The Ability of Family Physicians in the Caribbean to Promote Planetary Health Concepts and the Challenges of Implementing Changes in Practice

The global environment is rapidly changing and the subsequent effects on human health are devastating. Planetary Health is a field focused on characterizing the human health impacts of human-caused disruptions of Earth's natural systems. It has been determined that Family Physicians (FPs) are the best suited to advocate and raise awareness of Planetary Health. The purpose of this research is to assess FPs in the Caribbean, their knowledge of planetary health, their ability to implement planetary health concepts in their practice, and the challenges that may impede implementation.

Feasibility of single-use 3D-printed instruments for total knee arthroplasty.

AIMS: This aim of this study was to assess the feasibility of designing and introducing generic 3D-printed instrumentation for routine use in total knee arthroplasty. MATERIALS AND METHODS: Instruments were designed to take advantage of 3D-printing technology, particularly ensuring that all parts were pre-assembled, to theoretically reduce the time and skill required during surgery. Concerning functionality, ranges of resection angle and distance were restricted within a safe zone, while accommodating either mechanical or anatomical alignment goals. To identify the most suitable biocompatible materials, typical instrument shapes and mating parts, such as dovetails and screws, were designed and produced. RESULTS: Before and after steam sterilization, dimensional analysis showed that acrylonitrile butadiene styrene could not withstand the temperatures without dimensional changes. Oscillating saw tests with slotted cutting blocks produced debris, fractures, or further dimensional changes in the shape of Nylon-12 and polymethylmethacrylate (MED610), but polyetherimide ULTEM 1010 was least affected. CONCLUSION: The study showed that 3D-printed instrumentation was technically feasible and had some advantages. However, other factors, such as whether all procedural steps can be accomplished with a set of 3D-printed instruments, the logistics of delivery, and the economic aspects, require further study. Cite this article: Bone Joint J 2019;101-B(7 Supple C):115-120.

A systematic approach to the hip-spine relationship and its applications to total hip arthroplasty.

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research. Cite this article: Bone Joint J 2019;101-B:808-816.

Evaluation of the spine is critical in the workup of recurrent instability after total hip arthroplasty.

AIMS: While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA. PATIENTS AND METHODS: Prospectively collected data on 111 patients undergoing revision THA for recurrent instability from January 2014 to January 2017 at two institutions were included (protocol group) and matched 1:1 to 111 revisions specifically performed for instability not using this protocol (control group). Mean follow-up was 2.8 years. Protocol patients underwent standardized preoperative imaging including supine and standing anteroposterior (AP) pelvis and lateral radiographs. Each case was scored according to the Hip-Spine Classification in Revision THA. RESULTS: Survival free of dislocation at two years was 97% in the protocol group (three dislocations, all within three months of surgery) versus 84% in the control group (18 patients). Furthermore, 77% of the inappropriately positioned acetabular components would have been unrecognized by supine AP pelvis imaging alone. CONCLUSION: Using the Hip-Spine Classification System in revision THA, we demonstrated a significant decrease in the risk of recurrent instability compared with a control group. Without the use of this algorithm, 77% of inappropriately positioned acetabular components would have been unrecognized and incorrect treatment may have been instituted. Cite this article: Bone Joint J 2019;101-B:817-823.

Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion.

AIMS: Lumbar fusion is known to reduce the variation in pelvic tilt between standing and sitting. A flexible lumbo-pelvic unit increases the stability of total hip arthroplasty (THA) when seated by increasing anterior clearance and acetabular anteversion, thereby preventing impingement of the prosthesis. Lumbar fusion may eliminate this protective pelvic movement. The effect of lumbar fusion on the stability of total hip arthroplasty has not previously been investigated. PATIENTS AND METHODS: The Medicare database was searched for patients who had undergone THA and spinal fusion between 2005 and 2012. PearlDiver software was used to query the database by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedural code for primary THA and lumbar spinal fusion. Patients who had undergone both lumbar fusion and THA were then divided into three groups: 1 to 2 levels, 3 to 7 levels and 8+ levels of fusion. The rate of dislocation in each group was established using ICD-9-CM codes. Patients who underwent THA without spinal fusion were used as a control group. Statistical significant difference between groups was tested using the chi-squared test, and significance set at p < 0.05. RESULTS: At one-year follow-up, 14 747 patients were found to have had a THA after lumbar spinal fusion (12 079 1 to 2 levels, 2594 3 to 7 levels, 74 8+ levels). The control group consisted of 839 004 patients. The dislocation rate in the control group was 1.55%. A higher rate of dislocation was found in patients with a spinal fusion of 1 to 2 levels (2.96%, p < 0.0001) and 3 to 7 levels (4.12%, p < 0.0001). Patients with 3 to 7 levels of fusion had a higher rate of dislocation than patients with 1 to 2 levels of fusion (odds ratio (OR) = 1.60, p < 0.0001). When groups were matched for age and gender to the unfused cohort, patients with 1 to 2 levels of fusion had an OR of 1.93 (95% confidence interval (CI) 1.42 to 2.32, p < 0.001), and those with 3 to 7 levels of fusion an OR of 2.77 (CI 2.04 to 4.80, p < 0.001) for dislocation. CONCLUSION: Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their THA than age- and gender-matched patients without a lumbar spinal fusion. Cite this article: Bone Joint J 2017;99-B:585-91.

