to offloading as there was good evidence supporting this intervention. Grade B recommendation was assigned to deformity as there was fair evidence consistent with the hypothesis. Infection and vascular supply had poor quality evidence supporting the research question and grade C recommendation was assigned. Grade I recommendation was assigned to glycaemic control, smoking and nutrition as there was insufficient and conflicting evidence available. CONCLUSION: Our literature review revealed good evidence for some factors and insufficient literature on others. Further studies are needed to provide quality evidence regarding detriments to healing of diabetic ulcers.

Comprehensive Review of Non-Operative Management of Hallux Rigidus.

This article aims to provide an evidence-based literature review for the non-operative management of hallux rigidus. Currently, there is very little article on the evidence for the non-operative management of hallux rigidus. A comprehensive evidence-based literature review of the PubMed database conducted in November 2016, identified 11 relevant articles out of 560 articles assessing the efficacy of non-operative modalities for hallux rigidus. The 11 studies were then assigned to a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against the non-operative modality. Based on the results of this evidence-based review, there is poor evidence (grade C) to support use of intra-articular injections for pain relief for a period of three months and fair evidence (grade B) against the use of intra-articular injections for long term efficacy. There is poor evidence (grade C) to support manipulation and physical therapy and poor evidence (grade C) to support modifications in footwear, insoles and orthotics. There were no good evidence (grade A) recommending any interventions. In general, most of the interventions showed improvement. However, the evidence is poor in recommending orthosis, manipulation and intra-articular injections. There is a need for high-quality Level I randomized controlled trials with validated outcome measures to allow for stronger recommendations to be made. There is no study that looked solely at the use of pharmaceutical oral agents for the treatment of hallux rigidus. Non-operative management should still be offered, prior to surgical management.

Fracture of the os trigonum: A report of two cases and review of the literature.

We report two cases of acute fractures of the os trigonum. The os trigonum fracture related to the first case was sustained following a hyper-plantar flexion injury during a game of soccer. The second case involved a patient who fell from height and also sustained open fractures of the left distal tibia and lateral malleolus as well as the right calcaneus. In both cases, a preliminary diagnosis of a posterior talar process fracture was made from the initial radiographs of the ankle. The correct diagnosis of an os trigonum fracture rather than a fracture of the posterior talar process was only made following further assessment with CT imaging. Given that the course of treatment is largely determined by imaging findings, CT for further imaging evaluation should be performed in cases of suspected acute bony injuries of the posterior ankle, particularly when the limitations of using radiographs for the assessment of such injuries are expected to be encountered.

Anisotropic nanocrystal arrays organized on protein lattices formed by recombinant clathrin fragments.

Recombinant clathrin protein fragments form assemblies that template gold nanocrystals in an array across the latticed surface. The nanocrystals exhibit unusual anisotropic morphologies with long range ordering, both of which are dependent upon the presence of a hexahistidine tag on the clathrin heavy chain fragments.

Modulating substrate specificity of histone acetyltransferase with unnatural amino acids.

Controlling the substrate specificity of enzymes is a major challenge for protein engineers. Here we explore the effects of residue-specific incorporation of ortho-, meta- and para-fluorophenylalanine (oFF, mFF, pFF) on the selectivity of human histone acetyltransferase (HAT) protein, p300/CBP associated factor (PCAF). Varying the position of the fluorine group in the phenylalanine ring confers different effects on the ability of PCAF to acetylate target histone H3 as well as non-histone p53. Surprisingly, pFF-PCAF exhibits an increase in activity for non-histone p53, while mFF-PCAF is selective for histone H3. These results suggest that global incorporation of unnatural amino acids may be used to re-engineer protein specificity.

Mechanical thromboprophylaxis for patients undergoing hip fracture surgery.

PURPOSE: To evaluate the rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip fracture patients receiving mechanical thromboprophylaxis. METHODS: 123 men and 311 women (mean age, 76 years) admitted to our institution with hip fractures were included. 95% of patient received mechanical prophylaxis using pneumatic calf pumps intermittently for 20 hours or less per day before and after surgery. At the surgeon's discretion, 161 (37%) of them received concomitant chemical prophylaxis in the form of subcutaneous low-molecular-weight heparin (enoxaparin). Signs and symptoms of DVT and PE were monitored daily, as were calf and thigh circumference. Diagnoses were confirmed by duplex ultrasonography of the lower limbs and/or spiral computed tomography scan of the thorax. RESULTS: 13 patients developed symptomatic venous thromboembolism (VTE); 11 were DVT and 2 were PE. Among DVT patients, 2 had proximal and 9 had distal DVT. All these patients underwent anticoagulation and were discharged without any complications. No patients developed complications from pneumatic calf pumps (foot drop, skin abrasions or stasis). Eight patients developed bleeding tendencies during hospitalisation. No patient developed surgical wound infections. 12 patients died during hospitalisation; 8 of them from acute myocardial infarction or pneumonia, and none from PE. The median length of hospital stay was significantly longer in patients with VTE. CONCLUSION: Routine use of mechanical thromboprophylaxis is recommended in patients undergoing hip fracture surgery.

Mutagenesis of tGCN5 core region reveals two critical surface residues F90 and R140.

Tetrahymena General Control Non-Derepressor 5 (tGCN5) is a critical regulator of gene transcription via acetylation of histones. Since the acetylation ability has been attributed to the "core region", we perform mutagenesis of residues within the tGCN5 "core region" in order to identify those critical for function and stability. Residues that do not participate in catalysis are identified, mutated and characterized for activity, structure and thermodynamic stability. Variants I107V, Q114L, A121T and A130S maintain the acetylation function relative to wild-type tGCN5, while variants F90Y, F112R and R140H completely abolish function. Of the three non-functional variants, since F112 is mutated into a non-homologous charged residue, a loss in function is expected. However, the remaining two variants are mutated into homologous residues, suggesting that F90 and R140 are critical for the activity of tGCN5. While mutation to homologous residue maintains acetylation of histone H3 for the majority of the variants, the two surface-exposed residues, F90 and R140, appear to be essential for tGCN5 function, structure or stability.