Patients Requiring Both Total Hip Arthroplasty and Lumbar Spinal Fusion Have Lower Hip Functional Outcome Scores: A Matched Case-Control Study

BACKGROUND

While patients who undergo both lumbar spinal fusion (LSF) and total hip arthroplasty (THA) have increased complication rates compared to patients who have not undergone LSF, there is a paucity of literature evaluating THA functional outcomes in patients with a history of LSF. This study was conducted to determine whether patients undergoing THA with a history of LSF have inferior functional outcomes compared to patients having no history of LSF.

METHODS

A retrospective matched case-control study was conducted at an academic center. Patients who underwent both THA and LSF (cases) were matched with controls who underwent THA without LSF. Inclusion criteria required a minimum of 1-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS-JR]. Following propensity matching for age, sex, race, body mass index, and comorbidities, 291 cases and 1,164 controls were included, with no demographic differences.

RESULTS

Patients who underwent both THA and LSF had a significantly lower preoperative HOOS-JR (47 versus 50; P < .001), postoperative HOOS-JR (77 versus 85; P < .001), a significant lower rate of achieving the patient acceptable symptom state (55 versus 67%; P < .001), with no significant difference in delta HOOS-JR (34 versus 34; P = .834). When comparing patients undergoing THA before LSF or LSF before THA, no differences existed for preoperative HOOS-JR (50 versus 47; P = .304), but patients undergoing THA before LSF had lower postoperative HOOS-JR scores (74 versus 81; P = .034), a lower-delta HOOS-JR (27 versus 35; P = .022), and a lower rate of reaching the HOOS-JR minimal clinically important difference (62 versus 76%; P = .031).

CONCLUSIONS

Patients who have a history of LSF experience a similar improvement in hip function when undergoing THA compared to patients who do not have a history of LSF. However, due to lower preoperative function, they may have a lower postoperative functional outcome ceiling. Additionally, patients undergoing THA before LSF have worse hip functional outcomes than patients undergoing LSF before THA.

The Efficacy of Preoperative Video-Based Opioid Counseling on Postoperative Opioid Consumption After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

BACKGROUND

There are myriad strategies to reduce opioid consumption after total knee arthroplasty (TKA). Recent studies have suggested that preoperative counseling may reduce opioid use after a variety of orthopedic procedures. The purpose of this study was to investigate whether preoperative video-based patient education regarding opioid use and abuse reduces opioid consumption after TKA.

METHODS

In this prospective randomized controlled trial, patients were randomized before TKA to either receive preoperative video-based counseling or not. Counseling involved a pretaped 5-minute video that educated patients on statistics regarding the "opioid epidemic" and discussed safe use and alternatives to opioids after TKA. There were no significant differences in baseline patient demographics between groups. All patients received a similar multimodal perioperative pain management protocol and completed a daily diary for 2 weeks postoperatively. Diary records measured pain levels using a visual analog score, opioid consumption, side effects experienced, and patient opinion and satisfaction regarding their pain control.

RESULTS

Patients in the counseling group consumed significantly less morphine milligram equivalents on postoperative days 0 to 3 (78.8 versus 106.1, P = .020) and in week one postoperatively (129.9 versus 180.7, P = .028), with a trend of less consumption over 2 weeks postoperatively (186.9 versus 239.1, P = .194). There were no significant differences in the number of patients requiring refills, side effects, or daily pain levels between the 2 groups.

CONCLUSIONS

This study found significantly decreased opioid consumption within the first week after TKA in patients who received preoperative video counseling.

Return to Sport After Unicompartmental Knee Arthroplasty and Patello-Femoral Arthroplasty

BACKGROUND

Data on sports/physical activity participation following unicompartmental knee arthroplasty (UKA) and patello-femoral arthroplasty (PFA) is variable and limited. The purpose of this study was to assess participations, outcomes, and limitations in sports following UKA and PFA.

METHODS

Patients who underwent UKA and PFA at a single institution from 2015 to 2020 were surveyed on sports participation before and after surgery. Data was correlated with perioperative patient characteristics and outcome scores. Among 776 patients surveyed, 356 (50%) patients responded. Of respondents, 296 (83.1%) underwent UKA, 44 (12.6%) underwent PFA, and 16 (4.5%) underwent both UKA/PFA.

RESULTS

Activity participation rates were 86.5, 77.3, and 87.5% five years prior, and 70.9, 61.4, and 75% at one year prior to UKA, PFA, and UKA/PFA, respectively. Return to sports rates were 81.6, 64.7, and 62.3% at mean 4.6 years postoperatively, respectively. The most common activities were recreational walking, swimming, cycling, and golf. Patients returned to a similar participation level for low-impact activities, whereas participation decreased for intermediate- and high-impact activities. Patients participating in activities had higher postoperative Knee Injury and Osteoarthritis Outcome Score Joint Replacement (P < .001), 12-Item Short Form Physical Component Score (P = .045) and Mental Component Score (P = .012). Activity restrictions were reported among 25, 36.4, and 25% of UKA, PFA, and UKA/PFA patients, respectively, and were more commonly self-imposed than surgeon-directed.

CONCLUSIONS

Though UKA patients' postoperative sports participation may improve compared to one year preoperatively, participation for patients surgically treated for isolated osteoarthritis is decreased compared to 5 years preoperatively and varies among patient subsets.

Delta hemoglobin cutoffs do not predict readmission in patients undergoing primary simultaneous bilateral total hip or knee arthroplasty: A retrospective cohort study

Background/aims

Primary simultaneous bilateral total joint arthroplasty (simBTJA) can cause postoperative anemia. Clinicians might hesitate to discharge patients who have large changes in hemoglobin [Hgb], despite Hgb levels remaining above transfusion thresholds. This study was conducted to evaluate if delta Hgb or perioperative blood loss correspond with readmission in primary simBTJA patients not transfused perioperatively.

Methods

From 2015 - 2020, a retrospective chart review of primary simultaneous bilateral total hip/knee arthroplasty cases was conducted. Preoperative and postoperative Hgb levels were obtained from our database or chart review. Exclusion criteria comprised patients who had a preoperative transfusion or transfusion postoperatively during their surgical admission, and patients not discharged home. Outcomes included whether delta Hgb or perioperative blood loss were predictive of 90-day readmission postoperatively, postoperative anemia, and transfusion during readmission.

Results

The 510 individuals undergoing primary simBTJA possessed an average preoperative Hgb of 14.1 g/dL, starting blood volume of 5012 mL, postoperative Hgb of 10.0 g/dL, delta Hgb of 3.90 g/dL, and perioperative blood loss of 1403 mL. 19 patients (3.73 %) were readmitted, with none requiring transfusion. When constructing receiver operating characteristic (ROC) curves predicting readmission from delta Hgb, a threshold of 4.1 g/dL had an area under the curve (AUC) of 0.454, a sensitivity of 0.473, and a specificity of 0.56. For ROC curves predicting readmission from perioperative blood loss, a threshold of 1144 mL had an AUC of 0.453, a sensitivity of 0.842, and a specificity of 0.297. Similar AUCs, sensitivities, and specificities were obtained when adjusting ROC curves for preoperative Hgb or starting blood volume.

Conclusions

Delta Hgb and perioperative blood loss do not predict 90-day readmission after primary simBTJA in patients not transfused perioperatively. Patients with a large delta Hgb but stay higher than a 7 g/dL restrictive transfusion threshold may have a strong capacity to overcome postoperative anemia.

Robotic-Assisted Total Knee Arthroplasty Has Similar Rates of Prosthetic Noise Generation as Conventional Total Knee Arthroplasty

Background

Noise has been reported to occur with relatively high frequency after conventional total knee arthroplasty (C-TKA), and this may impact the incidence of patient satisfaction and function. The purpose of this study was to compare the rate of patient-reported prosthetic noise generation after robotically-assisted TKA (RA-TKA) and C-TKA.

Methods

A retrospective study was conducted of unilateral primary RA-TKAs and C-TKAs performed between 2018 and 2021. Patients completed a survey consisting of 4 Likert scale questions related to prosthetic noise generation and Knee Injury and Osteoarthritis Score Joint Replacement and Forgotten Joint Score were assessed prospectively preoperatively and at a minimum of 1-year of clinical follow-up. Statistical analysis was done utilizing T-tests and chi-square tests, with statistical significance defined as a P-value < .05.

Results

One hundred sixty-two RA-TKAs and 320 C-TKAs with similar baseline characteristics and functions were included. There were no significant differences in hearing or feeling grinding, popping, clicking, or clunking (40.7% vs 38.1%; P = .647) between groups. Most RA-TKAs and C-TKAs were not dissatisfied regarding noise generation (70.4% vs 73.1%; P = .596). In both cohorts, patients who reported noise generation had lower average Forgotten Joint Scores (45.5 vs 66.1; P < .001) and lower postoperative Knee Injury and Osteoarthritis Score Joint Replacement scores (72.0 vs 81.4; P < .001) than those who did not experience noise generation.

