Modified Wassel-Flatt Type III Radial Polydactyly: Subtypes and Their Outcomes

PURPOSE

We aimed to subdivide modified type III radial polydactyly and evaluate the applied surgical procedures and outcomes according to the subtypes.

METHODS

This study included 32 thumbs of 32 patients treated for modified Wassel-Flatt type III radial polydactyly from March 2008 to December 2018. Each patient was subclassified into parallel, divergent, and convergent types according to the alignment of the duplicated digit. The parallel type was further divided according to the treatment method applied. The parallel A group comprised patients treated with reconstructing the radial collateral ligament of the interphalangeal (IP) joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit, and the parallel B group comprised patients treated with excision of the extra digit at the bifurcation site of the proximal phalanx. We evaluated the Japanese Society for Surgery of the Hand scores and radiographic angulation of the IP and metacarpophalangeal joints at a mean follow-up of 38 months.

RESULTS

Fourteen cases were parallel type (6 and 8 in the parallel A and B groups, respectively), 14 were divergent type, and 4 were convergent type. Patients in the parallel A group had significantly better IP and metacarpophalangeal joint angulation and Japanese Society for Surgery of the Hand scores than those in the parallel B group. Patients in the parallel A group had significantly better Japanese Society for Surgery of the Hand scores than those in the divergent and convergent groups.

CONCLUSIONS

Reconstructing the radial collateral ligament of the IP joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit was associated with better outcomes than the excision of the extra digit at the bifurcation site in the parallel type cases. The parallel type treated with proximal phalanx preservation and ligament reconstruction had better clinical outcomes than other types of modified Wassel-Flatt type III radial polydactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Perpendicular Extraction - Visionary Concept with the Prospect of Generating the Perfect Extraction of Teeth, or a Misguided Vision that had to Fail Due to Anatomical Circumstances?

From the second half of the 18th century to the last third of the 19th century, a period of about 100 years, perpendicular (vertical) extraction, became an ideal for many authors, since molars were the most difficult teeth to remove. However, extraction instruments available at that time, caused pronounced damage to the alveolar bone and gingiva. For many authors and clinicians, vertical extraction was the only way to meet this challenge. This approach to tooth removal, while viable, came to an end when anatomically shaped forceps, adapted to the different morphologies of the various teeth were introduced, thereby changing 19th century dentistry with a new standard for tooth removal.

Exploring Synthetic Strategies for 1H-Indazoles and Their N-Oxides: Electrochemical Synthesis of 1H-Indazole N-Oxides and Their Divergent C-H Functionalizations

The selective electrochemical synthesis of 1H-indazoles and their N-oxides and the subsequent C-H functionalization of the 1H-indazole N-oxides are described. The electrochemical outcomes were determined by the nature of the cathode material. When a reticulated vitreous carbon cathode was used, a wide range of 1H-indazole N-oxides were selectively synthesized, and the electrosynthesis products were deoxygenated to N-heteroaromatics, owing to cathodic cleavage of the N-O bond via paired electrolysis, while Zn cathode was used. The scope of this electrochemical protocol is broad, as both electron-rich and electron-poor substrates were tolerated. The potency of our electrochemical strategy was demonstrated through the late-stage functionalization of various bioactive molecules, making this reaction attractive for the synthesis of 1H-indazole derivatives for pharmaceutical research and development. Detailed mechanistic investigations involving electron paramagnetic resonance spectroscopy and cyclic voltammetry suggested a radical pathway featuring iminoxyl radicals. Owing to the rich reactivity of 1H-indazole N-oxides, diverse C-H functionalization reactions were performed. We demonstrated the synthetic utility of 1H-indazole N-oxides by synthesizing the pharmaceutical molecules lificiguat and YD (3); key intermediates for bendazac, benzydamine, norepinephrine/serotonin reuptake inhibitors, SAM-531, and gamendazole analogues; and a precursor for organic light-emitting diodes.

