Effect of non-vascularized fibular harvest on the donor limb: radiological evaluation at a mean follow-up of twelve point eight years

PURPOSE

The study is aimed at evaluating the long-term (at a minimum follow-up of 10 years) impact of non-vascularized fibular harvest on the donor limbs.

METHODS

There were 27 donor limbs (n = 19 children) available for retrospective radiological review. The graft was obtained bilaterally in eight patients. The following parameters were evaluated in the follow-up radiographs: continuity/non-continuity of fibular regenerate, width of the regenerated fibula, distal fibular station, medial proximal tibial angle, posterior proximal tibial angle, lateral distal tibial angle (LDTA), anterior distal tibial angle, and tibia diaphyseal angulation (interphyseal angles). For analysis and comparisons, the donor limbs were compared to the healthy limbs (controls) of the children with unilateral harvest. Additionally, the impact of continuous and non-continuous fibular regeneration was separately analyzed.

RESULTS

The mean child's age at the time of fibular harvest was four years. The mean follow-up was 12.8 years. The fibula was found regenerated in continuity in 22 limbs of 15 children (81.5%). When analyzed as a combined group (both continuous and non-continuous fibular regenerations), all the donor limb radiological parameters matched those of healthy limbs except LDTA (p = 0.04). In the subgroup analysis between non-continuous and continuous fibulae, significant abnormalities were again obvious in LDTA (p = 0.0001). The non-continuous fibulae were significantly lesser in width. All limbs with non-continuous fibular regeneration manifested ankle valgus.

CONCLUSIONS

The non-vascularized fibula emerged as a relatively safe procedure in the long term with minimal affections of the knee, ankle, or tibial anatomy when longitudinal integrity of fibula was restored. The non-regenerations of the fibula may be prone to developing ankle valgus.

Role of Magnetic Resonance Imaging in Concomitant Periarticular Infections in Septic Arthritis of Large Joints in Children: A Systematic Review

Background

Septic arthritis associated with adjacent infections, presents a diagnostic challenge as the clinical presentation is similar to that of isolated septic arthritis, additional diagnostic tools are needed to detect these infections. The purpose of this study was to examine the effectiveness of magnetic resonance imaging (MRI) for diagnosis of concomitant infection in children with septic arthritis of large joints and its effect on patient outcome and treatment.

Materials and Methods

Electronic literature research of PubMed, Cochrane and Scopus, was conducted in January 2022 using a combination of MeSH, search terms and keywords. The data extracted included the study details, demographic data, the proportion of patients having a concomitant periarticular infection, clinical presentation, blood parameters and culture findings and outcomes.

Results

This review included seven studies with 499 patients. The mean age was 7.08 ± 2.38 years in the study. There was a male predominance, with 174 being males (62.36%). The most common joint involved was the hip joint (44.47%). 42.48% had concomitant periarticular infections detected by MRI. Osteomyelitis was the most common infection seen in 209 patients (41.84%). The mean duration of antibiotics given and hospital stay was significantly more in periarticular infections (P > 0.05). 32.5% of the patients with septic arthritis underwent a second surgical procedure whereas 61.11% of patients with periarticular infections underwent second procedure in this review (P > 0.05).

Conclusions

The use of MRI to diagnose these complicated infections appears to be beneficial. Multi-centric randomised control trials are needed to investigate the efficacy of MRI and its impact on patient care and outcome.

Management of Length Unstable Femur Fractures in Children by Flexible Intramedullary Nails: A Systematic Review

PURPOSE OF THE STUDY

Surgical options for paediatric femoral fractures include fl exible intramedullary nailing (FIN), plating, and external fi xators. Length unstable fractures are usually spiral, long oblique, or comminuted and are often associated with > 2 cm of shortening. The purpose of this study was to see whether FIN is effective for managing unstable femur fractures in children.

MATERIAL AND METHODS

An electronic literature search was performed up to 25 February 2022 in Cochrane Library, PubMed, and Embase databases using a combination of MeSH search terms and keywords related to the population (e.g., "child" AND "diaphyses" AND "femur"), and intervention (e.g., "nail" OR "ESIN"). The data extracted included the study details, Demographic data, surgical details, postoperative immobilization, complications, and outcome.

RESULTS

Eight studies with a total sample size of 369 patients were reviewed. The mean operative time, blood loss, and length of stay in the hospital were 67.62±12.32 minutes, 33.82±16.82 ml, and 4.9±1.27 days, respectively. The results were excellent in 61.92% of the patients, satisfactory in 32.61%, and poor in 5.43%. 4.54% of patients had major complications requiring reoperation and 32.46% of patients had minor complications. the most common complication was nail prominence seen in 26.30% of patients. Locked Ender's nail was associated with the least reoperation, malunion, and LLD rate compared to other types of FIN.

CONCLUSIONS

FIN along with a single walking spica cast is a good choice in all forms of paediatric femoral fracture patterns allowing proper alignment and rotation. Locked Ender's nail is safe and effective for managing unstable paediatric femur fracture.

KEY WORDS

pediatric femur fracture, length unstable, fl exible intramedullary nailing, submuscular plating, Flynn criterion.

Hemiepiphysiodesis using tension band plates: does the insertion technique or screw length influence the rate of correction?

We retrospectively studied the effect of certain characteristics of the insertion technique and the construct of tension band plates on its angular correction rates. The study included 68 physes in 28 children. The following preoperative radiological parameters were measured: interscrew angle; the length of the epiphyseal screw, its distance and angle (screw trajectory angle) with respect to the physis. Additionally, changes in the mechanical lateral distal femoral angle and medial proximal tibial angle were calculated from the follow-up radiographs. The statistical calculations involved correlating the above-mentioned parameters and correction rates using a correlation coefficient. The mean patient age at the time of surgery was 8.6 years and the follow-up was 12.1 months. The mean screw trajectory angle was 13.4 degrees, the interscrew angle 18.9 degrees and the proportion of screw length was 41.3%. The mean correction rate recorded was 1.1 degrees/ month. The child's age (R = -0.13), screw trajectory angle (R = -0.13), interscrew angle (R = -0.02), distance of screw from physis (R = 0.04), and length of screw (R = 0.07) did not show statistically significant correlation with the angular correction rates. The correction rate produced by the tension band plate was found nearly independent of the parameters recorded for insertion technique (screw trajectory angle, interscrew angle, distance of screw from the physis) or construct (length of the epiphyseal screw). It functions as long as the physis is tethered by a side plate adequately secured by appropriate length screws.

Prospective Characterization of Circulating Tumor Cell Kinetics in Patients with Localized Lung Cancer Treated with Radiotherapy or Chemoradiotherapy with Definitive Intent

PURPOSE/OBJECTIVE(S)

To characterize circulating tumor cell (CTC) kinetics in response to definitive therapy in patients with local or locoregional lung cancer and identify CTC kinetic profiles associated with favorable disease response versus progression.

MATERIALS/METHODS

In this single-institution prospective correlative biomarker study, we enrolled patients receiving definitive intent radiotherapy (RT) or chemoradiotherapy for non-metastatic lung cancer. Blood specimens were collected prior to RT (baseline), during RT and at follow up visits up to 24 months post RT. Subsequent lines of therapy were administered per standard of care. CTCs were captured and enumerated using a previously reported nanotechnology-based assay functionalized with aEpCAM, aHER-2, and aEGFR to facilitate biomimetic cell rolling and dendrimer-mediated multivalent binding. Disease status was assessed per RECIST 1.1 criteria. CTC kinetics and absolute values were analyzed to identify patterns associated with disease control versus progression.

