Defining reference values for the normal tibiofibular syndesmosis in adults using weight-bearing CT

Aims

Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views.

Patients and Methods

A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation.

Results

The upper limit of lateral translation in un-injured patients was 5.27 mm, so values higher than this may be indicative of syndesmotic injury. Anteroposterior translation lay within the ranges 0.31 mm to 2.59 mm, and -1.48 mm to 3.44 mm, respectively. There was no difference between right and left legs. Increasing age was associated with a reduction in lateral translation. The fibulae of men were significantly more laterally translated but data were inconsistent for rotation and anteroposterior translation.

Conclusion

We have established normal ranges for measurements in cross-sectional syndesmotic anatomy during weight-bearing and also established that no differences exist between right and left legs in patients without syndesmotic injury. Age and gender do, however, affect the anatomy of the syndesmosis, which should be taken into account at time of assessment. Cite this article: Bone Joint J 2019;101-B:348–352.

FM1-2 A prospective study on surgical management of foot deformities in charcot marie tooth disease

Objectives

Charcot-Marie-Tooth (CMT) Disease is the most common inherited peripheral neuropathy. Foot deformities are frequently observed in CMT patients and orthopaedic surgery is often required. Currently the evidence base on surgical management is limited. We prospectively studied surgical management of CMT patients attending our centre.

Subjects

Patients were assessed at baseline and yearly after surgery.

Methods

Assessment and data included: history of ankle instability, pain, skin condition, lower limb strength assessment, Charcot-Marie-Tooth Examination Score, Foot Posture Index, ankle dorsiflexion range of movement, questionnaires, details of surgical procedures.

Results

29 feet in 24 CMT patients (17 males, 7 females, mean age: 38.6±13) were evaluated prior to surgery. All patients but one had genetically confirmed CMT (18 CMT1A; 4 CMTX; 1 CMT4A). 17 feet in 12 pts were evaluated after 1 year; 10 feet in 9 pts were evaluated after 2 years; 8 feet in 7 pts were evaluated after 3 years. A wide range of surgical procedures were performed by one dedicated orthopaedic surgeon. There was significant improvement of foot alignment (p<0.001), callosities (p=0.002) and pain (p=0.022) after surgery. Surgery had no significant effect on strength, ankle range of movement, falls and fatigue.

Conclusions

The findings showed significant improvement of foot alignment, callosities and pain after surgery. Data acquired from this study will help developing orthopaedic intervention guidelines and identify areas for further research.

When to use single-inhaler triple therapy in COPD: a practical approach for primary care health care professionals

While single-inhaler triple therapy (SITT) devices were not available when the Global Initiative for Chronic Obstructive Lung Disease strategy and National Institute for Health and Care Excellence guidelines were developed, two devices are now available in the UK. This paper offers practical, patient-focused advice to optimize placement of SITT in the management of COPD. A survey of UK health care professionals (HCPs) identified issues around, and attitudes toward, SITT, which informed a multidisciplinary expert panel’s discussions. The survey confirmed the need to clarify the place of SITT in COPD management. The panel suggested three criteria, any one of which identifies a high-risk patient where escalation to triple therapy from monotherapy or double combination treatment is appropriate: 1) at least two exacerbations treated with oral corticosteroids, antibiotics, or both in the previous year; 2) at least one severe exacerbation that required hospital admission in the previous year; 3) one exacerbation a year on a repeated basis for 2 consecutive years. Appropriate non-pharmacological management is essential for all patients and should be considered before stepping up treatment. Regular review is essential. During each review, HCPs should consider stepping treatment up or down. If patients exacerbate despite adhering to triple therapy, an individualized approach should be considered if the inhaled corticosteroid (ICS) confers benefit or causes side effects. In this situation, the blood eosinophil count could aid decision making. ICSs should be continued when the history suggests that asthma overlaps with COPD. Training, counseling, and education should be individualized. HCPs should consider referral: 1) when there is limited response to treatment and persistent exacerbations; 2) where there is diagnostic uncertainty or suspected comorbidity; 3) whenever they feel “out of their depth.” Overall, the panel concurred that when used correctly, SITT has the potential to improve adherence, symptom control, and quality of life, and reduce exacerbations. Studies using real-world evidence need to confirm these benefits.

Venus nightside surface temperature

First global map of Venus nightside surface temperature using Akatsuki infrared measurements reveals hot Venus surface with an average surface temperature of about 698 K. Surface temperatures do not show any significant variation with changing latitudes because only a small amount (~2.5%) of solar energy reaches the surface. Surface temperatures are relatively colder at higher altitude regions as compared to lower altitude regions. However, the major temperature variation on Venus surface is governed by various lithospheric heat transport mechanisms. On a global scale, surface temperatures show a spatial variation of about 230 K.

The FCS-LIKE ZINC FINGER 6 and 10 are involved in regulating osmotic stress responses in Arabidopsis

The TARGET OF RAPAMYCIN-SNF1-RELATED PROTEIN KINASE 1 (TOR-SnRK1) arms race is a key regulator of plant growth in response to energy fluctuations and stress. Recently, we have identified that two members of the FCS-LIKE ZINC FINGER (FLZ) protein family, FLZ6 and 10, repress SnRK1 signaling and thereby involved in the activation of the TARGET OF RAPAMYCIN (TOR) signaling. In this study, we demonstrate that FLZ6 and 10 are also involved in the regulation of osmotic stress responses. Downregulation of FLZ6 and 10 results in enhanced expression of stress-responsive genes and better resilience towards osmotic stress at the seedling stage. These results indicate that FLZ6 and 10 are involved in the regulation of stress mitigation in plants through directly affecting SnRK1 signaling.

