--Eleven tips for operational researchers working with health programmes: our experience based on implementing differentiated tuberculosis care in south India

Due to the workload and lack of a critical mass of trained operational researchers within their ranks, health systems and programmes may not be able to dedicate sufficient time to conducting operational research (OR). Hence, they may need the technical support of operational researchers from research/academic organisations. Additionally, there is a knowledge gap regarding implementing differentiated tuberculosis (TB) care in programme settings. In this 'how we did it' paper, we share our experience of implementing a differentiated TB care model along with an inbuilt OR component in Tamil Nadu, a southern state in India. This was a health system initiative through a collaboration of the State TB cell with the Indian Council of Medical Research institutes and the World Health Organisation country office in India. The learnings are in the form of eleven tips: four broad principles (OR on priority areas and make it a health system initiative, implement simple and holistic ideas, embed OR within routine programme settings, aim for long-term engagement), four related to strategic planning (big team of investigators, joint leadership, decentralised decision-making, working in advance) and three about implementation planning (conducting pilots, smart use of e-tools and operational research publications at frequent intervals). These may act as a guide for other Indian states, high TB burden countries that want to implement differentiated care, and for operational researchers in providing technical assistance for strengthening implementation and conducting OR in health systems and programmes (TB or other health programmes). Following these tips may increase the chances of i) an enriching engagement, ii) policy/practice change, and iii) sustainable implementation.

The First Differentiated TB Care Model From India: Delays and Predictors of Losses in the Care Cascade

To reduce TB deaths in resource-limited settings, a differentiated care strategy can be used to triage patients with high risk of severe illness (i.e., those with very severe undernutrition, respiratory insufficiency, or inability to stand without support) at diagnosis and refer them for comprehensive assessment and inpatient care. Globally, there are few examples of implementing this type of strategy in routine program settings. Beginning in April 2022, the Indian state of Tamil Nadu implemented a differentiated care strategy called Tamil Nadu-Kasanoi Erappila Thittam (TN-KET) for all adults aged 15 years and older with drug-susceptible TB notified by public facilities. Before evaluating the impact on TB deaths, we sought to understand the retention and delays in the care cascade as well as predictors of losses. During April-June 2022, 14,961 TB patients were notified and 11,599 (78%) were triaged. Of those triaged, 1,509 (13%) were at high risk of severe illness; of these, 1,128 (75%) were comprehensively assessed at a nodal inpatient care facility. Of 993 confirmed as severely ill, 909 (92%) were admitted, with 8% unfavorable admission outcomes (4% deaths). Median admission duration was 4 days. From diagnosis, the median delay in triaging and admission of severely ill patients was 1 day each. Likelihood of triaging decreased for people with extrapulmonary TB, those diagnosed in high-notification districts or teaching hospitals, and those transferred out of district. Predictors of not being comprehensively assessed included: aged 25-34 years, able to stand without support, and diagnosis at a primary or secondary-level facility. Inability to stand without support was a predictor of unfavorable admission outcomes. To conclude, the first quarter of implementation suggests that TN-KET was feasible to implement but could be improved by addressing predictors of losses in the care cascade and increasing admission duration.

Effect of Substituents on the Photodynamic Action of Anthraquinones: EPR, Computational and In Vitro Studies

Anthraquinone class of compounds possesses a broad spectrum of therapeutic applications. Cancer cell targeting ability, together with photogeneration of reactive oxygen species, renders anthraquinones an interesting class of photosensitizers for photodynamic therapy (PDT). Screening of newer compounds for better singlet oxygen generation is of current interest to improve the practical usability in PDT. In this study, we investigate the photodynamic activity of nine commercially available anthraquinones, using EPR spectroscopy and computational techniques, to identify the role of substituents on singlet oxygen yield. Three anthraquinone derivatives, 1,5-diaminoanthraquinone, 15-dihydroxyanthraquinone and 1,2,7-trihydroxyanthraquinone, showed highest singlet oxygen quantum yield (0.21, 0.18 and 0.15, respectively) relative to Rose Bengal. Time-dependent density functional theory calculations indicate the singlet oxygen quantum yield of anthraquinones inversely correlate well with the excited singlet-triplet (S1-T1) energy gap. Electron-donating substituents present at positions 1, 2 and 5 of anthraquinone seem to reduce the S1-T1 energy gap, facilitating inter-system crossing and the production of singlet oxygen. This would greatly aid in the design of newer anthraquinone-based photosensitizers. This study also highlights the suitability of 1,5-diaminoanthraquinone for PDT applications as demonstrated by in vitro experiments of photoinduced DNA cleavage and photocytotoxicity in Dalton's lymphoma ascites.