RESULTS

We enrolled 24 patients with median follow up of 8 months corresponding to 114 CTC measurements. Seven patients (30%) had biopsy proven disease, while 17 (70%) were diagnosed based on clinical and radiographic features alone. Nineteen patients (79%) received stereotactic body radiation therapy. Median baseline CTC count was 12.6 CTCs/ml (range 0-290) and post RT decreased to median 4 CTCs/ml (0-42.7). For 95% of patients, a favorable kinetic profile (defined as stable CTC count, decreased CTC count or <24 CTCs/ml corresponding to the 80th percentile) during radiotherapy or at the time of first follow up corresponded to local control of the irradiated lesion. Five patients (20%) experienced disease progression within the follow up period. In the two patients with local progression of the irradiated lesion, the CTC count rose >10 fold prior to or at the time of radiographic detection of progression. In the three patients with systemic progression, CTC count rose 1.46-5.8-fold at the time of progression. Notably, four of the five patients with disease progression did not have initial biopsy confirmation of disease but did experience a CTC elevation at the time of progression.

CONCLUSION

Our data suggests CTCs may serve as a biomarker for response to therapy in patients being treated with RT with definitive intent for early stage or locally advanced lung cancer. This finding is of importance given important limitations in obtaining pathologic confirmation of disease in select patients and challenges distinguishing disease progression versus benign post radiotherapy radiographic changes. Further studies are needed to characterize the predictive and prognostic value of circulating biomarker levels and kinetics in lung cancer.

A prospective study on the role of foot evertor muscle activity in recurrence of clubfoot

BACKGROUND

Even after corrective casting and bracing, clubfoot recurrence is challenging throughout childhood, with around 14-40 % recurrence rates. Most of the literature on recurrence was attributed to various factors, and minimal research was conducted to know the role of foot evertor muscle activity and its stimulation benefits. This study aimed to assess the role of foot evertor muscle activity in idiopathic congenital clubfoot recurrence by using clinical, sonographic, and electromyographic parameters.

METHODS

A prospective cohort study was conducted at our tertiary care hospital from 2020 to 2022. The patient's demographic data, Pirani, Dimeglio, Clinical Evertor Muscle Activity scores, sonographic cross-sectional areas of leg muscle, and evertor motor activity using surface electromyography were recorded in adherence to the pre-defined intervals.

RESULTS

In total, 51 patients (51 feet) were included in the study, and the overall recurrence rate was 27.5 % (14/51). In this study, around 47 % (24/51) of children had mild or poor clinical evertor activity; among them, 58 % (14/24) children had a recurrence, and the insufficient clinical evertor activity and recurrence were strongly correlated (p = 0.01). Evertor muscle cross-sectional area ratio, motor unit potentials, and recruitment were comparatively less in the recurred group; however, only the cross-sectional area ratio was statistically significant (p = 0.02).

CONCLUSION

Early detection of evertor muscle weakness can help to individualize the treatment plans by predicting recurrence. Therefore, it should be included in routine clinical evaluations. Further research is required to determine the advantages of evertor muscle-strengthening activities in preventing idiopathic clubfoot deformity.

LEVEL OF CLINICAL EVIDENCE

A prospective cohort study, Level of evidence-II.

The Tug Test and Modified Ponseti Casting: A Simple and Reliable Method to Improve the Efficacy of Casting in Complex Clubfoot

Background

The clinical entity of complex clubfoot poses a significant challenge to correction by slippage of casts which further complicates the deformity and prolongs the treatment. A static and dynamic component associated with this deformity causing cast slippage was recognized. The purpose of this study was to evaluate the clinical outcomes at the end of the casting period while addressing these issues.

Methods

A retrospective study of 17 patients with 25 complex clubfeet over a period of 2 years was conducted. Tug test was used to ascertain the snugness of the cast. To address the dynamic component, distal extent of the cast was limited to metatarsal heads.

Results

The mean age of patients at diagnosis was 4.41 months (2-7 months). The mean pre-casting Pirani score was 4.8 (4-6) and post casting Pirani score was 0.4 (0-1). A total of 128 casts were applied to correct 25 complex clubfeet. The average number of casts required to achieve correction by the modified Ponseti technique was 5.12 (4-7). Overall, four incidences of cast slippage occurred.

Conclusion

The modified Ponseti technique is effective in the correction of complex clubfoot. Tug test can detect casts which are prone to slippage. Limiting the distal extent of the cast to the metatarsal heads can reduce cast slippage by reducing the repeated downward pressure by the toes on the cast.Level of evidence Level 4.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00910-w.

Comparison of Various Joint Decompression Techniques in Septic Arthritis of the Hip in Children: A Systematic Review and Meta-Analysis

The aim of this review is to conduct an analysis of existing literature on outcomes of application of various methods of joint decompression in management of septic arthritis of the hip in children. A search of literature in PubMed, Embase, and Google Scholar was conducted for identification of studies reporting on the outcomes of intervention for septic arthritis of the hip in children. Of the 17 articles selected, four were comparative studies; two of these were randomized controlled trials while the rest were single arm studies. Statistical difference was observed between the proportion of excellent clinical and radiological outcomes in arthrotomy (90%, 95% confidence interval [CI] 81-98%; 89%, 95% CI 80-98%), arthroscopy (95%, 95% CI 91-100%; 95%, 95% CI 90-99%), and arthrocentesis (98%, 95% CI 97-100%; 99%, 95% CI 97-100%), respectively. The highest overall rate of additional unplanned procedures was observed in the arthrocentesis group (24/207, 11.6%). Patients who underwent arthrocentesis had a statistically greater chance of excellent clinical and radiological outcomes, although the highest level of need for additional unplanned surgical intervention was observed in the arthrocentesis group, followed by the arthroscopy group and the arthrotomy group. Future conduct of a prospective multicentric study focusing on the developed and developing world, along with acquisition of data. such as delay of treatment and severity of disease will enable assessment of the efficacy of one technique over the other by surgeons worldwide.

A Meta-Analysis on Comparison of Open vs Closed Reduction of Gartland Type 3 Supracondylar Humerus Fractures in Children

PURPOSE OF THE STUDY Although there are numerous studies on outcomes and comparison of open and closed reduction but there is no clarity on relationship between outcomes and complications with type of surgical intervention done for Type 3 Gartland supracondylar humerus fracture. The aim of this study is to compare the outcomes and complications of closed vs open reduction in Type 3 Gartland supracondylar humerus fractures. MATERIAL AND METHODS Electronic literature searches of Embase, MEDLINE and the Cochrane Library was conducted in February 2022 using the terms "supracondylar", "humerus", "fracture", "Gartland type 3" and synonymous. The data extracted included the study details, demographic data, procedure performed, final functional and cosmetic outcome according to Flynn criteria and complications of included studies. RESULTS Pooled data analysis revealed no significant difference in mean satisfactory outcome rate according to Flynn cosmetic criteria in open group (97%, 95% CI 95.5%-98.5%), as compared to closed group (97.5%, 95% CI 96.3%-98.7%), although a statistically significant difference in mean satisfactory rate according to Flynn functional criteria in open group (93.4%, 95% CI 90.8%- 96.1%) as compared to closed group (98.5%, 95% CI 97.5%-99.4%) was noted. On separate comparison of the two-arm studies, closed reduction favoured better functional outcomes (RR 0.92, 95% CI 0.86-0.99). CONCLUSIONS Closed reduction and percutaneous fixation have better functional outcome than open reduction with K-wire fixation. But there was no significant difference in cosmetic outcomes, overall complication rate and nerve injury with either open or closed reduction. The threshold of converting a closed reduction to an open reduction in supracondylar humerus fractures of children should be high. Key words: supracondylar humerus, open reduction, percutaneous pinning, Flynn criteria.