Image-guided, stereotactic perforator flap surgery: a prospective comparison of current techniques and review of the literature.

BACKGROUND: Image-guided stereotaxy is a recent advancement in imaging technology, allowing computer guidance to aid surgical planning and accuracy. Despite the use of multiple techniques for patient registration in several surgical specialities, only fiducial marker registration has been described for use in soft tissue reconstructive surgery. The current study comprises an evaluation of the current techniques available for this purpose. METHODS: A cohort of nine consecutive patients planned for elective free flaps were recruited, with the first five patients (four for the abdominal wall and one anterolateral thigh donor site) undergoing fiducial marker registration with a variable number of fiducial markers in order to determine the optimal number of fiducial markers to be used. Four subsequent patients undergoing perforator flap surgery underwent registration using three available registration modalities: fiducial marker registration, surface matching pointer/landmark and surface matching laser registration. RESULTS: For the abdominal wall, registration was not able to be achieved with five fiducial markers, and was successfully achieved in all cases with either six or seven fiducial markers. For the anterolateral thigh, registration was achieved with either nine or ten markers. The four patients who also underwent surface-landmark registration and 'Z-touch' laser surface matching registration all failed the registration process. CONCLUSION: Stereotactic navigation is a useful adjunct to the preoperative imaging of perforator flaps. Fiducial marker registration was able to be achieved in all cases, can be successfully achieved with a low and predictable number of fiducial markers, is highly accurate, and was the only reliable registration process in our experience.

The cost-utility of high dose oral mesalazine for moderately active ulcerative colitis.

BACKGROUND: Mesalazine (mesalamine) is standard first line treatment for moderately active ulcerative colitis (UC). Recently, doubling the mesalazine dose (Asacol 4.8 g/day) was shown to improve efficacy with no increase in adverse events. The cost-effectiveness of this strategy remains unknown. AIM: To assess the cost-utility of high dose (HD) mesalazine (Asacol 4.8 g/day) compared with standard dose (SD) mesalazine (Asacol 2.4 g/day) as first line treatment for moderately active UC. METHODS: The costs and benefits associated with a treatment pathway beginning with HD or SD mesalazine were determined over 12 weeks using a decision tree analytical model. RESULTS: A 12-week treatment pathway starting with HD mesalazine cost an average of 2382 pounds per patient compared with 2474 pounds for SD mesalazine and generated 0.0016 more quality adjusted life years (QALYs). HD mesalazine dominated SD mesalazine, being both more effective and less costly. HD mesalazine treatment resulted in fewer patients requiring surgery or hospitalization for intensive pharmacological treatment. Probabilistic sensitivity analysis indicated a 72% chance that HD mesalazine was cost effective, based on a cost/QALY threshold of 30,000 pounds. CONCLUSIONS: This study suggests that HD mesalazine represents a cost-effective alternative to SD mesalazine for moderately active UC, while potentially reducing the need for hospitalization.

The antibacterial properties of secreted phospholipases A(2).

There is a considerable body of evidence to support the antibacterial properties of the group IIa phospholipase A(2) as an important physiological function. This enzyme is able to act as an acute phase protein and may be part of the innate defence system of the body, acting in concert with other antibacterial proteins and peptides. The enzyme is most effective against Gram-positive bacteria whereas penetration of the lipopolysaccharide coat of Gram-negative bacteria requires bactericidal/permeability-increasing protein (BPI) as an additional permeabilizing factor. The global cationic nature of this protein (pI>10.5) appears to facilitate penetration of the anionic bacterial cell wall. In addition, the considerable preference of the enzyme for anionic phospholipid interfaces provides specificity toward anionic bacterial membranes as opposed to zwitterionic eucaryotic cell membranes.