Rhodium-Catalyzed Diastereo- and Enantioselective Divergent Annulations between Cyclobutanones and 1,5-Enynes: Rapid Construction of Complex C(sp3)-Rich Scaffolds

Given the emerging demand to "escape from flatland" for drug discovery, synthetic methods that can efficiently construct complex three-dimensional structures with multi-stereocenters become increasingly valuable. Here, we describe the development of Rh(I)-catalyzed intramolecular annulations between cyclobutanones and 1,5-enyne groups to construct complex C(sp3)-rich scaffolds. Divergent reactivities are realized with different catalysts, and excellent diastereo- and enantioselectivity have been achieved. The use of (R)-H8-binap as the ligand favors forming the bis-bicyclic scaffolds with multiple quaternary stereocenters, while the (R)-segphos ligand prefers to generate the tetrahydro-azapinone products. Owing to the versatile reactivity of ketone moieties, these C(sp3)-rich scaffolds can be further functionalized. Experimental and computational mechanistic studies support a reaction pathway involving enyne-cyclometallation, 1,2-carbonyl addition, and then β-carbon elimination; the divergent reactivities are dictated by a product-determining Rh-alkyl migratory insertion step.

Divergent Aminocarbonylations of Alkynes Enabled by Photoredox/Nickel Dual Catalysis

A metallaphotoredox-catalyzed strategy for the selective and divergent aminocarbonylation of alkynes with amines and 1 atm of CO is reported. This synergistic protocol not only enables the Markovnikov-selective hydroaminocarbonylation of alkynes to afford α,β-unsaturated amides, but also facilitates a sequential four-component hydroaminocarbonylation/radical alkylation in the presence of tertiary and secondary alkyl boronate esters, which allows for straightforward conversion of alkynes into corresponding amides. Preliminary mechanistic studies disclose that a photoinduced oxidative insertion of aniline and CO into nickel followed by a migratory insertion of (carbamoyl)nickel species could be involved.

Implications of a highly divergent dengue virus strain for cross-neutralization, protection, and vaccine immunity

Although divergent dengue viruses (DENVs) have been isolated in insects, nonhuman primates, and humans, their relationships to the four canonical serotypes (DENV 1-4) are poorly understood. One virus isolated from a dengue patient, DKE-121, falls between genotype and serotype levels of sequence divergence to DENV-4. To examine its antigenic relationship to DENV-4, we assessed serum neutralizing and protective activity. Whereas DENV-4-immune mouse sera neutralize DKE-121 infection, DKE-121-immune sera inhibit DENV-4 less efficiently. Passive transfer of DENV-4 or DKE-121-immune sera protects mice against homologous, but not heterologous, DENV-4 or DKE-121 challenge. Antigenic cartography suggests that DENV-4 and DKE-121 are related but antigenically distinct. However, DENV-4 vaccination confers protection against DKE-121 in nonhuman primates, and serum from humans immunized with a tetravalent vaccine neutralize DENV-4 and DKE-121 infection equivalently. As divergent DENV strains, such as DKE-121, may meet criteria for serotype distinction, monitoring their capacity to impact dengue disease and vaccine efficacy appears warranted.

A meta-analysis of functional magnetic resonance imaging studies of divergent thinking using activation likelihood estimation

There are conflicting findings regarding brain regions and networks underpinning creativity, with divergent thinking tasks commonly used to study this. A handful of meta-analyses have attempted to synthesise findings on neural mechanisms of divergent thinking. With the rapid proliferation of research and recent developments in fMRI meta-analysis approaches, it is timely to reassess the regions activated during divergent thinking creativity tasks. Of particular interest is examining the evidence regarding large-scale brain networks proposed to be key in divergent thinking and extending this work to consider the role of the semantic control network. Studies utilising fMRI with healthy participants completing divergent thinking tasks were systematically identified, with 20 studies meeting the criteria. Activation Likelihood Estimation was then used to integrate the neuroimaging results across studies. This revealed four clusters: the left inferior parietal lobe; the left inferior frontal and precentral gyrus; the superior and medial frontal gyrus and the right cerebellum. These regions are key in the semantic network, important for flexible retrieval of stored knowledge, highlighting the role of this network in divergent thinking.