Distal Nerve Transfer to Restore Wrist and Finger Extension - A Systematic Review

Background: There are numerous options available for restoration of wrist and finger extension following radial nerve palsy. The aim of this study is to conduct a systematic review of the effectiveness of nerve transfer for radial nerve palsy. Methods: Electronic literature research of PubMed, Cochrane, Scopus and Lilacs database was conducted in June 2021 using the terms 'Distal nerve transfer' AND 'Radial nerve injury' 'Radial nerve palsy' OR 'Radial nerve paresis' OR 'Median nerve transfer' OR 'wrist extensor' OR 'finger extension' OR 'thumb extension' OR 'wrist motion'. The data extracted included the study details, demographic data, procedure performed and final functional outcome according to the muscle research council scale. Results: A total of 92.59% and 56.52% had satisfactory outcome following distal nerve transfer of median nerve to restore wrist and finger extension respectively. No significant correlation was found between time to injury duration and satisfactory outcomes. Conclusions: Outcomes of nerve transfers are comparable to tendon transfers. Multi-centric studies are needed to compare the results amongst various surgical procedures described. Level of Evidence: Level III (Therapeutic).

Physiologic lead placement with electroanatomic mapping: A case series

INTRODUCTION

His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have emerged as attractive alternatives to traditional biventricular pacing to achieve cardiac resynchronization therapy. Early reported results have been inconsistent, particularly amongst patients in whom initial placement with traditional approaches has been unsuccessful or those with complex anatomy or congenital abnormalities. In this report, we describe the use of three-dimensional electroanatomic mapping (EAM) in five selected cases.

METHODS

Five patients from multiple clinical sites underwent EAM-guided HBP or LBBAP by highly trained electrophysiologists with significant experience with conduction system pacing. Each patient in this series underwent EAM-guided conduction system pacing due to complex anatomy and/or prior failed lead implantation.

RESULTS

EAM-guided lead implantation was successful in all five cases. Capture thresholds were relatively low and patients continued to have evidence of successful lead implantation with minimum 1-month follow-up. The fluoroscopy time varied, likely owing to the variable complexity of the cases.

CONCLUSIONS

The use of EAM, in combination with traditional intracardiac electrograms with or without fluoroscopy, allows more targeted and precise placement of leads for HBP and LBBAP pacing. Further investigation is needed to determine this strategy's long-term performance and to optimize patient selection.

Methods for the Production of Recombinant Heparosan, a Critical Heparin Precursor, from Nonpathogenic E. coli Strains

Heparin is an essential anticoagulant drug discovered over a century ago. Heparin is the second most highly used natural drug and remains a mainstay of therapy with an expected global market share of more than $14 billion in the next 10 years. However, it is still naturally derived from unsustainable animal sources, such as bovine lungs and porcine intestines, as an unfractionated, heterogeneous complex mixture with unpredictable pharmacokinetic properties. Extensive research has been done in devising bioengineering and chemical approaches to produce structurally specific heparin and heparin-like polymers. Though several challenges remain, one of the main bottlenecks is the rapid, high-yield production of recombinant heparosan, a heparin precursor, which is originally isolated from a pathogenic E. coli K5 strain. Herein, we outline the methods for producing metabolically engineered size-specific heparosan, by transforming the essential heparosan biosynthetic genes into nonpathogenic E.coli strain BL21(DE3), in a highly controlled manner. The methods described herein are promising and can be easily scaled up for large-scale production of heparin-like structures.

Risk Factors for Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures

Introduction

A neck of femur fracture is a rare injury in the pediatric population and is of foremost importance, as it is associated with a high rate of complications. It usually occurs due to high-velocity trauma or a fall from a height. There is a scarcity of data on risk factors and their role in the prognostication of avascular necrosis. The purpose of the study was to retrospectively analyze the association of various risk factors with avascular necrosis (AVN) of the femoral head in patients with a neck of femur fracture in the pediatric age group.

Material and methods

The study included 21 (13 males and 8 females) pediatric patients with a neck of femur fracture treated at a university-level hospital. The patients were followed for a minimum of one year and the clinico-radiological outcome was analyzed using Ratliff criteria. The association of AVN with age, gender, side, fracture type, and injury with treatment delay, type of reduction, and type of internal fixation used was studied.

Results

The mean age of the treated patients was 11 (±3.178) years (range=5-16 years). Avascular necrosis was seen in four patients and coxa vara occurred in two of them. A statistically significant association was seen between the Delbet fracture type and avascular necrosis, and three out of four cases of AVN were a Type I fracture (p-value=0.006). Three out of six patients having concomitant skeletal or other organ injuries developed AVN (p-value=0.022). The rate of AVN was higher in patients who were managed after 48 hours of initial injury but no statistically significant correlation was found (p-value=0.314). No statistically significant association with AVN was found between gender, age, type of reduction (closed/open), or the implant used (cannulated screws/k-wires).

Conclusions

Multiple independent factors may have a role in the development of AVN of the femoral head in children. Prognostication should not be based on a single factor. Statistically significant results in this study have shown that the type of fracture and concomitant skeletal or other organ injuries are important risk factors and should be kept in mind. All independent risk factors must be noted and should be considered while prognosticating the outcome of a child with a neck of femur fracture.

Clinical outcomes of left bundle branch area pacing compared to right ventricular pacing: Results from the Geisinger-Rush Conduction System Pacing Registry

BACKGROUND

Left bundle branch area pacing (LBBAP) has been shown to be a feasible option for patients requiring ventricular pacing.

OBJECTIVE

The purpose of this study was to compare clinical outcomes between LBBAP and RVP among patients undergoing pacemaker implantation METHODS: This observational registry included patients who underwent pacemaker implantations with LBBAP or RVP for bradycardia indications between April 2018 and October 2020. The primary composite outcome included all-cause mortality, heart failure hospitalization (HFH), or upgrade to biventricular pacing. Secondary outcomes included the composite endpoint among patients with a prespecified burden of ventricular pacing and individual outcomes.

RESULTS

A total of 703 patients met inclusion criteria (321 LBBAP and 382 RVP). QRS duration during LBBAP was similar to baseline (121 ± 23 ms vs 117 ± 30 ms; P = .302) and was narrower compared to RVP (121 ± 23 ms vs 156 ± 27 ms; P <.001). The primary composite outcome was significantly lower with LBBAP (10.0%) compared to RVP (23.3%) (hazard ratio [HR] 0.46; 95%T confidence interval [CI] 0.306-0.695; P <.001). Among patients with ventricular pacing burden >20%, LBBAP was associated with significant reduction in the primary outcome compared to RVP (8.4% vs 26.1%; HR 0.32; 95% CI 0.187-0.540; P <.001). LBBAP was also associated with significant reduction in mortality (7.8% vs 15%; HR 0.59; P = .03) and HFH (3.7% vs 10.5%; HR 0.38; P = .004).

CONCLUSION

LBBAP resulted in improved clinical outcomes compared to RVP. Higher burden of ventricular pacing (>20%) was the primary driver of these outcome differences.