Conclusions

While RA-TKA may facilitate soft tissue balancing, there were no differences in prosthetic noise generation between RA-TKA and C-TKA. However, those who experience implant-generated noise have lower functional outcome scores.

Sulforaphane prevents the reactivation of HIV-1 by suppressing NFκB signaling

Despite more than 20 years of combination antiretroviral therapy (cART), complete eradication of HIV remains a daunting task. While cART has been very effective in limiting new cycles of infection and keeping viral load below detectable levels with partial restoration of immune functions, it cannot provide a cure. Evidently, the interruption of cART leads to a quick rebound of the viral load within a few weeks. These consistent observations have revealed HIV ability to persist as an undetectable latent reservoir in a variety of tissues that remain insensitive to antiretroviral therapies. The 'Block-and-Lock' approach to drive latent cells into deep latency has emerged as a viable strategy to achieve a functional cure. It entails the development of latency-promoting agents with anti-HIV functions. Recent reports have suggested sulforaphane (SFN), an inducer of NRF-2 (nuclear erythroid 2-related factor 2)-mediated antioxidative signaling, to possess anti-HIV properties by restricting HIV replication at the early stages. However, the effect of SFN on the expression of integrated provirus remains unexplored. We have hypothesized that SFN may promote latency and prevent reactivation. Our results indicate that SFN can render latently infected monocytes and CD4+ T cells resistant to reactivation. SFN treatments antagonized the effects of known latency reactivating agents, tumor necrosis pactor (TNF-α), and phorbol 12-myristate 13-acetate (PMA), and caused a significant reduction in HIV transcription, viral RNA copies, and p24 levels. Furthermore, this block of reactivation was found to be mediated by SFN-induced NRF-2 signaling that specifically decreased the activation of NFκB signaling and thus restricted the HIV-1 promoter (5'LTR) activity. Overall, our study provides compelling evidence to highlight the latency-promoting potential of SFN which could be used in the 'Block-and-Lock' approach to achieve an HIV cure.

Robotic-Assisted Total Knee Arthroplasty: What are Patients' Perspectives, Understanding and Expectations?

BACKGROUND

The rate of using robotic-assisted total knee arthroplasty (RA-TKA) has increased markedly. Understanding how patients view the role of robotics during total knee arthroplasty (TKA) informs shared decision making and facilitate efforts to appropriately educate patients regarding the risks and benefits of robotic assistance.

METHODS

A self-administered questionnaire was completed by 440 potential TKA patients at the time of their surgery scheduling. Participants answered 25 questions regarding RA-TKA, socioeconomic factors, and their willingness to pay (WTP) for RA-TKA. Logistic regressions were used to determine if population characteristics and surgeon preferences influenced the patients' perceptions of RA-TKA.

RESULTS

There were 39.7% of respondents who said that they had no knowledge regarding RA-TKA. Only 40.7% of participants had expressed a desire for RA-TKA to be used. There were 8.7% who were WTP extra for the use of RA-TKA. Participants believed that the main 3 benefits of RA-TKA compared to conventional methods were: more accurate implant placement (56.2%); better results (49.0%); and faster recovery (32.1%). The main 3 patient concerns were harm from malfunction (55.2%), reduced surgeon role in the procedure (48.1%), and lack of supportive research (28.3%). Surgeon preference of RA-TKA was associated with patient's willingness to have RA-TKA (odds ratio 4.60, confidence interval 2.98-7.81, P < .001), and with WTP extra for RA-TKA (odds ratio 2.05, confidence interval: 1.01-4.26, P = .049).

CONCLUSION

Patient knowledge regarding RA-TKA is limited. Nonpeer-reviewed online information may make prospective TKA candidates vulnerable to misinformation and aggressive advertising. The challenge for orthopaedic surgeons is to re-establish control and reliably educate patients about the proven advantages and disadvantages of this emerging technology.

Patients Who Have Had Three or More Levels Fused During Lumbar Spinal Fusion Have Worse Functional Outcomes After Total Hip Arthroplasty

BACKGROUND

Lumbar spinal fusion (LSF) and total hip arthroplasty (THA) are commonly performed in patients who have concomitant spine and hip pathology. While patients who have three or more levels fused during LSF have increased postoperative opioid consumption after undergoing THA, it is unknown whether the number of levels fused during LSF affects THA functional outcomes.

METHODS

A retrospective study was conducted at a tertiary academic center for patients who underwent LSF first and then had a primary THA performed with a minimum of one-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS-JR). Operative notes were reviewed to determine the number of levels fused during LSF. There were 105 patients who underwent one-level LSF, 55 patients underwent two-level LSF, and 48 patients underwent three-or-more-level LSF. No significant differences existed in age, race, body mass index, and comorbidities between the cohorts.

RESULTS

While preoperative HOOS-JR was similar among the three cohorts, patients who had three-or-more-level LSF had significantly lower HOOS-JR scores than patients who had two-level or one-level LSF (71.4 versus 82.4 versus 78.2; P = .010) and a lower delta HOOS-JR (27.2 versus 39.4 versus 35.9; P = .014). Patients who had three-or-more-level LSF had a significantly lower rate of achieving minimal clinically important difference (61.7% versus 87.2% versus 78.7%; P = .011) and the patient acceptable symptom state (37.5% versus 69.1% versus 59.0%; P = .004) for the HOOS-JR, compared to patients who had two-level or one-level LSF, respectively.

CONCLUSIONS

Surgeons should counsel patients who have had three-or-more-level LSF that they may have a lower rate of hip function improvement and symptom acceptability after THA, compared to patients who have had a less number of levels fused during LSF.

Hyponatremia Is an Overlooked Sign of Trouble Following Total Joint Arthroplasty

BACKGROUND

Hyponatremia is a common electrolyte abnormality in arthroplasty patients. This issue, underrecognized by surgeons, can impact the postoperative course of patients. There are, however, little data on the implications of sodium disturbances following total joint arthroplasty (TJA). The primary aims of this study were to (1) report the rate of hyponatremia following TJA, and (2) examine the impact of hyponatremia on the perioperative course of TJA patients.

METHODS

This was a retrospective analysis of 3,071 primary and revision TJAs performed between 2015 and 2017. Based on preoperative and postoperative sodium values (pre-post), patients were classified into 4 groups: normonatremic-normonatremic (Group 1), normonatremic-hyponatremic (Group 2), hyponatremic-normonatremic (Group 3), and hyponatremic-hyponatremic (Group 4). Primary end points were length of stay (LOS), postoperative discharge, in-hospital complications, and 90-day readmissions.

RESULTS

The distribution of cases was 84.6% Group 1, 9.4% Group 2, 2.1% Group 3, and 3.8% Group 4. Overall, 13.2% of patients had hyponatremia after TJA. Older age, hip arthroplasty, general anesthesia, higher Charlson Comorbidity Index, congestive heart failure, revision surgery, and history of stroke, liver disease, and chronic kidney disease were risk factors for postoperative hyponatremia. Patients with postoperative hyponatremia (Groups 2 and 4) had greater likelihoods of having a 90-day complication and non-home discharge and greater LOS.

CONCLUSIONS

Postoperative hyponatremia was a relatively common occurrence in patients undergoing TJA, and was associated with greater LOS, complications, and non-home discharge. Surgeons should identify patients at risk for developing sodium abnormalities in order to optimize these patients and avoid increased resource utilization.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Universal Screening for Malnutrition Prior to Total Knee Arthroplasty Is Cost-Effective: A Markov Analysis

BACKGROUND

Patients undergoing total knee arthroplasty (TKA) who have malnutrition possess an increased risk of periprosthetic joint infection (PJI). Although malnutrition screening and intervention may decrease the risk of PJI, it utilizes healthcare resources. To date, no cost-effectiveness analyses have been performed on the screening and treatment of malnutrition prior to TKA.

METHODS

A Markov model projecting lifetime costs and quality-adjusted life years (QALYs) was built to determine the cost-effectiveness of malnutrition screening and intervention for TKA patients from a societal perspective. Costs, health state utilities, and state transition probabilities were obtained from previously published literature, hospital costs at our institution, and expert opinions. Two important assumptions included that 30% of patients would be malnourished and that a malnutrition intervention would be 50% effective. The primary outcome of this study was the incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000 per QALY. One-way and two-way sensitivity analyses were performed to evaluate model parameter assumptions.

RESULTS

When using the base case values, universal malnutrition screening and intervention was cost-effective compared to no malnutrition screening or intervention, with an incremental cost-effectiveness ratio of $6,454 per QALY. Universal screening and intervention remained cost-effective, provided the cost of screening remained less than $3,373, the cost of nutritional intervention remained less than $12,042, the prevalence of malnutrition among surgical candidates was higher than 2%, and the risk of PJI among patients with malnutrition was greater than 1%.

CONCLUSION

Universal preoperative malnutrition screening and intervention among TKA candidates is cost-effective at parameters encountered in clinical practice. Nutritional optimization programs should be considered to facilitate malnutrition screening and intervention and future studies should evaluate their efficacy at lowering PJI risk.