Bacterial cell membrane hydrolysis by secreted phospholipases A(2): a major physiological role of human group IIa sPLA(2) involving both bacterial cell wall penetration and interfacial catalysis.

The ability of human group IIa secreted phospholipase A(2) (human sPLA(2)) to hydrolyse the phospholipid membrane of whole cell suspensions of Gram-positive bacteria is demonstrated in real time using a continuous fluorescence displacement assay. Micrococcus luteus is used as a model system and demonstrates an almost absolute specificity for this human enzyme compared with porcine pancreatic and Naja naja venom sPLA(2)s. This specificity is due to selective penetration of the highly cationic human sPLA(2)50%) phospholipid hydrolysis was observed and this was confirmed by electrospray mass spectrometry that allowed the identification of several molecular species of phosphatidylglycerol as the targets for hydrolysis. However, the bactericidal activity of the human enzyme under these assay conditions was low, highlighting the capacity of the organism to survive a major phospholipid insult. In addition to pure enzyme, the human sPLA(2) activity in tears was demonstrated using M. luteus as substrate. In comparison to M. luteus, cell suspensions of Staphylococcus aureus were highly resistant to hydrolysis by human sPLA(2) as well as to the pancreatic and venom enzymes. Treatment of this organism with the specific cell wall protease lysostaphin resulted in a dramatic enhancement in cell membrane phospholipid hydrolysis by all three sPLA(2)s. Overall, the results highlight the potential of the human sPLA(2) as a selective antimicrobial agent against Gram-positive bacteria in vivo because this enzyme is essentially inactive against mammalian plasma membranes. However, the enzyme will be most effective in combination with other antimicrobial agents that enhance the permeability of the bacterial cell wall and where potentiation of the effectiveness of other antibiotics would be expected.

Inhibition of secreted phospholipases A2 by annexin V. Competition for anionic phospholipid interfaces allows an assessment of the relative interfacial affinities of secreted phospholipases A2.

The ability of annexins, particularly annexin 1 (lipocortin 1), to inhibit phospholipase A2 (PLA2) is well known and a substrate depletion mechanism is now widely accepted as the explanation for most inhibitory studies. In this investigation we have examined the substrate depletion mechanism of annexin V using a variety of phospholipid substrates and secreted PLA2's (sPLA2). The results suggest that the term interfacial competition best describes the inhibitory effect of annexin V although the overall inhibitory process remains one of substrate sequestration by the annexin. We have utilised the competitive nature of the interaction of enzyme and annexin V for a phospholipid interface as a means of quantifying the relative affinity of sPLA2's for anionic phospholipid vesicles. The results highlight the very high affinity of the human non-pancreatic sPLA2 for such vesicles (Kd<<10-(10) M) while the Naja naja venom PLA2 and porcine pancreatic sPLA2 showed lower affinities. Hydrolysis of mixed vesicles containing phosphatidylserine and phosphatidylcholine by the venom and pancreatic enzymes were differentially inhibited by annexin V. This difference must reflect the preference of both annexin V and the pancreatic enzyme for an anionic phospholipid interface. In contrast, the venom enzyme is able to readily hydrolyse phosphatidylcholine domains that would be minimally affected by annexin V. Annexin V was an effective inhibitor of cardiolipin hydrolysis by the pancreatic PLA2, however the inhibition was of a more complex nature than seen with other phospholipids tested. Overall the results highlight the ability of annexin V to inhibit phospholipid hydrolysis by sPLA2's by an interfacial competition (substrate depletion) mechanism. The effectiveness of annexin V as an apparent inhibitor depends on the nature of the enzyme and the phospholipid substrate.

Monoacylglycerol binding to human serum albumin: evidence that monooleoylglycerol binds at the dansylsarcosine site.

The binding of monoacylglycerides of long-chain fatty acids to human serum albumin has been examined using monooleoylglycerol as the ligand. Binding was investigated using changes in tryptophan fluorescence and also the displacement of a variety of well-studied fluorescent ligands from human serum albumin (HSA). Monooleoylglycerol caused a decrease in fluorescence from tryptophan-214 when measured at 350 nm while oleic acid had no effect on fluorescence at this wavelength and did not compete with monooleoylglycerol. In contrast, oleic acid caused an increase in fluorescence at 330 nm whereas monooleoylglycerol did not affect fluorescence intensity at this wavelength. These results suggest that these two ligands do not bind to the same site on HSA. From competition studies using dansylglycine, dansylsarcosine, 11-(dansylamino)-undecanoic acid and 1-anilino-8-naphthalenesulfonic acid it was proposed that monooleoylglycerol binds at the dansylsarcosine site (site II) of HSA. Monooleoylglycerol was a competitive inhibitor of dansylsarcosine binding with a Kd of about 2.5 microM whereas oleic acid was not competitive with dansylsarcosine binding.