Role of Novel Drug Delivery Systems in Coronavirus Disease-2019 (COVID-19): Time to Act Now

The Coronavirus disease 2019 (COVID-19) has found its roots from Wuhan (China). COVID-19 is caused by a novel coronavirus SARS-CoV2, previously named as 2019-nCoV. It has spread across the globe and was declared as a pandemic by the World Health Organization (WHO) on 11th March, 2020. Currently, there is no standard drug or vaccine available for the treatment, therefore, repurposing of existing drugs is the only solution. Novel Drug Delivery Systems (NDDS) will be boon for the repurposing of drugs. The role of various NDDS in repurposing of existing drugs for the treatment of various viral diseases and their relevance in COVID-19 has been discussed in this paper. It focuses on the currently ongoing research in the implementation of NDDS in COVID-19. Moreover, it describes the role of NDDS in vaccine development for COVID-19. This paper also emphasizes how NDDS will help to develop the improved delivery systems (dosage forms) of existing therapeutic agents and also explore the new insights to find out the void spaces for potential targeted delivery. Therefore, in these tough times, NDDS and nanotechnology can be a safeguard to humanity.

Isolated multidrug-resistant tubercular tenosynovitis of the flexor tendon of the little finger

Isolated multidrug-resistant (MDR) tubercular tenosynovitis of the flexor tendons of finger without involvement of wrist is a rare presentation. Tenosynovitis of hand is an uncommon manifestation of extrapulmonary tuberculosis. Pyogenic flexor tenosynovitis of hand is frequently seen and is the closest differential. Non-specific clinical signs may lead to delay in diagnosis, which is often made after biopsy. Management includes surgical excision of necrotic tissue and infected synovium along with antitubercular therapy after histopathological diagnosis. MDR tuberculosis of hand is extremely rare and, to the best of our knowledge, has not been reported in the literature so far. We report an interesting case of MDR tubercular flexor tendon tenosynovitis of the little finger without any pulmonary involvement in an immunocompetent patient. The case was managed by complete synovectomy and second-line antitubercular therapy with complete resolution of disease and had no functional limitation.

Effect of Aging on the Load-to-Failure of Molar Implant-Supported Monolithic Zirconia Crowns: A Laboratory Study

PURPOSE

To evaluate the effect of hydrothermal aging on the load to failure and number of cycles to failure of implant-supported monolithic zirconia molar crowns under cyclic loading.

MATERIALS AND METHODS

Twenty identical implant-supported monolithic zirconia crowns with molar morphology were produced. Half of the crowns were aged according to ISO standard 13356 to simulate 5 years in vivo. The non-aged crowns served as a control group. All crowns were subjected to cyclic loading with increasing increments of load until failure. The load to failure, the number of cycles to failure, and the failure pattern were determined for each crown.

RESULTS

The load to failure values were 3,630 N (SD: 547.8 N) and 3,640 N (SD: 389.3 N) for the non-aged and aged crowns, respectively. The non-aged crowns failed after 33,480.1 cycles (SD: 23,138.4 cycles), and the aged crowns failed after 28,456.1 cycles (SD: 10,158.7 cycles). There was no significant difference between the two groups for the load to failure or number of cycles to failure. The predominant form of failure was catastrophic crown fracture, which was observed for all the non-aged crowns and 9 of the aged crowns.

CONCLUSION

Within the limitations of this study, aging of the implant-supported monolithic zirconia crowns with molar morphology did not affect the load to failure or the number of cycles to failure under cyclic loading. Since all the crowns failed at much higher loads than the expected physiologic loads, clinical application of implant-supported monolithic zirconia crowns to replace missing molars seems reasonable.

Results of a phase 2 trial of an oral CXCR4 antagonist, mavorixafor, for treatment of WHIM syndrome

Warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome is a rare primary immunodeficiency caused by gain-of-function mutations in the CXCR4 gene. We report the safety, tolerability, pharmacokinetics, pharmacodynamics, and preliminary efficacy of mavorixafor from a phase 2 open-label dose-escalation and extension study in 8 adult patients with genetically confirmed WHIM syndrome. Mavorixafor is an oral small molecule selective antagonist of the CXCR4 receptor that increases mobilization and trafficking of white blood cells from the bone marrow. Patients received escalating doses of mavorixafor, up to 400 mg once daily. Five patients continued on the extension study for up to 28.6 months. Mavorixafor was well tolerated with no treatment-related serious adverse events. At a median follow-up of 16.5 months, we observed dose-dependent increases in absolute neutrophil count (ANC) and absolute lymphocyte count (ALC). At doses ≥300 mg/d, ANC was maintained at >500 cells per microliter for a median of 12.6 hours, and ALC was maintained at >1000 cells per microliter for up to 16.9 hours. Continued follow-up on the extension study resulted in a yearly infection rate that decreased from 4.63 events (95% confidence interval, 3.3-6.3) in the 12 months prior to the trial to 2.27 events (95% confidence interval, 1.4-3.5) for patients on effective doses. We observed an average 75% reduction in the number of cutaneous warts. This study demonstrates that mavorixafor, 400 mg once daily, mobilizes neutrophil and lymphocytes in adult patients with WHIM syndrome and provides preliminary evidence of clinical benefit for patients on long-term therapy. The trial was registered at www.clinicaltrials.gov as #NCT03005327.

Does cardiac transplant protect against broken hearts?

Background

Takotsubo cardiomyopathy (TC) is a reversible stress-induced myocardial dysfunction with increased sympathetic activity caused by excessive release of catecholamines playing a central role in its pathophysiology. The occurrence of TC in transplanted hearts is rare given the complete denervation done during transplantation. However, it has been demonstrated that 40% of transplant recipients undergo sympathetic re-innervation. There have only been case reports describing TC in post-transplant recipients.

Purpose

To evaluate the incidence, baseline characteristics and outcomes of TC occurring in heart transplant recipients using Healthcare Cost and Utilization Project (HCUP) National (nationwide) Inpatient Sample (NIS) in United States from 2009 to 2014.

Methods

Using NIS data, we identified patients who underwent cardiac transplantation using ICD9 procedure codes 37.5 and 33.6. Among these patients, we identified those admitted to the hospital with diagnosis of TC based on ICD-9-CM code 429.83. We presented categorical data as percentages and continuous data as mean or median as appropriate.

Results

We identified 257 hospitalizations for TC in heart transplant recipient patients. There was an approximately 9-fold increase in admissions from 11 in 2009 to 95 in 2014. Among patients with TC, the mean age was 65.3±1.8 years and majority were female (76.6%). A majority of patients were Caucasians (63%) followed by smaller proportion of African-Americans (13.2%).

In-patient mortality in patients admitted with TC following heart transplant was 11.3% (n=29). During the hospitalization, 4.8% of patients had cardiogenic shock and 2.8% required mechanical circulatory support. The average length of stay for patients with TC was 16.6±3.3 days. The mean cost of hospitalization for these patients when adjusted for inflation were 237248±55709 dollars.

Conclusion

TC can still occur in substantially in heart transplant recipients and should be considered one of the differential diagnosis in transplant patients presenting to the hospital.

Funding Acknowledgement

Type of funding source: None

A nationwide 16 year analysis of trends and impact of arrythmias in transplant recipients

Background

Orthotopic heart transplantation is the most effective long-term therapy for end-stage heart disease. Denervation of transplanted heart with the loss of autonomic modulation, vasculopathy, utilization of immunosuppressant drugs, and risk of allograft rejection may result in change in the prevalence of arrhythmias in transplanted hearts.