Utility of Diagnostic Tests Before Reimplantation in Patients Undergoing 2-Stage Revision Total Joint Arthroplasty: A Systematic Review and Meta-analysis

INTRODUCTION

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty (TJA), with treatment failure occurring in 12% to 28% after 2-stage revision. It is vital to identify diagnostic tools indicative of persistent infection or treatment failure after 2-stage revision for PJI.

METHODS

The Cochrane Library, PubMed (MEDLINE), and EMBASE were searched for randomized controlled trials and comparative observational studies published before October 3, 2021, which evaluated the utility of serum/plasma biomarkers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], interleukin-6 [IL-6], fibrinogen, D-dimer), synovial biomarkers (white blood cell [WBC] count, neutrophil percentage [PMN %], alpha-defensin [AD], leukocyte esterase [LE]), tissue frozen section, tissue culture, synovial fluid culture, or sonicated spacer fluid culture indicative of persistent infection before the second stage of 2-stage revision for PJI or treatment failure after 2-stage revision for PJI.

RESULTS

A total of 47 studies including 6,605 diagnostic tests among 3,781 2-stage revisions for PJI were analyzed. Among those cases, 723 (19.1%) experienced persistent infection or treatment failure. Synovial LE (sensitivity 0.25 [0.10-0.47], specificity 0.99 [0.93-1.00], positive likelihood ratio 14.0 [1.45-135.58]) and serum IL-6 (sensitivity 0.52 [0.33-0.70], specificity 0.92 [0.85-0.96], positive likelihood ratio 7.90 [0.86-72.61]) had the highest diagnostic accuracy. However, no biomarker was associated with a clinically useful negative likelihood ratio. In subgroup analysis, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP had limited utility for detecting persistent infection before reimplantation (positive likelihood ratios ranging 2.33-3.74; negative likelihood ratios ranging 0.31-0.9) and no utility for predicting failure after the second stage of 2-stage revision.

CONCLUSIONS

Synovial WBC count, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP have modest sensitivity and specificity for predicting persistent infection during the second stage of 2-stage revision, suggesting some combination of these diagnostic tests might be useful before reimplantation. No biomarker or culture accurately predicted treatment failure after reimplantation.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Prior Meniscectomy in Patients Undergoing Primary Total Knee Arthroplasty is Associated With Worse Short-Term Outcomes

BACKGROUND

Patients undergoing total knee arthroplasty (TKA) who have prior meniscectomy may have increased rates of postoperative infection, arthrofibrosis, and revision. However, aside from an increased risk of complications, it is unclear whether prior meniscectomy impacts functional outcomes after TKA. This study was conducted to compare functional outcomes following TKA in patients who did and did not have a prior meniscectomy. We hypothesized that patients who had a prior ipsilateral meniscectomy would have worse functional outcomes after undergoing TKA.

METHODS

A retrospective matched case-control study was conducted at a tertiary academic center. Patients who underwent both meniscectomy and TKA (cases) or TKA alone (controls) from 2013 to 2020 were identified from our institutional database using current procedural terminology codes. Cases were matched in a 1:3 ratio to controls using age, sex, race, body mass index, and a comorbidity index. Inclusion criteria comprised a minimum of 1-year follow-up for the Knee Injury and Osteoarthritis Outcome Score Junior (KOOS-JR). Exclusion criteria included patients undergoing revision TKA and patients who had a history of ligamentous knee surgery or fracture. T- and Chi-squared analyses were conducted, with significance threshold being P < .05. A total of 589 cases and 1,767 controls were included after matching. There were no significant differences in demographic variables. Cases underwent TKA after their meniscectomy at a mean of 2.9 years (range: 42 days to 16 years).

RESULTS

While no significant difference existed for preoperative KOOS-JR scores (46.4 versus 46.4; P = .984), postoperative KOOS-JR scores were significantly lower in the case group (71.9 versus 75.3; P = .001). The case group also achieved the KOOS-JR minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) at significantly lower rates than the control group [(MCID: 71.0 versus 77.3%; P = .011) (PASS: 69.4 versus 76.7%; P = .001);].

CONCLUSION

Patients who had a prior meniscectomy may experience lower postoperative functional outcome scores after TKA and had a lower rate of achieving the MCID and PASS for KOOS-JR. Patient expectations should be adjusted accordingly.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record

BACKGROUND

Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning.

QUESTIONS/PURPOSES

(1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR?

METHODS

This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI).

RESULTS

Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR.

CONCLUSION

Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Surgeons Experience More Physiologic Stress and Strain During Revision Than Primary Total Joint Arthroplasty

BACKGROUND

Revision total knee arthroplasty (rTKA) and total hip arthroplasty (rTHA) procedures are more complex than primary TKA and THA, but their physiologic burden to the surgeon has not been quantified. While rTKA and rTHA have longer operative times, it is unknown whether differences exist in stress and strain compared to primary TKA and primary THA. The study was conducted to elicit whether differences exist in surgeon physiological response while performing rTKA and rTKA compared to primary TKA and primary THA.

METHODS

We evaluated a prospective cohort study of 70 consecutive cases (23 primary TKAs, 12 primary THAs, 16 rTKAs, and 19 rTHAs). Two high-volume fellowship-trained arthroplasty surgeons wore a smart vest that recorded cardiorespiratory data while performing primary THA, primary TKA, rTHA, and rTKA. Heart rate (beats/minute), stress index (correlates with sympathetic activation), respiratory rate (respirations/minute), minute ventilation (L/min), and energy expenditure (Calories) were collected for every case, along with patient body mass index (kilograms/meter²) and working operative time (minutes). T-tests were used to assess for differences between the two groups.

RESULTS

Compared to primary TKA, performing rTKAs had a significantly higher surgeon stress index (17 versus 15; P = .035), heart rate (104 versus 99; P = .007), energy expenditure per case (409 versus 297; P = .002), and a significantly lower heart rate variability (11 versus 12; P = .006). Compared to primary THA, performing rTHA had a significantly higher energy expenditure per case (431 versus 307; P = .007) and trended towards having a higher surgeon stress index (16 versus 14; P = .272) and a lower heart rate variability (11 versus 12; P = .185), although it did not reach statistical significance.

CONCLUSION

Surgeons experience higher physiological stress and strain when performing rTKA and rTHA compared to primary TKA and primary THA. This study provides objective data on what many surgeons feel and should promote further research on the specific stress and strain felt by surgeons who perform revision arthroplasty procedures.

Making a Joint Decision Regarding the Timing of Surgery for Elective Arthroplasty Surgery After Being Infected With COVID-19: A Systematic Review

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has caused a substantial number of patients to have their elective arthroplasty surgeries rescheduled. While it is established that patients with COVID-19 who are undergoing surgery have a significantly higher risk of experiencing postoperative complications and mortality, it is not well-known at what time after testing positive the risk of postoperative complications or mortality returns to normal.

METHODS

PubMed (MEDLINE), Excerpta Medica dataBASE, and professional society websites were systematically reviewed on March 7, 2022 to identify studies and guidelines on the optimal timeframe to reschedule patients for elective surgery after preoperatively testing positive for COVID-19. Outcomes included postoperative complications such as mortality, pneumonia, acute respiratory distress syndrome, septic shock, and pulmonary embolism.

RESULTS

A total of 14 studies and professional society guidelines met the inclusion criteria for this systematic review. Patients with asymptomatic COVID-19 should be rescheduled 4-8 weeks after testing positive (as long as they do not develop symptoms in the interim), patients with mild/moderate COVID-19 should be rescheduled 6-8 weeks after testing positive (with complete resolution of symptoms), and patients with severe/critical COVID-19 should be rescheduled at a minimum of 12 weeks after hospital discharge (with complete resolution of symptoms).

CONCLUSIONS

Given the negative association between preoperative COVID-19 and postoperative complications, patients should have elective arthroplasty surgery rescheduled at differing timeframes based on their symptoms. In addition, a multidisciplinary and patient-centered approach to rescheduling patients is recommended. Further study is needed to examine the impact of novel COVID-19 variants and vaccination on timeframes for rescheduling surgery.

Minimally Invasive Mid-Substance Achilles Tendon Repair Using the Percutaneous Achilles Repair System (PARS)

Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities^1,2. Many patients want to continue participating in recreational activities, which can be facilitated by operatively treating the injury in a timely fashion, maximizing their functional recovery. The Percutaneous Achilles Repair System (PARS) Jig (Arthrex) can be utilized in patients with acute mid-substance Achilles tendon ruptures^3,4.