Cardiolipin hydrolysis by human phospholipases A2. The multiple enzymatic activities of human cytosolic phospholipase A2.

The ability of mammalian phospholipases A2 (PLA2) to hydrolyse cardiolipin (diphosphatidylglycerol) was monitored with a fluorescent displacement assay which allows the use of natural phospholipid substrates. The mammalian enzymes used were porcine pancreatic (Group I) secretory PLA2 (sPLA2), human non-pancreatic (Group II) sPLA2 and human cytosolic PLA2 (cPLA2). High activity was observed with porcine pancreas sPLA2 whereas the human sPLA2 demonstrated only minimal activity with this substrate. In comparison, sPLA2 from Naja naja venom (Group I) also showed only modest activity with this substrate. Since many lipases possess PLA1 activity, a representative enzyme from Rhizopus arrhizus was also assessed for its ability to hydrolyse cardiolipin which proved to be a good substrate for this fungal lipase. In all cases dilysocardiolipin was the major product while some monolyso intermediate was detected after chromatographic separation. Human cPLA2 was unable to hydrolyse cardiolipin at a significant rate, however, both monolysocardiolipin and dilysocardiolipin, which are prepared by the PLA2-catalysed hydrolysis of cardiolipin, were good substrates providing a further example of the extensive lysophospholipase activity of this enzyme. Moreover, cardiolipin that was initially hydrolysed in situ with either excess porcine pancreatic PLA2 or R. arrhizus lipase (PLA1) was subsequently hydrolysed by human cPLA2. One explanation of this result is that human cPLA2 is able to hydrolyse both 1-acyl and 2-acyl-lysophospholipids. (c) 1998 Elsevier Science B.V.

Inhibition of human cytosolic phospholipase A2 by human annexin V.

The ability of annexins, particularly annexin 1 (lipocortin 1), to inhibit phospholipase A2 (PLA2) is well known and a substrate depletion mechanism is now widely accepted as the explanation for most inhibitory studies. However, there are only a very limited number of reported studies involving annexins and the high-molecular-mass cytosolic PLA2 (cPLA2). In this study we have examined the effect of human recombinant annexin V, a potentially abundant cytosolic protein, on the ability of human recombinant cPLA2 to hydrolyse a variety of phospholipid substrates. The results show clearly that, under the conditions of our study, annexin V can inhibit cPLA2 activity by a mechanism of substrate depletion and that this inhibition is dependent on the nature of the phospholipids and the concentration of Ca2+ ions in the assay. The hydrolysis of 1-stearoyl 2-arachidonyl phosphatidylcholine by cPLA2 was not significantly affected by annexin V over a range of Ca2+ concentrations (1 microM-2.5 mM), a result that presumably reflects the zwitterionic nature of the phospholipid and the known inability of annexins to bind to such interfaces. In contrast, the hydrolysis of dioleoyl phosphatidylglycerol, which is an effective anionic phospholipid substrate for this enzyme, and more significantly that of 1-stearoyl 2-arachidonyl phosphatidic acid, were readily inhibited by annexin V, although these effects were Ca2+-dependent. The Ca2+ concentrations required for inhibition in the assay system in vitro are greater than those associated with Ca2+-stimulated events within the cell, suggesting that a role for annexin V in regulating cPLA2 activity might not involve a substrate depletion mechanism in vivo unless factors in addition to Ca2+ and phospholipids contribute to the binding of annexin V to cell membranes.

More about recruitment--pick me!

In the search for the elusive perfect job, one critical activity you should not neglect is reading. Read solid books and articles about what is new and happening in the medical record/health information management environment. But also through reading and research, pursue insights into the ever-changing healthcare environment so that healthcare administrators can be impressed with your up-to-the-minute knowledge and awareness of issues. Do not neglect to bone up on career planning and recruitment. How-to's about the career chase can be most helpful. We hope that our review of the recruitment picture from the candidate's point of view will help you reach your job placement goals. A career advancement can be an energizing and invigorating experience. If you win and get what you want, as soon as you can, be sure to document how you did it and the errors or pitfalls you experienced. The next time you enter the job candidate pool, you can profit by your experiences. Do not forget to thank those who helped you in your endeavors. You will be glad later that you did because those receiving your thanks will remember you favorably.