A Review on Various Biofuels and its Applications

Biofuels derived from biofuels, plant or algae or animal wastes. Unlike fossil fuels such as petroleum, coal and natural gas, refilled immediately. Biofuels are fuels made from recently harvested plants. They act like fossil fuels: they burn when ignited, releasing energy that can be converted into kinetic energy in a car, or heat a home. Biofuels can be obtained from a variety of crops and from a wide range of plant products from other industries. Not only is biodiesel stable, it is also a highly environmentally friendly, clean burning option that can be used without modification in diesel engines. In fact, biodiesel reduces greenhouse gas emissions by 56% to 86%, which means that the use of biodiesel has already reduced carbon emissions by 75.5 million metric tons. Many countries promote the use of biodiesel. In 2001, global biodiesel consumption was approximately 0.3 billion gallons. Based on the raw material, biofuels are divided into four groups: third, fourth (FGBs), first biodiesel, which is the only is a locally produced, clean-burning, renewable alternative to petroleum diesel. The use of biodiesel as a vehicle fuel enhances energy conservation, improves air quality and the environment, and provides safety benefits. Biofuels are transport fuels such as ethanol and biomass based diesel fuels. These fuels are usually blended with petroleum fuels (petrol and distillation / diesel fuel and heating oil), but can also be used on their own. Scientists have found that, in practice, biofuels produced from agricultural crops cause less pollution and greenhouse gas emissions than conventional fossil fuels, causing some environmental problems. Biofuels can also affect the poor. Various problems arise due to high prices for crops. It can go from improved water quality to creating new jobs in economically backward areas. Some applications of bioenergy require a feed based on residues from dedicated field production (such as energy crops) or agricultural production. However, many plant species grown for biofuels release higher levels of the ozone precursor isoprene than conventional crops and plants. Excess ozone poses a well-documented risk to human health, with 22,000 premature deaths each year linked to ground ozone exposure in Europe.

Upshot of Concentration of Zirconium (IV) Oxynitrate Hexa Hydrate on Preparation and Analyses of Zirconium Oxide (ZrO₂) Nanoparticles by Modified Co-Precipitation Method

In the present work, pure nanocrystalline monoclinic Zirconia (ZrO₂) has been successfully synthesized and optimized by the modified co-precipitation method. The concentration of raw material has been optimized with the fixed amount of precipitation agent (Potassium hydroxide KOH). The thermal history of the precursor has been examined through TG/DTA analysis. All the samples are subjected to study the structure, fingerprints of the molecular vibrations, and morphology analyses. The representative sample has been analyzed through Transmission Electron Microscope (TEM) and X-ray Photo Electron Spectroscopy (XPS) analyses. The as-prepared sample exhibits the better crystallinity and surface morphology with lesser particle size (190 nm) when the raw material concentration is 0.2 M. The as-prepared ZrO₂ filler (0, 3, 6, 9, and 12 wt.%) is spread through the enhanced polymer electrolyte P(S-MMA) (27 Wt.%)-LiClO₄ (8 wt.%)-EC + PC (1;1 of 65 wt.%) complex system via solution casting method. The as-synthesized electrolyte films are examined via complex impedance analysis. P(S-MMA) (27 wt.%)-LiCIO₄ (8 wt.%)-EC + PC (1 ;1 of 65 wt.%)-6 wt.% of ZrO₂ shows the high ionic conductivity 2.35 × 10^-3 Scm^-1. Temperature-dependent ionic conductivity studies obey the non-linear behavior. The enhanced ZrO₂ has been expected to enhance the other electrochemical properties of the lithium secondary battery.