Description

Begin by positioning the patient prone with a thigh tourniquet on the operative side. Mark a 3-cm transverse incision 1 cm distal to the proximal Achilles stump and make the incision, taking care to protect the sural nerve laterally. Next, create a transverse paratenon incision and bluntly dissect it from the Achilles circumferentially. After gaining access to the proximal Achilles stump, clamp it with an Allis clamp and insert the PARS Jig between the Achilles tendon and paratenon, sliding it proximally to the myotendinous junction. To secure the jig to the proximal Achilles tendon, insert a guide pin into the jig position-1 hole. To pass sutures through the Achilles tendon, insert pins with their respective sutures into positions 2 through 5 and insert the FiberTape suture (Arthrex) in position 1. Remove the jig from the transverse incision, pulling the suture ends out of the incision. Once they are out, reorient the sutures on the medial and lateral sides to match their positions when initially placed. On both sides, wrap the blue suture around the 2 striped green-and-white sutures twice, and pull the blue suture through the looped green-and-white suture on the ipsilateral side. After doing that, fold the blue suture on itself to create a shuttling suture with the green-and-white suture. Next, pull on the medial non-looped green-and-white suture until it has been pulled out medially, and repeat that with the lateral non-looped green-and-white suture until it has been pulled out laterally, to create a locking stitch. Group the medial sutures together and the lateral sutures together, and utilize a free needle to further incorporate both bundles of sutures into the Achilles tendon. Next, create bilateral mini-incisions 1.5 cm proximal to the calcaneal tuberosity. Insert a rigid cannulated suture-passing device into each mini-incision, pass it through the distal Achilles tendon, load the ipsilateral suture bundle into the Nitinol wire, and pull the suture-passing device out the distal mini-incision to approximate the Achilles. To prepare the calcaneus, drill calcaneal tunnels toward the midline bilaterally, taking care to avoid convergence of the tunnels. Place a suture-passing needle in the tunnels to assist with placing the anchors. Next, tension the sutures, cycling them 5 to 10 times to remove any slack in the system. With the ankle in 15° of plantar flexion, anchor the sutures with cortical bioabsorbable interference screws, following the angle that the suture-passing needles are in. After confirming function of the Achilles tendon, close the peritenon, deep tissues, and superficial tissues, and place the ankle in a splint in 15° of plantar flexion.

Alternatives

Acute Achilles ruptures can be treated operatively or nonoperatively^1,2. Operative techniques include open, percutaneous, or minimally invasive Achilles tendon repair. Open Achilles tendon repair involves making a 10-cm posteromedial incision to perform a primary repair⁵, while percutaneous Achilles tendon repair involves the use of medial and lateral mini-incisions to pass needles and sutures into the Achilles tendon to repair it⁶. Minimally invasive Achilles tendon repair involves the use of a small 3 to 4-cm incision to introduce instrumentation such as modified ring forceps or an Achillon device (Integra)^7,8, along with a percutaneous technique, to repair the Achilles tendon. Nonoperative treatment can be utilized in patients with <5 mm of gapping between the ruptured tendon edges on dynamic ultrasound in 30° of plantar flexion⁹, in patients with limited activity, or in patients whose comorbidities make them high-risk surgical candidates. Nonoperative treatment includes a below-the-knee rigid cast in 30° of plantar flexion or the use of a functional splint in 30° of plantar flexion with gradual progression to a neutral position, along with early rehabilitation according to the postoperative protocol described in the present article.

Rationale

This technique allows patients to begin early postoperative rehabilitation, limits wound and soft-tissue complications such as superficial and deep infections, and protects neurovascular structures such as the sural nerve that may be injured if utilizing other techniques. These benefits are achieved through the use of a minimally invasive knotless approach that places nearly all of the suture material into the Achilles tendon, reducing friction within the paratenon and potentially facilitating improved gliding. Additionally, securing the sutures into the calcaneus minimizes postoperative Achilles tendon elongation and facilitates early postoperative rehabilitation.

Expected Outcomes

Patients undergoing this procedure can expect to return to their baseline physical activities by 5 months³, with the best functional results observed at ≥12 months postoperatively⁴. One retrospective cohort study compared the results of 101 patients who underwent Achilles repair with use of the PARS Jig and 169 patients who underwent open Achilles repair, and found that 98% of PARS patients returned to baseline activities in 5 months compared with 82% of patients undergoing open Achilles repair (p = 0.0001)³. Another retrospective chart review assessed the results of 19 patients who underwent Achilles repair with the PARS Jig⁴ and found that patients began to return to sport as early as 3 months postoperatively and that functional scores in patients increased as time progressed, with significant increases observed at 12 months and longer postoperatively.

Important Tips

Locate the Achilles tendon rupture site prior to marking the transverse incision.Bluntly dissecting the paratenon during closure stimulates healing and reduces scarring, thereby maintaining the integrity of the tissue¹⁰.When advancing the PARS Jig, ensure that the proximal Achilles tendon remains inside the device.Maintaining meticulous suture management and organization prevents tangles and improves suture shuttling.Ensure that the Achilles tendon is tensioned with the ankle in 15° of plantar flexion prior to distal anchor fixation.

Acronyms and Abbreviations

MRI = magnetic resonance imagingUS = ultrasoundBID = twice dailyPRN = as neededDVT = deep vein thrombosis.

Topical Cannabidiol (CBD) After Total Knee Arthroplasty Does Not Decrease Pain or Opioid Use: A Prospective Randomized Double-Blinded Placebo-Controlled Trial

BACKGROUND

Multimodal analgesia has become the standard of care for pain management following total knee arthroplasty (TKA). Cannabidiol (CBD) is increasingly utilized in the postoperative period. The purpose of this study was to analyze the analgesic benefits of topical CBD following primary TKA.

METHODS

In this randomized double-blinded placebo-controlled trial, 80 patients undergoing primary unilateral TKA applied topical CBD (CBD; n = 19), essential oil (EO; n = 21), CBD and essential oil (CBD + EO; n = 21), or placebo (PLA; n = 19) thrice daily around the knee for two weeks postoperatively. This supplemented a standardized multimodal analgesic protocol. Outcomes included visual analog scale (VAS) pain and numeric rating scale (NRS) sleep scores (collected on postoperative day [POD] 0, 1, 2, 7, 14, 42), and cumulative postoperative opioid use (42 days).

RESULTS

Demographic characteristics were similar among the four cohorts. Preoperative VAS and NRS scores were similar among groups. The CBD cohort had a higher mean VAS pain score on POD 2 compared to the EO cohort (CBD: 69.9 ± 19.3 versus. EO: 51.0 ± 18.2; P = .013). No statistically significant differences existed for VAS scores at other times, and no statistically significant differences were observed for postoperative NRS sleep scores or postoperative opioid use at any time point.

CONCLUSION

Utilization of topical CBD in supplement to multimodal analgesia did not reduce pain or opioid consumption, or improve sleep scores following TKA. These results suggest that the local effects of topical CBD are not beneficial for providing additional pain relief after TKA.

Direct Anterior Approach in Hip Hemiarthroplasty for Femoral Neck Fractures: Do Short-Term Outcomes Differ with Approach?: A Systematic Review and Meta-Analysis

BACKGROUND

Hip hemiarthroplasty (HA) is commonly used to treat femoral neck fractures, but it remains unclear if the surgical approach impacts patient outcomes for this commonly performed procedure. The objective of this systematic review and meta-analysis was to assess early postoperative outcomes in patients undergoing HA for femoral neck fracture with the direct anterior approach (DAA) compared with other approaches.

METHODS

The Cochrane Central Registry of Controlled Trials, MEDLINE, and Google Scholar databases were searched for randomized controlled trials, prospective nonrandomized trials, and retrospective studies published prior to September 7, 2021, comparing DAA with other approaches (anterolateral approach [ALA], direct lateral approach [DLA], and posterior-based approach [PA]) in HA for femoral neck fractures. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes included functional outcomes, total complications, prosthetic dislocation, periprosthetic fracture, periprosthetic joint infection (PJI), reoperation, mortality, pain, operative time, and perioperative blood loss. Fixed effect odds ratios, along with their 95% confidence intervals, were used to analyze dichotomous variables. Significance was set at p < 0.05. Meta-analysis was conducted with Review Manager 5.4.

RESULTS

In total, 19 studies were included for qualitative analysis and 16 studies were included for quantitative analysis, with a total of 1,604 cases analyzed (723 DAA, 215 ALA, 301 DLA, and 365 PA). Compared with other approaches, the use of the DAA for HA was associated with improved early postoperative functional outcomes, lower early postoperative pain scores, fewer total complications, and fewer prosthetic hip dislocations. The rates of periprosthetic fracture, PJI, and reoperation, pain scores beyond 40 days, operative time, perioperative blood loss, and mortality were not significantly different between surgical approaches.

CONCLUSIONS

Utilizing the DAA while performing HA for femoral neck fractures is associated with improved functional outcomes, lower early postoperative pain scores, lower incidence of prosthetic hip dislocation, and potentially fewer total complications.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Postoperative Anemia After Unilateral Primary Total Joint Arthroplasty: Restrictive Transfusion Thresholds are Safe for Discharge Regardless of Delta Hemoglobin

BACKGROUND

Primary unilateral total joint arthroplasty (TJA) is associated with acute postoperative anemia that may require blood transfusion. Clinicians may worry about discharging patients after surgery who experience substantial decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study was to determine whether differences between preoperative and postoperative Hgb values (Delta) correlate with 90-day readmission in patients who did not receive perioperative transfusions.