Purpose

To describe the trends, distribution and the clinical impact of arrhythmias in transplanted hearts in a large nationwide population.

Methods

We queried the National Inpatient Sample with administrative codes. Cardiac transplant patients were identified using procedure ICD-9-CM codes 37.5 and 33.6. Common arrhythmias were extracted using appropriate validated ICD-9-CM codes. Statistical Analysis System (SAS) version 9.4 was used for analysis of data.

Results

There was a total of 30,020 hospitalizations of heart transplant recipients between 1999 and 2014 in the United States and 16342 (54.4%) of these had arrhythmias. The prevalence of total arrhythmias increased from 53.6% (n=1,158) in 1999 to 67.3% (n=1,575) in 2014. The most common arrhythmia was atrial fibrillation (26.83%) followed by ventricular tachycardia (22.86%) and the prevalence of individual arrhythmias is as shown in Figure 1.

Cardiogenic shock was higher in transplanted hearts with arrhythmias when compared with patients without arrhythmias (25.96% vs 18.18%; p&lt;0.001). Transplant recipients with arrhythmias were also associated with an increased use of mechanical circulatory device (18.22% vs 12.67%, p&lt;0.001). The use of implantable cardiac defibrillators and permanent pacemaker was also higher in the arrhythmia group (2.19% vs 0.63% and 40.43% vs 30.24% respectively, p&lt;0.0001). However, there was no significant difference in inpatient mortality between transplant recipients with arrhythmias and without arrhythmias (7.72% vs 6.90%, p=0.225). Further, there was no significant difference in frequency of strokes between the groups (4.98% vs 5.08%; p=0.857).

The total hospital cost when adjusted for inflation was significantly higher in the arrhythmic patients, with an average cost of about $570,415±9,590 vs $439,707±8362 in patients without arrhythmias (p&lt;0.0001). The mean length of hospitalization was 44.2±0.8 days in patients with arrhythmias compared to 33.9±0.8 days in patients without arrhythmias (p&lt;0.0001).

Conclusion

A significant proportion of patients with heart transplant have cardiac arrhythmias and are associated with worse in-hospital outcomes of cardiogenic shock, increased length of stay, and cost of hospitalization. However, they are not associated with worse inpatient mortality.

Funding Acknowledgement

Type of funding source: None

A nationwide analysis of 16 year trends in cardiac transplantation for cardiac sarcoidosis

Background

Orthotopic heart transplant (OHT) is indicated for end-stage heart failure due to cardiac sarcoidosis (CS). However, utilization of OHT for CS has been controversial due to concern for involvement of other organs by sarcoidosis affecting long term outcomes.

Purpose

Our objective was to study the trends in OHT in patients with CS in the United States using Healthcare Cost and Utilization Project (HCUP) National (nationwide) Inpatient Sample (NIS) from 1999 to 2014.

Methods

Using NIS data, we identified patients older than 18 years with cardiac sarcoidosis using codes ICD 9-CM codes of 135 and 425.8. Among these patients, we identified those who underwent cardiac transplantation using ICD 9-CM procedure codes 37.5 and 33.6. We presented categorical data as percentages and continuous data as mean or median as appropriate.

Results

A weighted total of 24231 hospitalizations for CS was extracted from 1999 to 2014 of which 248 (1.02%) CS patients underwent OHT. The trends in cardiac transplant for CS is as shown in Figure 1.

The mean age of CS patients undergoing OHT was 51.7±1.1 years and 60.4% (n=150) were males. 114 (45.9%) were Caucasians and 27.8% (n=25) were African-American. 100% of the transplants were performed at medium (n=5) or large sized (n=243) teaching hospitals and 97.9% of cardiac transplants were also done at teaching hospitals. Heart transplants were mostly done in the South (36.3%) followed by Midwest (26.2%), West (25%) and Northeast (12.5%). Private insurance was the major payor source which covered 149 (60.1%) patients followed by Medicare covering 65 (26.2%) patients.

A total of 10 (3.9%) cardiac sarcoidosis patients died during the same hospitalization for cardiac transplantation. Following OHT, 84.2% (n=209) were discharged home and 11.6% (n=29) to short term hospitalization. The mean cost of hospitalization for OHT in CS when adjusted for inflation was 535144±56060 dollars while the average length of stay for heart transplant for CS was 46.2±6.6 days.

Conclusions

Cardiac transplant trends in CS have not changed from 1999 to 2014 despite recent studies showing improved outcomes and are associated with substantial cost of hospitalization and length of stay. Majority of cardiac transplant was done in Caucasians despite cardiac sarcoidosis being more common in African-Americans.

Funding Acknowledgement

Type of funding source: None

A nationwide analysis of 16 year trends in cardiac transplantation for acute myocarditis

Background

Orthotopic heart transplant (OHT) is indicated in 1–8% of patients with myocarditis. However, national trends in the utilization of transplantation and outcomes in myocarditis across the United States are not well established.

Purpose

Our objective was to study the trends and baseline characteristic of myocarditis patients undergoing heart transplant in the United States using Healthcare Cost and Utilization Project (HCUP) National (nationwide) Inpatient Sample (NIS) from 1999 to 2014.

Methods

Using NIS data, we identified patients older than 18 years with myocarditis using codes ICD9 codes of 422.0 and 422.9. Among these patients, we identified those who underwent cardiac transplantation using ICD9 procedure codes 37.5 and 33.6. We presented categorical data as percentages and continuous data as mean or median as appropriate.

Results

We identified a total of 62,264 hospitalizations for myocarditis from 1999–2014. 430 (0.69%) myocarditis patients underwent OHT which consisted of 0.82% of all 29990 cardiac transplants identified in the same period. The trends in OHT for myocarditis is as shown in Figure 1.

The mean age was 32.9±2.4 years and 51.1% (n=219) were females. 235 (54.6%) were Caucasians and 60 (13.9%) were Hispanic. Majority of the transplants were performed at medium (16%) and large sized hospitals (80.4%). Cardiac transplants were mainly done at teaching hospitals (98.9%). Further, with regards to the geographical distribution of transplant procedure, most were done in the West (37.2%) followed by South (25.3%), Northeast (21.4%) and Mid-west (16%) of the United States. Private insurance was the major payor source which covered 245 (58%) patients followed by Medicaid covering 112 (26%) patients.

A total of 26 (6%) myocarditis patients died during the same hospitalization for OHT. In terms of discharge following OHT in myocarditis 85.8% (n=369) were discharged home and 8.1% (n=35) to short term hospitalization. The average length of stay for OHT for myocarditis was 64.3±6.3 days. Also, the mean cost of hospitalization for heart transplant in myocarditis when adjusted for inflation was 789,566±93,108 dollars.

In-patient mortality following OHT was not significantly different in large sized hospital compared to small and medium sized hospitals (7.6% vs 5.7%, p=0.54). However, the cost of hospitalization was significantly lesser in small and medium sized hospitals (588,363±154,349 vs 826,864±106,110 dollars, p&lt;0.0001).

Conclusions

Only a small percentage of OHT is done for myocarditis with high proportion done in female when compared to OHT for other etiologies. Further studies need to be done to compare long term outcomes of heart transplant in myocarditis.