Emerging Role and Clinicopathological Significance of AEG-1 in Different Cancer Types: A Concise Review

Tumor breakthrough is driven by genetic or epigenetic variations which assist in initiation, migration, invasion and metastasis of tumors. Astrocyte elevated gene-1 (AEG-1) protein has risen recently as the crucial factor in malignancies and plays a potential role in diverse complex oncogenic signaling cascades. AEG-1 has multiple roles in tumor growth and development and is found to be involved in various signaling pathways of: (i) Ha-ras and PI3K/AKT; (ii) the NF-κB; (iii) the ERK or mitogen-activated protein kinase and Wnt or β-catenin and (iv) the Aurora-A kinase. Recent studies have confirmed that in all the hallmarks of cancers, AEG-1 plays a key functionality including progression, transformation, sustained angiogenesis, evading apoptosis, and invasion and metastasis. Clinical studies have supported that AEG-1 is actively intricated in tumor growth and progression which includes esophageal squamous cell, gastric, colorectal, hepatocellular, gallbladder, breast, prostate and non-small cell lung cancers, as well as renal cell carcinomas, melanoma, glioma, neuroblastoma and osteosarcoma. Existing studies have reported that AEG-1 expression has been induced by Ha-ras through intrication of PI3K/AKT signaling. Conversely, AEG-1 also activates PI3K/AKT pathway and modulates the defined subset of downstream target proteins via crosstalk between the PI3K/AKT/mTOR and Hedgehog signaling cascade which further plays a crucial role in metastasis. Thus, AEG-1 may be employed as a biomarker to discern the patients of those who are likely to get aid from AEG-1-targeted medication. AEG-1 may play as an effective target to repress tumor development, occlude metastasis, and magnify the effectiveness of treatments. In this review, we focus on the molecular mechanism of AEG-1 in the process of carcinogenesis and its involvement in regulation of crosstalk between the PI3K/AKT/mTOR and Hedgehog signaling. We also highlight the multifaceted functions, expression, clinicopathological significance and molecular inhibitors of AEG-1 in various cancer types.

Sol-gel based synthesis and biological properties of zinc integrated nano bioglass ceramics for bone tissue regeneration

Bone is a flexible and electro active tissue that is vulnerable to various traumatic injuries. The self-healing of damaged bone tissue towards reconstruction is limited due to the lack of proper niche compliances. Nevertheless, the classical grafting techniques like autograft/allograft for bone repair pose challenges like bacterial infections and donor-site morbidity with unsatisfactory outcomes. The use of appropriate biomaterial with osteogenic potential can meet these challenges. In this regard, bioactive glass ceramics is widely used as a bone filler or graft material because of its bonding affinity to bone leading towards bone reconstruction applications without the challenge of post implant infections. Hence, the current study is aimed at addressing this potentiality of zinc (Zn) for doped the bioglass at nano-scale advantages for bone tissue repair. Since, Zn has been demonstrated to have not only antibacterial property but also the stimulatory effect on osteoblasts differentiation, mineralization by enhancing the osteogenic genes expression. In view of these, the present study is focused on sol-gel synthesis and pysico-chemical characterization of Zinc-doped bioglass nanoparticles (Zn-nBGC) and also analyzing its biological implications. The surface morphological and physiochemical characterizations using SEM, EDX, FT-IR and XRD analysis has shown the increased surface area of Zn-nBGC particles providing a great platform for biomolecular interaction, cytocompatibility, cell proliferation and osteogenic differentiation. The obtaining hydroxy apatite groups have initiated in vitro mineralization towards osteogenic lineage formation. Zn has not only involved in enhancing cellular actions but also strengthen the ceramic nanoparticles towards antibacterial application. Hence the finding suggests a biomaterial synthesis of better biomaterial for bone tissue engineering application by preventing post-operative bacterial infection.