METHODS

A retrospective review of patients undergoing primary unilateral TJA between 2015 and 2020 was performed. The primary outcome was whether a specific cutoff delta Hgb was predictive of readmission within 90 days due to anemia-related causes. Secondary outcomes included the presence of acute postoperative anemia and transfusion during readmission.

RESULTS

Six thousand seven hundred and ninety one patients had a median delta Hgb of 2.80. In total, 268 patients (3.95%) were readmitted within 90 days postoperatively, with two patients requiring transfusion during readmission. A significantly higher rate of readmission was found in patients with cardiovascular disease (5.16% versus 3.68%; P = .020). When constructing receiver operating characteristic curves, a cutoff value of 3.20 resulted in an area under curve of 0.595 (0.486-0.704). In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an area under curve of 0.626 (0.466-0.787).

CONCLUSION

The magnitude of Hgb change was not predictive of anemia-related readmission within 90 days in patients who did not receive a perioperative transfusion. Patients experiencing higher delta Hgb values but remaining above the transfusion threshold may have a greater physiologic reserve.

Image processing based fault classification in power systems with classical and intelligent techniques

This paper is devoted to develop interest of power system engineers in learning basic concepts of image processing and consequently using deep networks to solve problems of complex power system networks. To this end, we study fault classification in a power system through automation of equal area (EAC) criterion. By considering EAC graphs as images and using classical image processing techniques, we successfully distinguish between different transient conditions including sudden change of input power as well as short circuit at the sending end and middle points of a single and double circuit transmission lines. In addition to classification, some parameters are also determined from EAC images such as initial rotor angle, clearing angle, and maximum rotor angle. Further, the use of deep networks is introduced to perform the same task of fault classification and a comparison is drawn with multilayer perceptron neural networks. Developed algorithms are tested in MATLAB as well as Pytorch environments.

Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty

BACKGROUND

While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA.

METHODS

This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections.

RESULTS

648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI.

DISCUSSION

A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.

Providing Care with Cultural, Racial, and Ethnic Humility: the Framework for an Additional Entrustable Professional Activity

Healthcare inequities are rampant in the USA. There is a lack of standardization for training medical students in providing care with cultural, racial, and ethnic humility. This innovation is the framework of an entrustable professional activity that can be utilized to address this vital issue.

Surgeons Experience Greater Cardiorespiratory Strain and Stress During Total Hip Arthroplasty Than Total Knee Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are physically demanding, with a high prevalence of work-related injuries among arthroplasty surgeons. It is unknown whether there are differences in cardiorespiratory output for surgeons while performing THA and TKA. The objective of this study is to characterize whether differences in surgeon physiological response exist while performing primary THA vs TKA.

METHODS

This is a prospective cohort study including 3 high-volume, fellowship-trained arthroplasty surgeons who wore a smart garment that recorded cardiorespiratory data on operative days during which they were performing primary conventional TKA and THA. Variables collected included patient body mass index (BMI), operative time (minutes), heart rate, heart rate variability, respiratory rate, minute ventilation, and energy expenditure (calories).

RESULTS

Seventy-six consecutive cases (49 THAs and 27 TKAs) were studied. Patient BMI was similar between the 2 cohorts (P > .05), while operative time was significantly longer in TKAs (60.4 ± 12.0 vs 53.6 ± 11.8; P = .029). During THA, surgeons had a significantly higher heart rate (95.7 ± 9.1 vs 90.2 ± 8.9; P = .012), energy expenditure per minute (4.6 ± 1.23 vs 3.8 ± 1.2; P = .007), and minute ventilation (19.0 ± 3.0 vs 15.5 ± 3.3; P < .001) compared to TKA.

CONCLUSION

Surgeons experience significantly higher physiological strain and stress while performing THA. While scheduling THAs and TKAs, surgeons should consider the higher physical demand associated with THAs and ensure adequate personal preparation and sequence of cases.

Human immunodeficiency virus-1 Tat exerts its neurotoxic effects by downregulating Sonic hedgehog signaling

We previously showed that HIV-1 can alter the expression of tight junction proteins by downregulating Sonic hedgehog (Shh) signaling, thereby disrupting blood-brain barrier (BBB) integrity. In this study, we employed a conditional, CNS specific, Tat transgenic murine model to investigate if HIV-Tat exerts its neurotoxic effects by downregulating Shh signaling. Results indicate that Tat + mice exhibit significantly reduced expression of Shh and Gli1. HIV-Tat induced downregulation of Shh signaling correlated with disruption of BBB function and induced infiltration of peripheral leukocytes into the brain tissue. Further, our in vivo and in vitro experiments suggest that activation of Shh signaling can rescue detrimental effects of Tat on endothelial function by inducing the expression of junctional proteins and by decreasing the levels of inflammatory cytokines/chemokines.

Effect of head covering on phototherapy induced hypocalcemia in term neonates with hyperbilirubinemia: A randomised controlled study

BACKGROUND

Phototherapy is the primary treatment for hyperbilirubinemia in neonates. Hypocalcemia is a lesser known but potential detrimental effect of phototherapy. It has been hypothesized that phototherapy inhibits pineal secretion of melatonin, which blocks the effect of cortisol on bone calcium. Therefore, unchecked cortisol increases bone uptake of calcium and induces hypocalcemia. Covering head during phototherapy in order to prevent light reaching to the pineal gland which eventually leads to the prevention of hypocalcemia is hypothesized to prevent hypocalcemia but it lacks sufficient evidence worldwide.

METHOD

It is a prospective, randomized controlled study. 112 neonates were randomized into two groups of 56 neonates. Group A underwent phototherapy without head cover and group B with head covered by a cap.

RESULT

The mean decline in serum ionic calcium after 48 hours of phototherapy in group A and group B was 0.57±0.37 mg/dl and 0.34±0.24 mg/dl respectively. This decline in serum ionic calcium was significantly higher in group A. (p < 0.001). 26.8% newborns from group A developed hypocalcemia while in group B only 14.3% developed hypocalcemia however it was not found to be statistically significant. Incidence of symptomatic hypocalcemia between the two groups was also not significant.

CONCLUSION

There was significant reduction in serum calcium in neonates undergoing phototherapy without head cover as compared to neonates with head cover but risk of hypocalcemia was not significant. Further studies with larger sample size including preterm are recommended.

Comparing the Effects of General Versus Regional Anesthesia on Postoperative Mortality in Total and Partial Hip Arthroplasty

Purpose

Total hip arthroplasty (THA) and partial hip arthroplasty (PHA) are performed in patients with hip joint dysfunction such as osteoarthritis or hip fractures and are associated with complications including mortality. There is a lack of evidence in the literature regarding whether the type of anesthesia (regional vs. general) is associated with increased postoperative mortality in patients undergoing hip arthroplasty. The present study compares early postoperative mortality between general or regional anesthesia administered to patients undergoing either THA or PHA.

Methods

A retrospective cohort was assembled using the 2015-2016 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients undergoing hip arthroplasty under general or regional anesthesia were included. Patients were excluded if receiving any other type of anesthesia, as well as having an American Society of Anesthesiologists (ASA) physical status classification score ≥ 4, preoperative acute renal failure, severe congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or ascites. Adjusted odds of 30 days all-cause postoperative mortality according to the type of anesthesia were estimated by fitting multiple logistic regression models that included potential confounders and effect modifiers.

Results

A total of 60,897 patients were included in the study. Given that the interaction between the type of anesthesia and the type of arthroplasty was statistically significant, separated models were fitted for each type of arthroplasty. There was no evidence of an association between type of anesthesia and postoperative mortality in hip arthroplasty patients regardless of whether the arthroplasty was partial (odds ratio {OR} = 0.85; confidence interval {CI} 0.59-1.22) or total (OR = 0.68; CI 0.43-1.08).

Conclusion

The overall early postoperative mortality in adult hip arthroplasty patients is low in the absence of risk factors such as severe CHF, COPD, ascites, acute renal failure, and ASA score of 4 or higher. Our findings suggest there is no association between the type of anesthesia received (general vs. regional) and early postoperative mortality rates in patients undergoing hip arthroplasty, regardless of type (total vs. partial).

Preliminary Comparative Assessment of Brucellergene Skin Test for Diagnosis of Brucellosis in Dromedary Camels (Camelus dromedarius)

This study was conducted to evaluate the use of Brucellergene skin test (BST) for the diagnosis of Brucellosis in camels (Camelus dromedarius) in comparison with Rose Bengal test (RBT) and competitive enzyme-linked immunosorbent assay (c-ELISA). A total of 68 apparently healthy adult dromedary camels of either gender from three different geographical locations of Abu Dhabi Emirate, United Arab Emirates (UAE), were included in the study. The skin test was applied on two shaved areas at the middle of the neck: one for the test and the other area was injected with normal saline as a control. Reading was done 72 h postinjection. Results were subjected to Bayesian analysis to assess the test performances in camels. The model estimated the following sensitivity and specificity median values: BST: Se = 70.72%, Sp = 98.82%; RBT: Se = 93.27%, Sp = 97.79%; and c-ELISA: Se = 94.78%, Sp = 98.48%. As the BST investigated in this study proved to be a highly specific test, we propose using it as a confirmatory test in camels particularly when the serological tests give doubtful results on individual animals.