Promoting Individual and Collective Creativity in Science Students

Creativity is a scientific skill necessary to develop a successful research career. We expose the importance of a growth mindset, divergent, lateral, and associative thinking, serendipity, and being part of a nonhierarchical and diverse research team to improve both individual and collective creativity.

'Not clinically effective but cost-effective' - paradoxical conclusions in randomised controlled trials with 'doubly null' results: a cross-sectional study

OBJECTIVES

Randomised controlled trials in healthcare increasingly include economic evaluations. Some show small differences which are not statistically significant. Yet these sometimes come to paradoxical conclusions such as: 'the intervention is not clinically effective' but 'is probably cost-effective'. This study aims to quantify the extent of non-significant results and the types of conclusions drawn from them.

DESIGN

Cross-sectional retrospective analysis of randomised trials published by the UK's National Institute for Health Research (NIHR) Health Technology Assessment programme. We defined as 'doubly null' those trials that found non-statistically significant differences in both primary outcome and cost per patient. Paradoxical was defined as concluding in favour of an intervention, usually compared with placebo or usual care. No human participants were involved. Our sample was 226 randomised trial projects published by the Health Technology Assessment programme 2004 to 2017. All are available free online.

RESULTS

The 226 projects contained 193 trials with a full economic evaluation. Of these 76 (39%) had at least one 'doubly null' comparison. These 76 trials contained 94 comparisons. In these 30 (32%) drew economic conclusions in favour of an intervention. Overall report conclusions split roughly equally between those favouring the intervention (14), and those favouring either the control (7) or uncertainty (9).

DISCUSSION

Trials with 'doubly null' results and paradoxical conclusions are not uncommon. The differences observed in cost and quality-adjustedlife year were small and non-statistically significant. Almost all these trials were also published in leading peer-reviewed journals. Although some guidelines for reporting economic results require cost-effectiveness estimates regardless of statistical significance, the interpretability of paradoxical results has nowhere been addressed.

CONCLUSIONS

Reconsideration is required of the interpretation of cost-effectiveness analyses in randomised controlled trials with 'doubly null' results, particularly when economics favours a novel intervention.

Genetically divergent porcine sapovirus identified in pigs, United States

Porcine sapoviruses (SaVs) are genetically diverse and widely distributed in pig-producing countries. Eight genogroups of porcine SaV have been identified, and genogroup III is the predominant type. Most of the eight genogroups of porcine SaV are circulating in the United States. In the present study, we report detection of porcine SaVs in pigs at different ages with clinical diarrhoea using next-generation sequencing and genetic characterization. All seven cases have porcine SaV GIII strains detected and one pooled case was found to have a porcine SaV GVI strain IA27912-B-2018. Sequence analysis showed that seven GIII isolates were genetically divergent and formed four different lineages on the trees of complete genome, RdRP, VP1 and VP2. In addition, these seven GIII isolates had three different deletion/insertion patterns in an identified variable region close to the 3' end of VP2. The GVI strain IA27912-B-2018 was closely related to strains previously detected in the United States and Japan. A 3-nt deletion in VP1 region of GVI IA27912-B-2018 was identified. Our study showed that genetically divergent SaVs of different genogroups are co-circulating in pigs in the United States. Future studies comparing the virulence of these different genogroups in pigs are needed to better understand this virus and to determine if surveillance and vaccine development are needed to monitor and control porcine SaVs.