Two-year clinical results of a novel load redistribution device for the treatment of medial knee OA

PURPOSE

A potential method to relieve the pain from medial osteoarthritis of the knee is to offload the medial compartment. The Latella^™ Knee Implant is a novel device designed to offload the medial compartment. The objective of the Cotera-1 study was to evaluate the preliminary safety and feasibility of the Latella implant to treat patients with medial OA of the knee, by a 2-year follow-up of a prospective multicenter feasibility study (Cotera-1) performed in the Netherlands and UK METHODS: In this first-in-man study, 11 participants received the Latella implant and were followed for 2 years, documenting physician assessment, Patient-Reported Outcome (PRO) scoring (KOOS, IKDC, Kujala, SF-36); Patient Global Assessment (PGA), radiographic analysis and MRI analysis, complications, reoperation rate and hip-knee-ankle axis.

RESULTS

The Latella Knee Implant system proved to be well tolerated and demonstrated a low-risk safety profile up to 24 months post-treatment. A responder analysis was performed of the subjects who still had the Latella implanted at 24-month time point (n = 9). Based on a MCID of eight for KOOS pain sub-scale, 78% of the subjects at the 24 month time point would be considered as responders. Similarly, based on improvement in the medial knee pain compared to baseline using the NRS scale of 1-10, 89% of the subjects at the 24-month time point would be considered as responders. Two patients were revised during follow-up: one for arthrofibrosis and one converted to TKA for progression of OA.

CONCLUSIONS

The early clinical experience with the Latella Knee Implant in this pilot feasibility study has been encouraging. It appears to be a safe implant with possible effect on medial OA. Additional studies need to be performed to assess the safety and efficacy of the procedure in a larger patient population.

LEVEL OF EVIDENCE

II.

Benefits of aged garlic extract in modulating toxicity biomarkers against p-dimethylaminoazobenzene and phenobarbital induced liver damage in Rattus norvegicus

Garlic (Allium sativum L.), a popular spice, has been used for decades in treating several medical conditions. Although Allicin, an active ingredient of garlic has been extensively studied on carcinogen-induced hepatotoxicity and oxidative stress in rats (Rattus norvegicus), no systematic study on the beneficial effects of generic aged garlic and specific aged garlic extract-Kyolic has been done. The present study involves rats fed chronically with two liver carcinogens, p-dimethylaminoazobenzene and phenobarbital, to produce hepatotoxicity. The aged garlic extract was characterized by UV-spectra, FTIR, HPLC and GC-MS. Biochemical and pathophysiological tests were performed by keeping suitable controls at four fixation intervals, namely, 30, 60, 90, and 120 days, utilizing several widely accepted toxicity biomarkers. Compared to the controls, remarkable elevation in the activities of lactate dehydrogenase, gamma glutamyl transferase and decline in catalase and glucose-6-phosphate dehydrogenase were observed in the carcinogen fed rats. Daily administration of aged garlic extract, could favorably modulate the elevated levels of various toxicity biomarkers including serum triglyceride, creatinine, urea, bilirubin, blood urea nitrogen except total cholesterol. It also altered the levels of blood glucose, HDL-cholesterol, albumin, AST, ALT, and hemoglobin contents in carcinogen intoxicated rats, indicating its protective potential against hepatotoxicity and oxidative stress in the experimental rats. Down-regulation of Bcl-2 and p53 proteins caused cell cycle arrest and apoptosis in garlic fed group. Kyolic exhibited additional benefits by arresting cell viability of cancer cells. This study would thus validate the use of aged garlic extract in the treatment of diseases causing liver toxicity including hepatocarcinoma.

Appropriateness of metformin prescription for type 2 diabetes mellitus patients with chronic kidney disease (Stages 3-5)

INTRODUCTION

Metformin is the first-line pharmacological therapy for type 2 diabetes mellitus (T2DM). Guidelines recommend metformin to be given at reduced dosages for those with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m² and omitted in those with eGFR<30 mL/min/1.73m². Lactic acidosis is a known complication of those on metformin. This study aimed to determine the appropriateness of metformin prescription in T2DM patients with chronic kidney disease (CKD) stages 3-5 in a tertiary centre in Malaysia.