Alpha lipoic acid supplementation ameliorates the wrath of simulated tropical heat and humidity stress in male Murrah buffaloes

A supplement which ameliorates temperature-humidity menace in food producing livestock is a prerequisite to develop climate smart agricultural packages. A study was conducted to investigate the heat stress ameliorative efficacy of alpha lipoic acid (ALA) in male Murrah water buffaloes (Bubalus bubalis). Eighteen animals (293.61 ± 4.66Kg Bwt) were randomly allocated into three groups (n = 6); NHSC (non-heat-stressed control), HS (heat-stressed) and HSLA (heat-stressed-supplemented with ALA@32 mg/kg Bwt orally) based on the temperature humidity index (THI) and ALA supplementation. HS and HSLA were exposed to simulated heat challenge in a climatically controlled chamber (40 °C) for 21 consecutive days, 6 h daily. Physiological responses viz. Respiration rate (RR), Pulse rate (PR) and Rectal temperature (RT) were recorded daily before and after heat exposure. Blood samples were collected at the end of heat exposure on days 1, 6, 11, 16, and 21 and on day 28 (7th day post exposure which is considered as recovery) for peripheral blood mononuclear cells (PBMCs) separation, followed by RNA and Protein extraction for Real time quantitative PCR and Western blot analysis respectively, of heat shock proteins (HSPs). Two-way repeated measure ANOVA was performed between groups at different experimental periods. RR (post exposure) in HS and HSLA was significantly higher (P < 0.05) than NHSC from day 1 onwards but HSLA varied significantly from the HS 8th day onwards. Post exposure RT and PR in both HS and HSLA varied (P < 0.05) from NHSC throughout the study; but between HS and HSLA, RT significantly varied on initial 2 days and last 6 days (from days 16 to 21). HSP70 mRNA expression significantly up regulated in high THI groups with respect to the low THI group throughout the experimental period. During chronic stress (days 16 and 21) HSP70 significantly (P < 0.05) increased in HS but not in HSLA (P > 0.05) with respect to NHSC. ALA supplementation up-regulates and sustains (P < 0.05) the expression of HSP90 in HSLA in comparison to the HS and NHSC. HSP105 expression was significantly up-regulated (P < 0.05) in HS on days 16 and 21 (during long-term exposure) but only on day 21 (P < 0.05) in HSLA. HSP70, HSP90, and HSP105 protein expression dynamics were akin to the mRNA transcript data between the study groups. In conclusion, supplementing ALA ameliorates the deleterious effect of heat stress as reflected by improved physiological and cellular responses. ALA supplementation improved cellular antioxidant status and sustained otherwise easily decaying heat shock responses which concertedly hasten the baton change from a limited window of thermo tolerance to long run acclimatization.

Cryopreservation of Axillary Buds of Cannabis sativa L. by V-Cryoplate Droplet-Vitrification: The Critical Role of Sucrose Preculture

BACKGROUND

Cryopreservation is the only method allowing the safe and cost-effective long-term conservation of important germplasm. Recent use of the cryo-plate system has proven beneficial in further simplifying the cryopreservation protocols.

OBJECTIVE

Developing an efficient protocol for the cryopreservation of axillary buds of Cannabis sativa elite cultivars (MX and V1-20) by the V-cryoplate droplet-vitrification technique.

MATERIALS AND METHODS

Stem segments (~5 cm in length) with mature axillary buds collected from indoor-grown plants were surface sterilized and then either precultured on MS basal medium with 0.1 M sucrose (1^st step preculture) for 72 h or non-precultured. All mature axillary buds (~1 mm) were aseptically excised from stem segments and precultured for an additional 48 h on MS basal medium with sucrose (0.3 M) and 5% DMSO prior to cryopreservation (2^nd step preculture). Biomass samples of fully mature mother plants and regrown cryopreserved plants were analyzed for Δ⁹-THC and CBD content using gas chromatography-flame ionization detector (GC/FID).

RESULTS

The survival and regrowth rates of cryopreserved axillary buds of cultivar MX following this two-step preculture were 45% and 42% respectively, while those of cultivar V1-20 were 47% and 44% respectively. A direct preculture of axillary buds (2^nd step preculture) on high sucrose (0.3M sucrose) significantly decreased both the survival and regrowth levels of axillary buds of cultivar MX (5% and 3% respectively) as well as those of cultivar V1-20 (20% and 17% respectively). Δ⁹-THC and CBD content of mother plants and regrown cryopreserved plants were found to be highly comparable to each other.

CONCLUSION

The resulting plants after cryopreservation appeared normal without any callus formation or morphogenetic variation. On maturity, mother plants and re-grown cryopreserved plants were comparable in terms of Δ⁹-THC and CBD content. This report provides an efficient protocol for cryopreservation of axillary buds of Cannabis sativa cultivars which may be applicable to other important cultivars, plant parts and other related medicinal plants.

Dynamics of antibiotic resistance with special reference to Shiga toxin-producing Escherichia coli infections

The discovery of antibiotics was paralleled by the evolution of antibiotic resistance which is probably the best example of contemporary evolution in action. The selection pressure, imposed by indiscriminate use of antibiotics, has changed the scale, mode and tempo of antibiotic resistance evolution. The presence of multidrug resistance, wide range of adaptability features and the infectivity make antibiotic resistance of Shiga toxin-producing Escherichia coli (STEC) more dangerous. The characterization, prevalence and the virulence factors of STEC have been profusely reported, whereas, the antibiotic resistance has been largely ignored because the antibiotic use in STEC infections is controversial. Thus, the current review has focussed on the source, evolution, persistence, mechanism, dissemination and control of antibiotic resistance viz-a-viz the STEC infections. The resistance development occurs by the inactivation of antibiotics, regulating the membrane permeability, modification of natural antibiotic targets or the use of efflux pumps against antibiotics. And, the dissemination of resistance genes occurs vertically by DNA replication and horizontally by conjugation, transduction and transformation. The prevention of development and dissemination of antibiotic resistance needs international public health bodies to rationalize the antibiotic use, prevent the flux of antibiotics into the environment, develop the rapid diagnostics tests, undertake proper surveillance of antibiotic resistance, promote the research on antibiotic resistance prevention, promote the research and development of novel alternative antibiotics, and encourage the widespread social awareness campaigns against the inappropriate antibiotic usage.

Assessment of allelic diversity among drought-resistant cotton genotypes using microsatellite markers

Drought, in conjunction with high temperature, is an important environmental constraint to cotton production. Development of cotton varieties with increased tolerance against adverse environmental conditions has been proposed as effective strategy for ensuring reliable yields. In the present study, 30 simple sequence repeat (SSR) primers were used to estimate genetic divergence among 22 cotton genotypes for drought stress tolerance. Genetic diversity is a prerequisite for developing drought resistant cotton genotypes. Eleven SSR primers out of 30 were able to discriminate among the cotton genotypes, implying that 37% of the primers were informative. In total, 41 alleles were detected, with an average of 3.72 alleles per primer. The number of alleles per locus ranged from one (JESPR-284) to six (JESSPR-302), and the allelic diversity in the experimental material was 0.40. Genetic similarity coefficients ranged from 0.87-1.00. The result of principal component analysis confirmed the clustering of 21 cotton genotypes in two groups leaving one genotype (CIM-109) ungrouped. Overall, genetic diversity among the 22 cotton genotypes was low. More polymorphic SSR markers are needed to explore the workable genetic variation among the screened cotton genotypes in future studies.

Anionic and Cationic Silver Nanoparticle Binding Restructures Net-Anionic PC/PG Monolayers with Saturated or Unsaturated Lipids

We have examined the interactions between polymer-coated anionic (Ag-COOH) and cationic (Ag-NH) silver nanoparticles, and net-anionic lipid monolayers using dynamic surface pressure measurements. Monolayers composed of saturated or monounsaturated mixtures of anionic phosphatidylglycerol (PG) and zwitterionic phosphatidylcholine (PC) lipids (3:1 molar ratio) were used to determine how lipid packing and monolayer phase state influence the extent of nanoparticle binding and the monolayer response. Anionic Ag-COOH inserted into saturated dipalmitoyl-PC/PG (DPPC/DPPG) and dioleoyl-PC/PG (DOPC/DOPG) monolayers at a low initial surface pressure (10 mN m^-1) and caused lipid condensation at high initial surface pressures (20 and 30 mN m^-1). Hydrophobic interactions were responsible for insertion, while electrostatic and charge-dipole interactions with PCs were responsible for condensation. In contrast, cationic Ag-NH inserted only into saturated DPPC/DPPG monolayers and otherwise led to lipid condensation. For Ag-NH, adsorption was driven primarily by electrostatic interactions with PGs. Analysis of the subphase Ag and phosphorus concentrations confirmed that Ag-NH had a higher degree binding compared to Ag-COOH, and that the monolayer response was not due to lipid extraction.