Funding Acknowledgement

Type of funding source: None

Pharmacokinetic and pharmacodynamic evaluation of Solid self-nanoemulsifying delivery system (SSNEDDS) loaded with curcumin and duloxetine in attenuation of neuropathic pain in rats

The present investigation is focused on improving oral bioavailability of poorly soluble and lipophilic drugs, curcumin (CRM) and duloxetine (DXH), through the solid self-nanoemulsifying drug delivery system (S-SNEDDS) and identifying their potential against attenuation of NP in chronic constriction injury (CCI)-induced rats through the solid self-nanoemulsifying drug delivery system (S-SNEDDS). The optimized batch of S-SNEDDS reported was containing CRM and DXH (30 mg each), castor oil (20% w/w), tween-80 (40% w/w), transcutol-P (40% w/w), and syloid 244 FP (1 g). The high dose of each of naïve CRM (NCH), naïve DXH (NDH), physical mixture of DXH and CRM (C-NCM-DXH), S-SNEDDS-CRM (SCH), S-SNEDDS-DXH (SDH), and S-SNEDDS-CRM-DXH (C-SCH-SDH) was subjected for MTT assay. The developed formulations were subjected to pharmacokinetic studies and results showed about 8 to 11.06 and 2-fold improvement in oral bioavailability of CRM and DXH through S-SNEDDS. Furthermore, CCI-induced male Wistar rats were treated with SSNEDDS containing CRM and DXH, S-SNEDDS containing individual drug, individual naïve forms, and their combination from the day of surgery for 14 days and evaluated for behavioral at pre-determined time intervals. On the terminal day, animals were sacrificed to assess tissue myeloperoxidase, superoxide anion, protein, tumor necrosis factor-α, total calcium levels, and histopathological changes. Pronounced effect was observed in rats treated with S-SNEDDS containing both drugs with respect to rats receiving any of other treatments owing to enhanced oral bioavailability through S-SNEDDS. Therefore, it can be concluded that S-SNEDDS of both drugs and their coadministration can accelerate the prevention of NP.

Assessment of Anterior Cruciate Ligament Tibial Footprint Sagittal Diameter and Orientation of the Ligament in the Intercondylar Notch in Indian Population: A Magnetic Resonance Imaging (MRI) Analysis

Aim: To study the relevant anatomy of anterior cruciate ligament tibial footprint and orientation of the ligament in the intercondylar roof in Indian population the using MRI.

Methods: A total of 70 knee MRI with intact anterior cruciate ligament (ACL) was assessed for intercondylar roof angle, ACL inclination angle, ACL-bluemensaat angle, ACL sagittal center, and tibial insertion size.

Results: The ACL tibial sagittal center was found to be at 43.5% of the anteroposterior tibial length. Tibial insertion size averaged 15.40 (±1.29) mm with no significant difference in males and females (p > 0.05). The roof angle was 36.29 (± 4.02) ˚ and the ACL inclination angle and ACL-bluemensaat angle were 51.22 (± 3.39) ˚ and 4.70 (±3.35) ˚ respectively with no significant sex difference (p > 0.05).

Conclusion: The ACL tibial insertion size averaged 15.40 mm and its center was at 43.51% along the Staubli and Rauschning line. The mean roof angle was 36.29 degrees and the ACL-bluemensaat angle was 4.70 degrees. Understanding of the tibial footprint morphology and the relation of the ligament to the roof of the intercondylar notch helps in anatomical graft placement during reconstruction.

Trochanteric Advancement and Limb Lengthening by Monorail External Fixator in Sequelae of the Septic Hip in Children - A Simpler Alternative to Other Complex Procedures

INTRODUCTION

Acute septic arthritis of the hip in children requires prompt diagnosis and treatment. The resulting sequelae of septic arthritis are diverse. Varieties of procedures have been described in the orthopedic literature. The common goal of treatment of all these procedures is to achieve a mobile, stable, pain-free hip joint with minimal limp and limb length inequality.

CASE REPORT

We present two cases of Choi's Type 2 septic hip sequelae, a 14-year-old female and a 13-year-old male, both had painless limp and limb length discrepancy managed by greater trochanteric advancement with limb lengthening by monorail external fixator at single sitting.

CONCLUSION

Distal greater trochanteric advancement with limb lengthening by monorail external fixator is a useful technique to treat septic hip sequelae with stable hip joint.

P1500Effects of empagliflozin on cardiac function in patients with type 2 diabetes mellitus: echocardiographic substudy of the EMPA-HEART cardiolink-6 trial

Background

The EMPA-HEART trial showed a reduction in left ventricular (LV) mass index by cardiac MRI at 6 months in patients treated with Empagliflozin vs placebo. A secondary analysis of key echocardiographic parameters was performed to provide further insight into the mechanism of LV remodeling.

Methods

All patients enrolled prospectively underwent transthoracic echocardiography (TTE) at baseline and at 6 months. Measurements were performed according to the American Society of Echocardiography guidelines. Key outcomes of interest included changes in diastolic function and right ventricle parameters at 6 months in patients treated with Empagliflozin vs placebo.

Results

A total of 97 patients were enrolled (49 treated with Empagliflozin and 48 in the placebo group). There was no significant difference in the change in average E/E' at 6-months in the Empagliflozin group vs placebo (−0.4 vs +0.2, adjusted difference −0.2, 95% CI [−1.3 to 0.82], p=0.7) Similarly, there was no difference between the groups in secondary TTE parameters (Table 1). Subgroup analyses showed no benefit among patients with baseline LVEF >50% vs. ≤50%, and baseline LV mass index ≥60 g/m2 vs <60 g/m2.

Echocardiographic Parameter Placebo (n=48) Empagliflozin (n=49) Adjusted Difference Between Groups 95% CI P-Value Baseline 6 months Change Baseline 6 months Change LVEF (%)* 55.5 (8.7) 54.3 (8.9) −1.0 (6.5) 58.0 (7.5) 59.1 (8.57) 0.72 (5.1) 2.2 (−0.2, 4.7) 0.1 Diastolic Parameters:   Average E/e' 10.1 (3.1) 10.3 (2.5) 0.2 (3.0) 10.6 (3.0) 10.5 (3.6) −0.4 (2.5) −0.2 (−1.3, 0.8) 0.7   Medial E/e' 12.3 (3.9) 12.5 (3.6) 0.1 (3.7) 12.6 (4.2) 12.6 (5.2) −0.3 (3.3) −0.3 (−1.7, 1.1) 0.7   Lateral E/e' 8.0 (2.8) 8.2 (2.2) 0.2 (2.7) 8.7 (2.6) 8.4 (2.5) −0.4 (2.7) −0.1 (−1.0, 0.8) 0.8   E velocity (cm/sec) 68.6 (15.2) 70.6 (14.7) 1.8 (15.4) 74.4 (18.2) 71.2 (16.8) −3.2 (15.1) −2.3 (−7.9, 3.3) 0.4   A velocity (cm/sec) 74.7 (17.9) 77.9 (18.8) 2.9 (15.9) 76.2 (16.5) 75.8 (14.5) −1.4 (11.7) −3.5 (−8.9, 1.6) 0.2   LA volume index (mL/m2) 32.7 (7.9) 30.8 (8.1) −2.0 (6.7) 30.2 (6.7) 28.7 (5.5) −1.6 (6.5) −0.9 (−3.4, 1.6) 0.5 RV Parameters:   TAPSE (cm) 1.8 (0.5) 1.8 (0.4) 0.1 (0.4) 2.0 (1.2) 1.8 (0.4) −0.3 (1.4) −0.1 (−0.3, 0.1) 0.3   RV S' TDI (cm/sec) 10.9 (2.9) 10.6 (2.5) −0.1 (2.2) 10.4 (2.7) 10.2 (2.6) −0.4 (2.0) −0.3 (−1.2, 0.5) 0.4 *Measured by cardiac MRI. LA, left atrium; LVEF, left ventricular ejection fraction; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion; TDI, tissue Doppler imaging. Data expressed as mean (standard deviation).