MATERIALS AND METHODS

A cross-sectional design using retrospective secondary data of T2DM patients on metformin attending nephrology and diabetic clinics in the year 2017. eGFR calculated using the CKD-EPI formula identified those in CKD stage 3-5 defined using the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative criteria. Metformin prescription was considered appropriate when the metformin maximum daily dosage does not exceed 1500 mg in CKD stage 3a and 1000 mg in CKD stage 3b and metformin stopped in CKD stages 4 and 5.

RESULTS

A total of 143 patients were included. Majority were in the elderly age group (62.9%), male (60.8%) and had concurrent hypertension (85.3%). Median HbA1c was 8.3% (67 mmol/mol) with most patients (88.8%) having HbA1c above 6.5% (48 mmol/ mol). Majority (92.3%) were categorised as stage 3 CKD. Eleven (7.7%) subjects had inappropriate metformin prescription. Seven of nine (78%) subjects in CKD stage 4 were on metformin with a maximum daily dose of 500 mg to1000 mg. Three patients had serum lactate measured.

CONCLUSION

The majority of CKD patients had appropriate metformin prescription. However, a considerable number of CKD stage 4 patients continued to be on metformin. The many benefits of metformin may be a reason why it is still continued against recommendations. Only three patients had lactate measured which, although may suggest that lactic acidosis is not a common occurrence, the potential for metformin-associated lactic acidosis especially in those at risk should be considered.

Study on structural atrophy changes and functional connectivity measures in Alzheimer's disease

Alzheimer's disease (AD) is characterized by the progressive accumulation of neurofibrillary tangles associated with amyloid plaques. We used 80 resting-state functional magnetic resonance imaging and 80 T 1 images acquired using MP-RAGE (magnetization-prepared rapid acquisition gradient echo) from Alzheimer's Disease Neuroimaging Initiative data to detect atrophy changes and functional connectivity patterns of the default mode networks (DMNs). The study subjects were classified into four groups (each with n = 20 ) based on their Mini-Mental State Examination (MMSE) score as follows: cognitively normal (CN), early mild cognitive impairment, late mild cognitive impairment, and AD. The resting-state functional connectivity of the DMN was examined between the groups using the CONN functional connectivity toolbox. Loss of gray matter in AD was observed. Atrophy measured by the volume of selected subcortical regions, using the Functional Magnetic Resonance Imaging of the Brain (FMRIB) Software Library's Integrated Registration and Segmentation Tool (FIRST), revealed significant volume loss in AD when compared to CN ( p < 0.05 ). DMNs were selected to assess functional connectivity. The negative connectivity of DMN increased in AD group compared to controls. Graph theory parameters, such as global and local efficiency, betweenness centrality, average path length, and cluster coefficient, were computed. Relatively higher correlation between MMSE and functional metrics ( r = 0.364 , p = 0.001 ) was observed as compared to atrophy measures ( r = 0.303 , p = 0.006 ). In addition, the receiver operating characteristic analysis showed large area under the curve ( A Z ) for functional parameters ( A Z > 0.9 ), compared to morphometric changes ( A Z < 0.8 ). In summary, it is observed that the functional connectivity measures may serve a better predictor in comparison to structural atrophy changes. We postulate that functional connectivity measures have the potential to evolve as a marker for the early detection of AD.

Comparative study on anti-proliferative potentials of zinc oxide and aluminium oxide nanoparticles in colon cancer cells

BACKGROUND AND AIM OF THE STUDY

Use of commercial products containing nanoparticles formulated from zinc oxide (ZnO) and aluminium oxide (Al2O-3) has increased significantly. These nanoparticles are widely used as ingredient in cosmetics, and also in food packaging industry although their toxicity status is yet to be studied. Here, we aimed to explore the effect of zinc oxide nanoparticles (ZnO-NPs) and aluminium oxide nanoparticles (ANPs) in human HT29 colon cancer cell line.