Chemical composition and biological activities of Artemisia judaica essential oil from southern desert of Jordan

ETHNOPHARMACOLOGIC RELEVANCE

Artemisia judaica L. (Arabic name: Beithran), is a medicinal and aromatic plant growing in the valley bottoms of desert areas, particularly in the southern desert of Jordan nearest to the Jordan-Saudi Arabia borders and in Wadi Araba in the Southern Badia. In Jordan, A. judaica is widely used in traditional medicine being recommended by aboriginal Bedouins in the North Badia region of Jordan as calmative. Furthermore, it is used for the treatment of stomach ache, heart diseases, sexual weakness, diabetes, gastro-intestinal disorders and external wounding. Additionally, other folk medicines of the Arabic region commonly use this aromatic plant for the treatment of inflammatory-related diseases, for instance fungal infections, diabetes, atherosclerosis, cancer and arthritis.

AIM OF THE STUDY

Considering the traditional medicinal uses and the lack of scientific studies addressing the cellular and molecular mechanisms behind A. judaica claimed activities, the present study was designed to validate some of the traditional uses ascribed to this species, specifically the antifungal and anti-inflammatory activities of A. judaica essential oil at doses devoid of cytotoxicity to mammalian cells.

MATERIALS AND METHODS

Chemical analysis of A. judaica essential oil isolated by hydrodistillation from aerial parts was carried out by gas chromatography (GC) and gas chromatography-mass spectrometry (GC-MS). The antifungal activity (minimal inhibitory concentrations and minimal lethal concentrations) was evaluated against yeasts, dermatophyte and Aspergillus strains. In order to deeply explore the mechanisms behind the anti-fungal effect of the essential oil, the germ tube inhibition assay and the biofilms formation assay were evaluated using Candida albicans. The assessment of cell viability was accomplished using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay in both hepatocytes and macrophages. Furthermore, the in vitro anti-inflammatory potential of A. judaica oil was evaluated by measuring nitric oxide (NO) production using lipopolysaccharide (LPS)-stimulated mouse macrophages.

RESULTS

Oxygen containing monoterpenes are a representative group of constituents (68.7%) with piperitone (30.4%), camphor (16.1%) and ethyl cinnamate (11.0%) as main compounds. The highest antifungal activity of the oil was observed against Cryptococcus neoformans, with a MIC value of 0.16µL/mL. The oil revealed an important inhibitory effect on germ tube formation in C. albicans with 80% inhibition of filamentation at a concentration of 0.16µL/mL. Importantly, the oil also interfered with pre-formed biofilms by reducing the amount of the attached biomass. Furthermore, the essential oil significantly inhibited NO production evoked by LPS on macrophages at concentrations with very low toxicity (0.32µL/mL) or without toxicity (0.16µL/mL) to both macrophages and hepatocytes.

CONCLUSIONS

The present study revealed that A. judaica essential oil from Jordan significantly inhibited germ tube formation and disrupted preformed biofilms of C. albicans, emphasizing the therapeutic potential for the treatment of disseminated candidiasis. Additionally, safe concentrations of this essential oil significantly inhibited NO production elicited by LPS in macrophages, highlighting its potential anti-inflammatory activity. Overall, A. judaica bears promising therapeutic potential for further drug development. Importantly, this work also validates some of the traditional uses of A. judaica.

ErbB2-dependent downregulation of a pro-apoptotic protein Perp is required for oncogenic transformation of breast epithelial cells

The ability of breast cancer cells to resist anoikis, apoptosis caused by detachment of the non-malignant epithelial cells from the extracellular matrix (ECM), is thought to be critical for breast tumor growth, invasion and metastasis. ErbB2, an oncoprotein that is often overproduced in breast tumors, can block breast cancer cell anoikis via mechanisms that are understood only in part. In an effort to understand them better we found that detachment of the non-malignant human breast epithelial cells from the ECM upregulates a protein Perp in these cells. Perp is a component of the desmosomes, multiprotein complexes involved in cell-to-cell adhesion. Perp can cause apoptosis via unknown mechanisms. We demonstrated that Perp upregulation by cell detachment is driven by detachment-induced loss of epidermal growth factor receptor (EGFR). We also found that Perp knockdown by RNA interference (RNAi) rescues detached cells from death which indicates that Perp contributes to their anoikis. We observed that ErbB2, when overexpressed in detached breast epithelial cells, causes Perp downregulation. Furthermore, ErbB2-directed RNAi or treatment with lapatinib, an ErbB2/EGFR small-molecule inhibitor used for breast cancer therapy, upregulated Perp in ErbB2-positive human breast and ovarian carcinoma cells. We established that ErbB2 downregulates Perp by activating an ErbB2 effector protein kinase Mek that blocks detachment-induced EGFR loss in a manner that requires the presence of a signaling protein Sprouty-2. Finally, we observed that restoration of the wild-type Perp levels in ErbB2-overproducing breast epithelial cells increases their anoikis susceptibility and blocks their clonogenicity in the absence of adhesion to the ECM. In summary, we have identified a novel mechanism of ErbB2-mediated mechanism of anoikis resistance of ErbB2-overproducing breast epithelial cells. This mechanism allows such cells to grow without adhesion to the ECM and is driven by ErbB2-induced activation of Mek, subsequent EGFR upregulation and further EGFR-dependent Perp loss.

Comparative studies on the chemical and enzymatic stability of alpha- and beta-arbutin

OBJECTIVE

The aim of this study was to establish a comparative analysis of the chemical and enzymatic stability of α- and β-arbutins as potential sources of the substance of concern hydroquinone (HQ). The study was performed using an array of techniques including HPLC-PDA, nuclear magnetic resonance (NMR) and optical rotation (OR). Both arbutins are emerging as popular and effective skin whiteners, acting as tyrosinase inhibitors in a fashion similar to the popular whitening agent HQ. Due to their structural similarity to the regulated agent HQ, both arbutins may be regarded as potential sources of the active aglycone after chemical or metabolic conversion.

METHODS

Various cosmetic formulations including creams, sera, gels and lotions were analysed by HPLC-PDA for their arbutin and HQ content in freshly opened and aged samples stored for 16 months. Solutions of pure compounds were also aged and periodically checked for degradation products using 1D and 2D NMR experiments and OR measurements. The metabolic stability was investigated using pear peels as a biological model.

RESULTS

Both arbutins were found to be stable in water and methanol solutions in the absence of buffer or stabilizers. Their stability in cosmetic formulations, however, was found to depend on the type of formulation and pH. Both compounds were unstable under strong hydrolytic conditions, with consequent release of HQ. Enzymatic instability of both arbutins was also observed, although no formation of HQ was observed under the chosen experimental conditions.

CONCLUSION

Both arbutins were found to possess similar stability profiles, and to be more prone to in vivo rather than in chemico degradation, although no HQ was found after enzymatic hydrolysis. Also, no epimerization was observed in any of the tested conditions. Diverse experimental approaches can be applied to analyse the chemical and enzymatic stability of arbutins in regard to the potential release of HQ in different types of preparations. These result showed the potential use of NMR and OR as complementary investigative tools for the stability and safety assessment of arbutin along with more established HPLC methods.

Stem cell intervention ameliorates epigallocatechin-3-gallate/lipopolysaccharide-induced hepatotoxicity in mice

Stem cells are identified as a novel cell therapy for regenerative medicine because of their ability to differentiate into many functional cell types. We have shown earlier a new model of hepatotoxicity in mice by administering (1500 mg/kg) epigallocatechin-3-gallate (EGCG) intragastric (IG) for 5 days after a single intraperitoneal dose (6 mg/kg) of lipopolysaccharide (LPS). In this study, we aimed to study the effect of intrahepatic (IH) injection of mouse embryonic stem cells (MESCs) on the hepatotoxicity induced by EGCG/LPS in mice. Mice were administered EGCG/LPS and rested for 3 days. MESCs were obtained from American Type Culture Collection and cultured in vitro for 4 days. Stem cells were injected IH. Seven days later, a single dose of LPS (6 mg/kg) followed by daily doses of IG administration of EGCG were re-administered for 5 days. At the end of the experiment, blood samples were collected for analysis of biochemical parameters associated with liver. Results showed that the group of mice that were administered MESCs prior to EGCG/LPS showed lower levels of alanine amino transferase, alkaline phosphatase, and bilirubin, higher albumin/globulin ratio, and less remarkable histopathological lesions. Also, that group of mice showed less expression of oxidative stress biomarkers (oxidized low-density lipoprotein Ox.LDL and chemokine CXCL16), less expression of nuclear protein receptors (retinoic acid receptor and retinoid X receptor), and less expression of inflammatory biomarkers (tumor necrosis factor α and transforming growth factor β1) compared with other groups of mice that were not given MESCs. In conclusion, MESCs can ameliorate EGCG/LPS-induced hepatotoxicity in mice.