Adjuvant activity of ethanol extract of Hippophae rhamnoides leaves with inactivated rabies virus antigen

CONTEXT

Hippophae rhamnoides L. (Elaeagnaceae), commonly known as seabuckthorn (SBT), is known for its medicinal and nutritional properties.

OBJECTIVE

Evaluation of in vivo adjuvant activity of SBT leaf extract (SBTE) with inactivated rabies virus antigen (Rb).

MATERIALS AND METHODS

Swiss albino mice were immunized with aqueous-alcoholic SBTE (100 mg/kg body weight) or algel (aluminium hydroxide gel) with or without Rb (5% v/v). After priming, booster was administered on day 14. Rabies virus neutralizing antibody (RVNA) titers were estimated by rapid fluorescent focus inhibition test in sera samples collected on days 7, 14, 21, 28 and 35. Effect of adjuvant administration on cytotoxic T lymphocytes (CTLs), memory T cells, plasma and CD11c⁺ cells was studied by flow cytometry. In vitro hemolysis was assayed in human RBC.

RESULTS

RVNA titers were significantly enhanced (p < 0.05) after booster administration in mice immunized with SBTE + Rb as compared to the controls. In combination, SBTE, algel and Rb, enhanced the RVNA titers. CTLs significantly increased (p < 0.05) in SBTE + Rb immunized mice. Memory T cells and plasma cells were 27.9 and 15.9%, respectively, in SBTE + Rb immunized mice as compared to that of 20.3 and 11.3%, respectively, in Rb immunized group. SBTE + Rb enhanced peritoneal CD11c⁺ cells (25.8%) as compared to 9.4% cells in Rb immunized mice, showed 3.2-fold increment in LPS induced IL-1β. No RBC hemolysis was observed with SBTE.

CONCLUSIONS

This study demonstrates the potential adjuvant activity of SBTE with Rb by increasing RVNA titers and CTL response.

Abnormalities in Protocol Graft Kidney Biopsy 6 Months Posttransplantation in a Tertiary Care Center Hospital of Nepal

BACKGROUND

Increasing graft survival is the prime focus of every transplantation program. Detection of subclinical abnormalities with the help of protocol renal graft biopsies performed at predetermined intervals after transplantation has been one of the approaches. The objective was to study the abnormalities in protocol renal graft biopsy specimens at 6 months posttransplantation.

METHODS

This was a hospital-based observational descriptive study. It included the recipients who underwent kidney transplantation between October 2014 and September 2015. The recipients were followed up postoperatively on an outpatient basis, as per the institution protocol. At 6 months posttransplantation, protocol graft biopsy was performed in all patients with normal functioning allograft without proteinuria after obtaining informed written consent.

RESULTS

A total of 57 patients with chronic kidney disease underwent renal transplantation during the study period. Protocol biopsy was performed in 47 recipients. Subclinical rejection was found in 4 (8.5%) recipients. Two recipients had significant tubulitis and interstitial inflammation. One of them showed features of Banff Type IA cellular rejection (t2, i2) and another showed Banff Type IB cellular rejection (t3, i2). Biopsy specimen of 1 recipient showed significant glomerulitis and peritubular capillaritis (g3, ptc1). Another recipient showed significant peritubular capillaritis (ptc2) with C4d positivity. IgA nephropathy was present in 6 (12.8%) recipients. BK virus nephropathy was found in 2 (4.3%) recipients.

CONCLUSION

This study demonstrates that abnormal histologic findings occur in protocol graft biopsy specimens at 6 months post renal transplantation in patients without any clinical or laboratory abnormalities.

Long-Term Effect of Breast Symptoms Reported at Mammography Screening Visit on Cancer Incidence and Mortality

Background: Efforts to reduce mortality through early detection and diagnosis has intensified in the recent decade. An important risk factor, 'breast symptoms' reported by women during screening visit, is still overlooked. Aim: To study the association between breast symptoms reported at screening visit and the risk of cancer incidence and mortality in a prospective manner over a period of 24-years. Methods: This population based matched cohort study was based on the follow-up of the ongoing Finnish National Breast Cancer Screening Program (FNBCSP) that began in 1987. Symptomatic subjects who attended screening with symptoms (lump, 39,965 visits; retraction, 24,190 visits; nipple discharge, 7882 visits) were identified from the Finnish Cancer Registry database. For each visit with symptoms, nonsymptomatic controls were matched (1:1 for lump and retraction; 1:2 for nipple discharge) based on age at screening visit (within 2 years), year of invitation (2 years band), number of invited visits, and municipality of invitation. The primary outcomes were incidence of breast cancer and incidence-based mortality, including all-cause mortality. Results: Women who reported lump or retraction had about twofold risk of breast cancer incidence, threefold risk of breast cancer mortality and all-cause mortality respectively as compared with women without respective symptoms. We found a substantial difference in mortality rates throughout the follow-up period between symptomatic and asymptomatic group. In absolute terms, for lump, in every 1000 screening visits, 20 women died of breast cancer as compared with 7 women without lump, and 30 vs 11 all-cause deaths in women with and without lump, respectively after 24 years of follow-up. We also found difference in the number of deaths in women who reported retraction or nipple discharge. Conclusion: This study provides comprehensive evidence that women with breast symptoms remain in a higher risk of dying over a very long period. Guidelines to reduce these inequalities needs to be developed.