METHODS

In this study, ZnO-NPs were synthesized by chemical method and ANPs synthesized by sol-gel method and were characterized using UV-Vis spectroscopy, X ray diffraction and Transmittance electron microscopy. The effects of ZnO-NPs and ANPs was determined by cell viability, membrane integrity and colony formation potentials.

RESULTS

ZnO-NPs and ANPs inhibit HT29, colon cancer cell proliferation in a dose dependent manner, and affect the membrane potentials and also prevent the colony formation.

CONCLUSIONS

The results suggest that ZnO NPs are found to be more effective than ANPs in reducing colon cancer cell proliferation.

A review on role of ATM gene in hereditary transfer of colorectal cancer

Colorectal cancer found to be the most commonly occurring cancer worldwide which can be prevented by screening and its curable if diagnosed early. Lynch syndrome/HNPCC being an autosomal genetic disease and propensity in forming colorectal cancer is inherited wherein genomic instabilities and epigenetic changes are being the characteristic forms in hereditary cancers. It is very important to determine the polymorphism in several DNA repairing genes such as ATM, RAD51, XRCC2, XRCC3 and XRCC9 to study the risk exploring both the prognosis and the developing of colorectal cancer. The role of ATM gene has been studied which involves in the hereditary transfer of colorectal cancer associated with other related cancers such as stomach, lung and breast cancers. ATM found to be the mutation target and also a modifier gene with more risk of developing the disease by its polymorphism in variant of ATM D1853N. It was identified that ATM gene polymorphism did not drastically change HNPCC age of onset. ATM expression levels were studied and it has been concluded that the complete loss of ATM expression resulted in a propensity of worse survival and no better prognosis with increase in mortality rate. This ATM gene might be considered to be a predicted biomarker in colorectal cancer.

Facile Synthesis and Characterization of ZrO₂ Nanoparticles via Modified Co-Precipitation Method

The crystalline Zirconium oxide (ZrO2) nano particles were synthesized using optimized content of Zirconium nitrate (Zr(NO3)2·3H2O) with varying KOH concentration (0.5, 1 and 1.5 M) by co-precipitation method. The thermal history of the precursor was carefully analyzed through Thermogravimetric (TG/DTA) measurement. The as prepared samples were characterized to ensure structural, functional, morphological, compositional, chemical composition and band gap by X-ray diffractometer (XRD), Fourier transform infrared spectroscopy (FTIR), Laser Raman, scanning electron microscopy (SEM), High resolution Transverse Electron Microscopy (HR-TEM), X-ray photo electron spectroscopy (XPS), EDX, Photo luminescence spectroscopy (PL). The monoclinic structure with space group P21/c has been confirmed from XRD (JCPDS 89-9066). The Zr-O stretching vibration and Zr-O2-Zr bending vibrations were confirmed through FTIR analysis. The well dispersed particles with spherical morphology were confirmed through SEM and TEM analysis. The oxidation states of Zr, O and C were confirmed through XPS analysis. The oxygen vacancies and band gap of the particles were investigated through PL analysis.

C-type natriuretic peptide signalling drives homeostatic effects in human chondrocytes

Signals induced by mechanical loading and C-type natriuretic peptide (CNP) represent chondroprotective routes that may potentially prevent osteoarthritis (OA). We examined whether CNP will reduce hyaluronan production and export via members of the multidrug resistance protein (MRP) and diminish pro-inflammatory effects in human chondrocytes. The presence of interleukin-1β (IL-1β) increased HA production and export via MRP5 that was reduced with CNP and/or loading. Treatment with IL-1β conditioned medium increased production of catabolic mediators and the response was reduced with the hyaluronan inhibitor, Pep-1. The induction of pro-inflammatory cytokines by the conditioned medium was reduced by CNP and/or Pep-1, αCD44 or αTLR4 in a cytokine-dependent manner, suggesting that the CNP pathway is protective and should be exploited further.

Antibacterial activity of various leaf extracts of Merremia emarginata

OBJECTIVE

To investigate the antibacterial activity and phytochemical screening of the aqueous, methanol and petroleum ether leaf extracts of Merremia emarginata (M. emarginata).