Transcribe this way: Rap1 confers promoter directionality by repressing divergent transcription

In eukaryotes, divergent transcription is a major source of noncoding RNAs. Recent studies have uncovered that in yeast, the transcription factor Rap1 restricts transcription in the divergent direction and thereby controls promoter directionality. Here, we summarize these findings, propose regulatory principles, and discuss the implications for eukaryotic gene regulation.

Repression of Divergent Noncoding Transcription by a Sequence-Specific Transcription Factor

Many active eukaryotic gene promoters exhibit divergent noncoding transcription, but the mechanisms restricting expression of these transcripts are not well understood. Here, we demonstrate how a sequence-specific transcription factor represses divergent noncoding transcription at highly expressed genes in yeast. We find that depletion of the transcription factor Rap1 induces noncoding transcription in a large fraction of Rap1-regulated gene promoters. Specifically, Rap1 prevents transcription initiation at cryptic promoters near its binding sites, which is uncoupled from transcription regulation in the protein-coding direction. We further provide evidence that Rap1 acts independently of previously described chromatin-based mechanisms to repress cryptic or divergent transcription. Finally, we show that divergent transcription in the absence of Rap1 is elicited by the RSC chromatin remodeler. We propose that a sequence-specific transcription factor limits access of basal transcription machinery to regulatory elements and adjacent sequences that act as divergent cryptic promoters, thereby providing directionality toward productive transcription.

Biomechanical Comparison of 3 Syndesmosis Repair Techniques With Suture Button Implants

Background:

Suture button fixation of syndesmotic injury is growing in popularity, as it has been shown to provide adequate stability in a more cost-effective manner than screw fixation while allowing more physiologic distal tibiofibular joint motion. However, the optimal repair technique and implant orientation have yet to be determined.

Purpose/Hypothesis:

The purpose of this study was to biomechanically compare 3 suture button construct configurations/orientations for syndesmosis fixation: single, parallel, and divergent. The authors hypothesized that all 3 methods would provide adequate stabilization but that the divergent technique would be the most stable.

Study Design:

Controlled laboratory study.

Methods:

The fixation strengths of 3 stabilization techniques with suture button devices were compared with 10 cadaveric legs each (N = 30). Ankle motion under cyclic loading was measured in multiple planes: first in the intact state, then following simulated syndesmosis injury, and then following fixation with 1 of 3 randomly assigned constructs—1 suture button, 2 suture buttons in parallel, and 2 divergent suture buttons. Finally, axial loading with external rotation was applied to failure.

Results:

All syndesmotic fixation methods provided stability to the torn state. There was no statistically significant difference among the 3 fixation techniques in biomechanical stability. Failure most commonly occurred through fibular fracture at supraphysiologic loads.

Conclusion:

Suture button implant fixation for syndesmotic injury appears to provide stability to the torn syndesmosis, and the configuration of the fixation does not appear to affect the strength or security of the stabilization.

Clinical Relevance:

This study provides further insight into the biomechanics and optimal configuration of suture button fixation of the torn syndesmosis. Based on these results, the addition of a second suture button may not significantly contribute to immediate postoperative stability.

Neuropsychopharmacological regulation of performance on creativity-related tasks

A number of factors affect performance on tasks associated with creativity. Two pharmacological systems in particularly been identified as important for their impact on creativity, the noradrenergic system and the dopaminergic systems. Furthermore, stress is also established as an important factor impacting performance, most likely mediated by its effects on these neurotransmitter systems. Herein, we review the current literature on the relationships between stress, the noradrenergic system, the dopaminergic system, and other pharmacological factors and their effects on performance on tasks associated with creativity.