Conclusion

This study showed no significant change in key echocardiographic parameters in patients treated with Empagliflozin, suggesting that changes in loading conditions induced by empagliflozin (i.e. preload) do not mediate the reduction in LV mass.

P5602Comparison of innominate vs axillary artery cannulation for cerebral protection on neurocognitive outcomes in aortic surgery: a pre-specified analysis of the ACE CardioLink-3 randomised trial

Background

Success after aortic surgery depends on avoidance of neurocognitive dysfunction, thus novel adjuncts to proximal aortic surgery must be evaluated for efficacy of cerebral protection during circulatory arrest. We report the primary neurocognitive results from the ACE CardioLink-3 randomised controlled trial comparing innominate to axillary artery cannulation for cerebral protection (NCT02554032).

Methods

The primary safety endpoint was the proportion of patients with new radiologically severe ischaemic cerebral lesions found on post-operative versus pre-operative diffusion weighted magnetic resonance imaging (DW-MRI). Neurocognitive outcomes were assessed using the Mini-Mental State Exam (MMSE), and the Montreal Cognitive Assessment (MoCA). Continuous and binary outcomes were analysed using ANCOVA (controlling for baseline score) and chi-square/Fisher's exact tests.

Results

Of the 111 patients randomised, 102 patients were included in the primary safety per-protocol analysis. The primary safety outcome (significant new ischaemic lesions on DW-MRI) occurred in 34% in the innominate group and 38.8% in the axillary group (OR 0.81; 0.41 to 1.60; P=0.0009 for non-inferiority). Rates of post-operative stroke/transient ischaemic attack, seizure, delirium, and encephalopathy were similar between groups. The rate of patients with a post-operative MoCA score less than 26 was 44.9% and 39.1% in the innominate and axillary groups respectively (P=0.807). A post-operative MMSE score of less than 24 was observed in 2% vs. 6.5% of the patients in the innominate and axillary groups respectively (P=0.866). A >1-point decrease in the MoCA score from pre-operatively to post-operatively was seen in 32.7% and 34.8% in the innominate and axillary groups respectively (P=0.962). A >1-point decrease in the MMSE score from pre-to post-operative was observed in 20.4% in the innominate artery group compared with 30.4% in the axillary group (P=0.346).

Conclusion

Post-operative neurocognitive dysfunction and DW-MRI incidence of severe ischaemic lesions did not differ in patients randomised to innominate artery cannulation vs, conventional axillary artery cannulation, though the burden of new severe ischaemic lesions is high in both groups.

P3753Does empagliflozin modulate the autonomic system among patients with type 2 diabetes and coronary artery disease? Insights from the Holter sub-study of the EMPA-Heart CardioLink-6 Randomised Trial

Introduction

The mechanism behind how empagliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, reduces all-cause and cardiovascular mortality among patients with type 2 diabetes (T2DM) and coronary artery disease (CAD) is unknown. Autonomic tone, as reflected by changes in heart rate variability (HRV), is an established prognosticator in patients with CAD and/or heart failure.

Purpose

To assess if empagliflozin treatment changes HRV in subjects with T2DM and CAD.

Methods

In the double-blind EMPA-Heart trial, 97 subjects with T2DM and CAD were randomised to empagliflozin 10 mg/day or placebo for 6 months and underwent 24-hour Holter monitoring at baseline and 6 months. Using automated algorithms, time and frequency HRV domain measures were obtained (standard deviation of NN intervals (SDNN); SD of the average NN intervals for each 5-minute segment (SDANN); root mean square of successive RR interval differences (rMSSD); % interval differences of successive NN intervals >50 ms (pNN50); ratio of low to high frequency (LF/HF)). Changes of these HRV parameters were calculated over 6 months. Between-group differences in HRV parameters were compared using ANCOVA.

Results

Complete Holter data (baseline and 6-month) were available for 68% (n=66) of the cohort. The average heart rate (HR) at baseline/6 months was 69.5±9.8 bpm/72.8±8.1 bpm and 76±10.4 bpm/76.5±10.6 in the placebo group and empagliflozin group, respectively. Both groups had similar changes in average HR over 6 months. Key Holter data are summarised in the table. SDNN and SDANN were higher in the placebo vs. empagliflozin group at 6 months; no significant difference was noted for all other measures.

Empagliflozin 10 mg/day (n=33) Placebo (n=33) Adjusted difference between Empagliflozin and Placebo (ANCOVA) Baseline, Mean (SD) 6-month, Mean (SD) Baseline, Mean (SD) 6-month, Mean (SD) Mean, (95% CI) P-value SDNN (ms) 100.49 (43.74) 98.05 (38.86) 109.35 (30.02) 125.08 (43.83) −18.55 (−34.28, −2.82) 0.022 SDANN (ms) 86.84 (39.34) 83.76 (35.53) 94.70 (28.52) 118.28 (77.41) −20.24 (−37.27, −3.21) 0.021 rMSSD (ms) 27.00 (11.84) 27.22 (13.48) 28.00 (11.58) 27.17 (9.38) −1.23 (−6.02, 3.55) 0.608 pNN50 (%) 7.81 (7.59) 8.32 (9.51) 8.26 (7.8) 6.93 (5.35) 0.51 (−2.61, 3.62) 0.746 LF/HF ratio 1.63 (0.52) 1.65 (0.51) 1.53 (0.43) 1.83 (0.82) −0.08 (−0.38, 0.22) 0.602

Conclusions

Among subjects with T2DM and CAD, changes in HRV over 6 months were similar in the empagliflozin and placebo arms suggesting that the mortality benefit conferred by empagliflozin is not associated with positive modulation of autonomic tone.

Acknowledgement/Funding

This trial was supported by an unrestricted investigator-initiated study grant from Boehringer Ingelheim.

Wear Behavior of Graded Glass/Zirconia Crowns and Their Antagonists

Monolithic zirconia crowns have become very popular; their surface finish is considered a key factor for restoration longevity. While polishing has shown excellent results in vivo, the surface glass infiltration of zirconia may offer superior damage resistance and aesthetic advantages by using tooth-colored glasses. Thus, the purpose of this study is to evaluate the efficacy of polishing and glass infiltration on the wear behavior of monolithic zirconia crowns. The wear behavior of intact natural molar teeth was investigated as a reference. Zirconia crowns were divided into 3 groups: PolZ-sintered then polished; PolGZ-polished in the presintered state and then glass infiltrated and sintered; NoPolGZ-as machined, glass infiltrated and sintered. Crowns were adhesively bonded to a dentin-like abutment. Zirconia crowns and molar teeth ( n = 15) were subjected to contact-slide-liftoff cyclic loading (200 N, 1.25 million cycles) with a steatite sphere ( r = 3 mm) as an antagonist in water. Surface and subsurface damages were investigated with optical and scanning electron microscopies. Wear depth and volume loss were determined with micro-computed tomography. PolGZ and NoPolGZ crowns exhibited shallow wear scars, where material loss remained within the glass/zirconia layer with no visible cracks. Meanwhile, PolZ crowns presented no visible wear damage. Volume loss (mm³) in the steatite antagonist was as follows (mean ± SD): PolZ = 0.022 ± 0.007, PolGZ = 0.011 ± 0.004, and NoPolGZ = 0.014 ± 0.006. Molar teeth yielded no measurable wear on the antagonist, while the wear scar on the teeth was greater than that on zirconia crowns, ranging from 0.07 to 0.35 mm³. The combination of polishing and glass infiltration on the occlusal surface of monolithic zirconia crowns yielded reduced wear on both crown and antagonist.