METHODS

The antibacterial activity of leaf extracts of M. emarginata were evaluated by agar well diffusion method against four selected bacterial species.

RESULTS

The presence of tannins, flavonoids, amino acids, starch, glycosides and carbohydrates in the different leaf extracts was established. The methanol extract was more effective against Bacillus cereus and Escherichia coli, whereas aqueous extract was more effective against Staphylococcus aureus and Pseudomonas aeruginosa.

CONCLUSIONS

: The results in the present study suggest that M. emarginata leaf can be used in treating diseases caused by the tested organisms.

Protective role of naringenin against doxorubicin-induced cardiotoxicity in a rat model: histopathology and mRNA expression profile studies

Doxorubicin (DOX) is one of the most effective and widely used chemotherapeutic agents. Its efficacy has been proven in various malignancies alone and combined with other cytocidal agents. However, the clinical usefulness of DOX is restricted by the risk of developing congestive heart failure. Formation of free radicals and oxidative stress during DOX treatment may result in adverse side effects. Naringenin (NAR) is one of the potential bioflavonoids with excellent antioxidant properties and free-radical scavenging capability. This study was designed to evaluate whether NAR exerts a protective role against DOX-induced cardiotoxicity in rats. Male Wistar rats were administered DOX (3 mg/kg) intravenously for 10 consecutive weeks along with oral treatment with NAR (50 mg/kg/day). DOX-induced cardiac toxicity was characterized by the marked biochemical alterations of lactic acid dehydrogenase (LDH), troponin T, malondialdehyde (MDA), reduced cardiac enzymatic activities (SOD, GPx, CAT) and histopathological observations. Administration of NAR to DOX-challenged rats ameliorated alterations in biochemical markers. Indeed, DOX increased the mRNA expression levels of TGF-β1, TNF-α, IL-6, and IL-10 compared with the control group. However, cotreatment with NAR attenuated the mRNA expression levels of these inflammatory markers and improved histological cardiac damage and cardiac functions. Thus, supplementation of NAR may be beneficial in reducing DOX toxicity.

Reverse Ponseti-type treatment for children with congenital vertical talus: comparison between idiopathic and teratological patients

Children with congenital vertical talus (CVT) have been treated with extensive soft-tissue releases, with a high rate of complications. Recently, reverse Ponseti-type casting followed by percutaneous reduction and fixation has been described, with excellent results in separate cohorts of children with CVT, of either idiopathic or teratological aetiology. There are currently no studies that compare the outcome in these two types. We present a prospective cohort of 13 children (21 feet) with CVT of both idiopathic and teratological aetiology, in which this technique has been used. Clinical, radiological and parent-reported outcomes were obtained at a mean follow-up of 36 months (8 to 57). Six children (nine feet) had associated neuromuscular conditions or syndromes; the condition was idiopathic in seven children (12 feet). Initial correction was achieved in all children, with significant improvement in all radiological parameters. Recurrence was seen in ten feet. Modification of the technique to include limited capsulotomy at the initial operation may reduce the risk of recurrence. The reverse Ponseti-type technique is effective in the initial correction of CVT of both idiopathic and teratological aetiology. Recurrence is a problem in both these groups, with higher rates than first reported in the original paper. However, these rates are less than those reported after open surgical release.

Strategic approach to breakdown maintenance on construction plant – UAE perspective

Purpose

– The purpose of this paper is to develop a systematic strategic approach to handle corrective maintenance onto the failures/breakdowns of construction equipment. For the maintenance crew/team, a breakdown code management is proposed, which will provide focused and unambiguous approach to manage any kind of breakdowns in construction equipments.

Design/methodology/approach

– The past breakdown records of a construction organization in the UAE are considered for analysis. From the failure data, through cause effect analysis (CEA) tools, the components and the breakdown codes namely breakdown main codes (BMC) and breakdown sub-codes (BSC) are formulated. With Pareto analysis, the critical codes are identified and validated through failure modes and effects analyses (FMEA) tools for the critical effect on the affected components. From this identified BSC's further closer failure identification codes namely breakdown symptom codes (BSyC) and breakdown reason codes (BRC) are identified through fault tree analysis (FTA) tools. The approach to modified breakdown maintenance management (MB2M) with breakdown maintenance protocol (BMP) is envisaged.