Anoikis of colon carcinoma cells triggered by β-catenin loss can be enhanced by tumor necrosis factor receptor 1 antagonists

Detachment of non-malignant epithelial cells from the extracellular matrix causes their apoptosis, a phenomenon called anoikis. By contrast, carcinoma cells are anoikis-resistant, and this resistance is thought to be critical for tumor progression. Many oncogenes trigger not only anti- but also pr-apoptotic signals. The proapoptotic events represent an aspect of a phenomenon called oncogenic stress, which acts as a safeguard mechanism blocking tumor initiation. In cells that become malignant, oncogene-induced antiapoptotic signals outbalance the proapoptotic ones. It is now thought that treatments blocking the antiapoptotic events but preserving the proapoptotic signals can be particularly effective in killing tumor cells. Whether or not oncogenes induce any proanoikis signals that can be used for enhancing the efficiency of approaches aimed at triggering anoikis of cancer cells has never been explored. β-Catenin is a major oncoprotein that is often activated in colorectal cancer and promotes tumor progression via mechanisms that are understood only in part. We found here that β-catenin triggers both anti- and proanoikis signals in colon cancer cells. We observed that the antianoikis signals prevail and the cells become anoikis-resistant. We further established that one proanoikis signal in these cells is triggered by β-catenin-induced downregulation of an apoptosis inhibitor tumor necrosis factor receptor 1 (TNFR1) and subsequent reduction of the activity of a transcription factor NF-κB (nuclear factor-κB), a mediator of TNFR1 signaling. We also found that the effect of β-catenin on TNFR1 requires the presence of transcription factor TCF1, a β-catenin effector. We demonstrated that ablation of β-catenin in colon cancer cells triggers their anoikis and that this anoikis is enhanced even further if low TNFR1 or NF-κB activity is artificially preserved in the β-catenin-deprived cells. Thus, inhibition of TNFR1 or NF-κB activity can be expected to enhance the efficiency of approaches aimed at blocking β-catenin-driven anoikis resistance of colon carcinoma cells.

DNA barcoding for species identification in the Palmae family

DNA barcoding is a promising tool for species identification at the molecular level. The barcoding system is well established for species differentiation in animals, while it is less common in plants. We evaluated 2 barcoding regions, maturase K (matK) and ribulose bisphosphate carboxylase (rbcL), to compare species of Palmae according to amplification success, discrimination power, and inter- and intra-specific divergence. Both regions appear to have potential to discriminate most species of Palmae, but 2 species, Phoenix dactylifera and Phoenix sylvestris, did not show variation in the nucleotides of the barcode genes. P. sylvestris is said to be the sister species of P. dactilyfera according to its morphological and genetic proximity to the cultivated date palm. Thus, the status of these 2 species needs to be re-evaluated considering more genes as barcodes. Furthermore, rbcL has a higher discrimination power (90%) than matK (66.6%) and can thus be potentially used as a standard barcode to discriminate the species of Palmae.

Identification and authentication of Rosa species through development of species-specific SCAR marker(s)

Roses (Rosa indica) belong to one of the most crucial groups of plants in the floriculture industry. Rosa species have special fragrances of interest to the perfume and pharmaceutical industries. The genetic diversity of plants based on morphological characteristics is difficult to measure under natural conditions due to the influence of environmental factors, which is why a reliable fingerprinting method was developed to overcome this problem. The development of molecular markers will enable the identification of Rosa species. In the present study, randomly amplified polymorphic DNA (RAPD) analysis was done on four Rosa species, Rosa gruss-an-teplitz (Surkha), Rosa bourboniana, Rosa centifolia, and Rosa damascena. A polymorphic RAPD fragment of 391 bp was detected in R. bourboniana, which was cloned, purified, sequenced, and used to design a pair of species-specific sequence-characterized amplified region (SCAR) primers (forward and reverse). These SCAR primers were used to amplify the specific regions of the rose genome. These PCR amplifications with specific primers are less sensitive to reaction conditions, and due to their high reproducibility, these species-specific SCAR primers can be used for marker-assisted selection and identification of Rosa species.

Modulation of ethanol toxicity by Asian ginseng (Panax ginseng) in Japanese ricefish (Oryzias latipes) embryogenesis

Alcohol consumption by women during pregnancy often induces fetal alcohol spectrum disorder (FASD) in children who have serious central nervous system (CNS), cardiovascular, and craniofacial defects. Prevention of FASD, other than women abstaining from alcohol drinking during pregnancy, is not known. A limitation of the use of synthetic anti-alcoholic drugs during pregnancy led us to investigate herbal products. In particular, many plants including Asian ginseng (Panax ginseng) have therapeutic potential for the treatment of alcoholism. We used Japanese ricefish (medaka) (Oryzias latipes), an animal model of FASD, for identifying herbal medicines that can attenuate ethanol toxicity. Fertilized eggs in standard laboratory conditions were exposed to ginseng (PG) root extract (0-2 mg/mL) either 0-2 (group A) or 1-3 (group B) day post fertilization (dpf) followed by maintenance in a clean hatching solution. The calculated IC50 as determined 10 dpf in A and B groups were 355.3±1.12 and 679.7±1.6 μg/mL, respectively. Simultaneous exposure of embryos in sub-lethal concentrations of PG (50-200 μg/mL) and ethanol (300 mM) for 48 h disrupted vessel circulation and enhanced mortality. However, PG (100 μg/mL) may partially protect trabecular cartilage (TC) deformities in the neurocranium in B group embryos induced by ethanol (300 mM). To understand the mechanism, embryonic ethanol concentration was measured at 2 dpf and adh5, adh8, aldh2, aldh9a, catalase, GST, and GR mRNAs were analyzed at 6 dpf. It was observed that although ethanol is able to reduce adh8 and GST mRNA contents, the simultaneous addition of PG was unable to alter ethanol level as well as mRNA contents in these embryos. Therefore, antagonistic effects of PG on ethanol toxicity are mediated by a mechanism which is different from those regulating ethanol metabolism and oxidative stress.

Establishment of an in vitro regeneration system for genetic transformation of selected sugarcane genotypes

A good culture system provides considerable quantities of highly regenerable target tissues. Embryogenic callus cultures are ideal for micro-projectile-mediated transformation, because regenerable cells are not very stable. Effective exploitation of genetic transformation requires good regeneration systems. We selected three sugarcane genotypes for the establishment and optimization of good in vitro regeneration systems, viz., S-2003-us-359, S-2006-sp-30, and S-2003-us-165. Three callus induction media were investigated. These media were composed of Murashige and Skoog (MS) medium salt plus 1, 2, and 3 mg/L 2,4-dichlorophenoxyacetic acid (2,4-D). Medium with 3 mg/L 2,4-D gave the greatest mass of embryogenic calli. The calli produced on the three callus induction media were transferred to 18 types of regeneration media (RM1-RM18). They varied with respect to plant growth regulators and sucrose levels but the basal medium was MS. Two levels of sucrose (30 and 40 g/L), three levels of 2,4-D (0.1, 0.25, 0.5 mg/L) and three levels of 6-benzylaminopurine (0, 0.25 and 0.5 mg/L) were studied in the regeneration media. The effects of callus age on regeneration were evaluated by transferring the calli to regeneration media after 15, 21, 28, and 35 days of culture. The 21-day-old callus of the genotype S-2003-us-359 on RM3 yielded the largest number of plants and was selected as the best for transformation. Six RAPD DNA primers were used to check genetic stability; this medium did not affect the sugarcane genomes.

Development of a species-specific sequence-characterized amplified region marker for roses

DNA fingerprints of four rose species, Rosa centifolia, R. Gruss-an-Teplitz, R. bourboniana, and R. damascena, were developed using RAPD-PCR. We identified a unique polymorphic band in R. centifolia. This 762-bp fragment was produced by the random primer GLI-2. The fragment was eluted and directly cloned in a TA cloning vector, pTZ57R/T. Digestion of the plasmid with EcoRI confirmed the cloning of GLI-2(762) in pTZ57R/T. A second enzyme, PstI, used in combination with EcoRI, gave complete digestion of the plasmid, and the 762-bp fragment was confirmed on the gel. Subsequently, the polymorphic amplicon was sequenced with an AB1 373 DNA sequencer system using the PRISM(TM) Ready Reaction DyeDeoxy(TM) Terminator Cycle Sequencing kit. After sequencing, specific primers (23 bp long) were designed based on the sequence of the flanking regions of the original RAPD fragment. These primers will effectively allow fingerprinting for the identification of R. centifolia species. In essence, we developed an SCAR marker to authenticate the identity of R. centifolia species and to distinguish it from its substitutes. Such techniques are required not only to complement conventional parameters in creating the passport data of commercial and medicinal products of rose, but also for routine quality control in commercial and government rosaries and rose nurseries.