Managing maxillary proclination with novel designed angulated implants

Implant-supported removable dental prostheses may be supported by a variety of splinted (bar and clip) attachment systems or nonsplinted abutment-based attachments (ball, magnets, and resilient stud attachments such as locators [Zest Anchors], ERA [Sterngold], and nonresilient-stud attachments such as ANKYLOS SynCone [Dentsply Implants]). Nonsplinted attachments are preferred as they are more economical, less technique sensitive, easier to clean, repair, and maintain than splinted (bar and clip) attachment systems, but they work favorably only when implants in the arch are placed parallel to each other. Often implants in the anterior maxilla have to be placed with a labial inclination (due to the proclination of the premaxilla), resulting in lack of parallelism between the anterior and posterior implants, making it challenging to fabricate a removable dental prostheses supported by nonsplinted attachments, and necessitating the use of angled abutments. Recently, a novel implant design with a 12° restorative platform angulation has been introduced by Southern Implants (Co-axis, Keystone Dental, Inc., Burlington, MA, USA). These new angulated implants aid in minimizing the divergence between the anterior and posterior maxillary implants without using angled abutments. The purpose of this article was to report a case utilizing the novel angulated implants (Co-axis, Keystone Dental, Inc., Burlington, MA, USA) in the premaxilla for fabrication of maxillary removable dental prostheses supported and retained by nonsplinted attachments.

Whole genome investigation of a divergent clade of the pathogen Streptococcus suis

Streptococcus suis is a major porcine and zoonotic pathogen responsible for significant economic losses in the pig industry and an increasing number of human cases. Multiple isolates of S. suis show marked genomic diversity. Here, we report the analysis of whole genome sequences of nine pig isolates that caused disease typical of S. suis and had phenotypic characteristics of S. suis, but their genomes were divergent from those of many other S. suis isolates. Comparison of protein sequences predicted from divergent genomes with those from normal S. suis reduced the size of core genome from 793 to only 397 genes. Divergence was clear if phylogenetic analysis was performed on reduced core genes and MLST alleles. Phylogenies based on certain other genes (16S rRNA, sodA, recN, and cpn60) did not show divergence for all isolates, suggesting recombination between some divergent isolates with normal S. suis for these genes. Indeed, there is evidence of recent recombination between the divergent and normal S. suis genomes for 249 of 397 core genes. In addition, phylogenetic analysis based on the 16S rRNA gene and 132 genes that were conserved between the divergent isolates and representatives of the broader Streptococcus genus showed that divergent isolates were more closely related to S. suis. Six out of nine divergent isolates possessed a S. suis-like capsule region with variation in capsular gene sequences but the remaining three did not have a discrete capsule locus. The majority (40/70), of virulence-associated genes in normal S. suis were present in the divergent genomes. Overall, the divergent isolates extend the current diversity of S. suis species but the phenotypic similarities and the large amount of gene exchange with normal S. suis gives insufficient evidence to assign these isolates to a new species or subspecies. Further, sampling and whole genome analysis of more isolates is warranted to understand the diversity of the species.

Near full-length HIV type 1M genomic sequences from Cameroon : Evidence of early diverging under-sampled lineages in the country

Background: Cameroon is the country in which HIV-1 group M (HIV-1M) likely originated and is today a major hotspot of HIV-1M genetic diversity. It remains unclear, however, whether the highly divergent HIV-1M lineages found in this country arose during the earliest phases of the global HIV-1M epidemic, or whether they arose more recently as a result of recombination events between globally circulating HIV-1M lineages.

Methodology: To differentiate between these two possibilities, we performed phylogenetic analyses of the near full genome sequences of nine newly sequenced divergent HIV-1M isolates and 15 previously identified, apparently unique recombinant forms (URFs) from Cameroon.

Results: Although two of the new genome sequences were clearly classifiable within subtype G, the remaining seven were highly divergent and phylogenetically branched either outside of, or very near the bases of clades containing the well characterised globally circulating viral lineages that they were most closely related to. Recombination analyses further revealed that these divergent viruses were likely complex URFs. We show, however that substantial portions (>1 Kb) of three of the new genome sequences and 15 of the previously characterised Cameroonian URFs have apparently been derived from divergent parental viruses that branch phylogenetically near the bases of the major HIV-1M clades.