Pharmacokinetic and Drug-Drug Interaction Profiles of the Combination of Tezacaftor/Ivacaftor

Drug–drug interaction (DDI) studies are described for tezacaftor/ivacaftor, a new cystic fibrosis transmembrane conductance regulator modulator therapy for the treatment of cystic fibrosis. Three phase I DDI studies were conducted in healthy subjects to characterize the DDI profile of tezacaftor/ivacaftor with cytochrome P450 (CYP)3A substrates, CYP3A inhibitors, and a permeability glycoprotein (P‐gp) substrate. The effects of steady‐state tezacaftor/ivacaftor on the pharmacokinetics (PKs) of digoxin (a P‐gp substrate), midazolam, and ethinyl estradiol/norethindrone (CYP3A substrates) were evaluated. Effects of strong (itraconazole) and moderate (ciprofloxacin) CYP3A inhibitors on tezacaftor/ivacaftor PKs were also determined. Tezacaftor/ivacaftor increased digoxin area under the curve (AUC) by 30% but did not affect midazolam, ethinyl estradiol, or norethindrone exposures. Itraconazole increased the AUC of tezacaftor 4‐fold and ivacaftor 15.6‐fold. Ciprofloxacin had no significant effect on tezacaftor or ivacaftor exposure. Coadministration of tezacaftor/ivacaftor may increase exposure of sensitive P‐gp substrates. Tezacaftor/ivacaftor is unlikely to impact exposure of drugs metabolized by CYP3A, including hormonal contraceptives. Strong CYP3A inhibitors significantly increase the exposures of tezacaftor and ivacaftor.

Nanovesicles for Nanomedicine: Theory and Practices

Lipid-based nanovesicles such as liposomes, niosomes, and ethosomes are now well recognized as potential candidates for drug delivery and theranostic applications. Some of them have already stepped forward from laboratory to market. The property to entrap lipophilic drugs in their bilayers and hydrophilic drugs in the aqueous milieu makes them a unique carrier for drug delivery. Delivery of drugs/diagnostics to various organs/tissues/cells via nanovesicles is considered to be a topic of long-standing interest with new challenges being posed to formulation scientists with new developments. The key challenge in this context is the physiological and pathological conditions, which make the delivery of drugs extremely difficult at the disease locus and makes their precise delivery ineffective. This chapter gives an insight into the role of novel nanovesicles in the field of drug delivery. We present an overview of the formulation and characterization and role of diverse nanovesicles. A comprehensive update about their application and current as well as potential challenges have also been discussed.

A neutral wind instrument for nano-satellite platforms

Here we describe the first neutral wind sensor developed specifically for use on resource limited nano-satellite platforms. The instrument is a next generation redesign of the ram wind sensor flown on the Communications/Navigation Outage Forecasting System satellite for measurements of neutral velocity, temperature, and composition. Results of subsystem tests in vacuum conditions show low-power operation, promising design, and good resolution of measured parameters over the operational pressure and energy ranges expected in the low Earth orbit environment.

Ethosomes and Transfersomes: Principles, Perspectives and Practices

BACKGROUND

The success story of liposomes in the treatment of systemic infectious diseases and various carcinomas lead the scientists to the innovation of elastic vesicles to achieve similar success through transdermal route. In this direction, ethosomes and transfersomes were developed with the objective to design the vesicles that could pass through the skin. However, there is a lack of systematic review outlining the principles, method of preparation, latest advancement and applications of ethosomes and transfersomes. This review covers various aspects that would be helpful to scientists in understanding advantages of these vesicular systems and designing a unique nano vesicular delivery system.

METHODS

Structured search of bibliographic databases for previously published peer-reviewed research papers was explored and data was culminated in terms of principle of these vesicular delivery systems, composition, mechanism of actions, preparation techniques, methods for their characterization and their application.

RESULTS

A total of 182 papers including both, research and review articles, were included in this review in order to make the article comprehensive and readily understandable. The mechanism of action and composition of ethosomes and transfersomes was extensively discussed. Various methods of preparation such as, rotary film evaporation method, reverse phase evaporation method, vortex/ sonication method, ethanol injection method, freeze thaw methods, along with their advantages has been discussed. It was also discussed that both these elastic nanocarriers offer unique advantages of ferrying the drug across membranes, sustaining drug release as well as protecting the encapsulated bio actives from external environment. The enhanced bioavailability and skin penetration of ethosomes as compared to conventional vesicular delivery systems is attributed to the presence of ethanol in the bilayers while that for transfersomes accrues due to their elasticity along with their ability to retain their shape because of the presence of edge activators. Successful delivery of synthetic drugs as well as phytomedicines has been extensively reported through these vesicles.

CONCLUSION

Though these vesicular systems offer a good potential for rational drug delivery, a thoughtfully designed process is required to optimize the process variables involved. Industrial scale production of efficacious, safe, cost effective and stable formulations of both these delivery systems appears to be a pre-requisite to ensure their utility as the trans-dermal vehicles.

Stable Co-crystals of Glipizide with Enhanced Dissolution Profiles: Preparation and Characterization

Present study deciphers preparation of co-crystals of lipophilic glipizide by using four different acids, oxalic, malonic, stearic, and benzoic acids, in order to achieve enhanced solubility and dissolution along with stability. All co-crystals were prepared by dissolving drug and individual acids in the ratio of 1:0.5 in acetonitrile at 60-70°C for 15 min, followed by cooling at room temperature for 24 h. FT-IR spectroscopy revealed no molecular interaction between acids and drug as the internal structure and their geometric configurations remain unchanged. Differential scanning calorimetry revealed closer melting points of raw glipizide and its co-crystals, which speculates absence of difference in crystallinity as well as intermolecular bonding of the co-crystals and drug. PXRD further revealed that all the co-crystals were having similar crystallinity as that of raw glipizide except glipizide-malonic acid co-crystals. This minor difference in the relative intensities of some of the diffraction peaks could be attributed to the crystal habit or crystal size modification. SEM revealed difference in the crystal morphology for all the co-crystals. Micromeritic, solubility, dissolution, and stability data revealed that among all the prepared co-crystals, glipizide-stearic acid co-crystals were found superior. Hence, it was concluded that glipizide-stearic acid co-crystals could offer an improved drug design strategy to overcome dissolution and bioavailability related challenges associated with lipophilic glipizide.

Nanosuspension: Principles, Perspectives and Practices

In the last three decades, nano-sizing of hydrophobic drugs has emerged as one of the most commonly used strategies to overcome their solubility and bioavailability related issues. Nanosuspensions offer versatile features and unique advantages over other approaches that have been utilized for this purpose. The unique inherent properties of nanosuspensions have been explored for a wide variety of applications. Commercial production of stable nanosuspensions has been made possible by the use of techniques such as media milling and high pressure homogenization. This article reviews various techniques being employed for production, characterization, merits and limitations of nanosuspensions and mechanisms that play a role in the physicochemical stability of nanosuspensions. The common strategies applied so far to overcome their stability and commercialization related aspects are also highlighted.