Conclusions and implications: Our analyses indicate the presence in Cameroon of contemporary descendants of numerous early-diverging HIV-1M lineages. Further efforts to sample and sequence viruses from such lineages could be crucial both for retracing the earliest evolutionary steps during the emergence of HIV-1M in humans, and accurately reconstructing the ancestral sequences of the major globally circulating HIV-1M lineages.

Divergent elbow dislocation and risk of compartment syndrome

BACKGROUND

Divergent pediatric elbow dislocations are very rare injuries.

CASE

An eight-year-old boy presented to the emergency department with elbow pain after a fall. On examination his elbow was swollen; skin and neurovascular function were intact. Radiographs demonstrated a divergent elbow dislocation. After successful closed reduction under sedation, the arm was casted; gentle motion was initiated at three weeks. At four months, the patient had full strength, no symptoms, and nearly full range of motion.

INTERPRETATION

The literature on the treatment of this injury is limited because of its rarity. We present a case of successful nonoperative management. The return of this patient for compressive symptoms should serve as a reminder that these injuries may be at high risk for compartment syndrome, possibly due to the high level of soft tissue disruption.

Detection of a phylogenetically distinct IMP-type metallo-β-lactamase, IMP-35, in a CC235 Pseudomonas aeruginosa from the Dutch-German border region (Euregio)

OBJECTIVES

To characterize a highly divergent IMP-type metallo-β-lactamase (MBL) variant detected in a multidrug-resistant Pseudomonas aeruginosa clinical isolate.

METHODS

P. aeruginosa isolate 1876 was recovered from an anal swab of an inpatient at a German hospital in the Dutch-German border region (Euregio), where cross-border patient healthcare occurs. MICs were determined by agar dilution and phenotypic screening for MBL production by Etest MBL. Typing was performed by multilocus sequence typing (MLST). PCR assays and nucleotide sequencing were employed for identification of bla gene types. The class 1 integron carrying the blaIMP-type gene was characterized by PCR mapping and sequencing using a set of specific primers. A phylogenetic tree was constructed for the new blaIMP variant.

RESULTS

Isolate 1876 was phenotypically positive for MBL production, exhibited resistance to carbapenems and harboured a new blaIMP-type gene, blaIMP-35. MLST showed that the allelic profile corresponded to ST622, which belongs to the prevalent international clonal complex CC235. The blaIMP-35 gene was located in a class 1 integron as the first gene cassette, followed by blaOXA-35, aacA6, qacEΔ1 and sul1, suggesting its recent integration. IMP-35 was highly divergent, possessing 33/246 (13.4%) different amino acid residues from its closest IMP variants (IMP-8 and IMP-12) and was phylogenetically distinct, representing a separate group in the phylogenetic tree of IMP proteins.

CONCLUSIONS

The identification of this phylogenetically distinct IMP-type variant in a CC235 P. aeruginosa suggests the ongoing spread of new IMP-type carbapenemases as well as the potential of the blaIMP-35 gene to evolve in the hospital environment.

Right atrial myxoma with glandular differentiation: A rare entity in pediatric age group

Cardiac myxomas (CMs) account for nearly half of the primary cardiac tumors in the elderly. They arise from sub-endocardial “reserve” or lepidic” cells, which may show divergent differentiation. We describe a CM with glandular differentiation in the right atrium of a 10-year-old child who presented with respiratory distress on exertion, of 2 months duration. On echocardiography, two large interconnected masses measuring 34×30 mm and 20×17 mm were seen to arise from the free wall of the right atrium. Cut surface of the excised mass was myxoid with areas of calcification. On microscopy, there were typical features of a myxoma with prominent glandular differentiation and characteristic immunophenotype. The case is being reported due to its rarity in pediatric age group as well as its glandular differentiation, which must be recognized as a spectrum of histomorphologic diversity and must not be mistaken for a metastatic adenocarcinoma.