Findings

– The study was conducted on four different types of heavy lifting/earth moving/material handling system of equipment and further focused with two earth moving equipment namely dumpers and wheel loaders. Failure analysis is performed and the failure ratio and the component contribution to the failures are identified. Based on the information, the preliminary codes namely BMC and BSC are identified through CEA tools and the BMC and BSC are identified to find the most contributing codes to the maximum number of failures through Pareto analysis. Further the critical sub-codes are further verified through FMEA tools on the severity levels of the sub components due to these codes. The FTA methods are used to identify the closer reasoning and relations of these codes and the further codes namely BSyC and BRC are identified which are the exact cause of the failures. The management of breakdowns is further proposed through MB2M which includes BMP which provides all resources for the breakdowns.

Research limitations/implications

– The failure data collected are only pertaining to the Middle East region and applicable to similar regions for similar plant mix in construction companies. The sample equipment is only part representative of the construction equipment. A more robust model can be suggested in the future covering all aspects and for other regions as well.

Practical implications

– The proposed methodology and model approach is highly adaptable to similar industries operating in the Middle East countries.

Originality/value

– Many authors have studied the preventive maintenance models and procedures and proposals have been proposed. On the breakdown maintenance management of construction equipment, very few studies have been proposed mostly on the cost analysis. This model attempts to provide a code management solution to manage the unpredictable failures in construction equipment through failure data analysis on a construction organization.

Management of developmental dysplasia of the hip in young adults

The term developmental dysplasia of the hip (DDH) describes a spectrum of disorders that results in abnormal development of the hip joint. If not treated successfully in childhood, these patients may go on to develop hip symptoms and/or secondary osteoarthritis in adulthood. In this review we describe the altered anatomy encountered in adults with DDH along with the management options, and the challenges associated with hip arthroscopy, osteotomies and arthroplasty for the treatment of DDH in young adults.

Cite this article: Bone Joint J 2013;95-B:732–7.

Surgical treatment of femoroacetabular impingement in patients with slipped capital femoral epiphysis: A review of current surgical techniques

Slipped capital femoral epiphysis (SCFE) is relatively common in adolescents and results in a complex deformity of the hip that can lead to femoroacetabular impingement (FAI). FAI may be symptomatic and lead to the premature development of osteoarthritis (OA) of the hip. Current techniques for managing the deformity include arthroscopic femoral neck osteochondroplasty, an arthroscopically assisted limited anterior approach to the hip, surgical dislocation, and proximal femoral osteotomy. Although not a routine procedure to treat FAI secondary to SCFE deformity, peri-acetabular osteotomy has been successfully used to treat FAI caused by acetabular over-coverage. These procedures should be considered for patients with symptoms due to a deformity of the hip secondary to SCFE.

Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature

A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations. Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.

The World Health Organization '5 moments of hand hygiene': the scientific foundation

The World Health Organization (WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the '5 moments of hand hygiene' in 2009 in an attempt to reduce the burden of health care associated infections. Many NHS trusts in England adopted this model of hand hygiene, which prompts health care workers to clean their hands at five distinct stages of caring for the patient. Our review analyses the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. We found no strong scientific support for this regime of hand hygiene as a means of reducing health care associated infections. Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively. We recommend caution in the universal adoption of the WHO '5 moments of hand hygiene' by orthopaedic surgeons and other health care workers and emphasise the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.

Arthroscopy of the hip for paediatric and adolescent disorders

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’ disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes.

This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions.

Management of congenital talipes equinovarus using the Ponseti method: a systematic review

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.

Elastic intramedullary nailing of paediatric fractures of the forearm

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

Orthopaedic aspects of paediatric non-accidental injury

Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures.

Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death.

Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.

The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved.

The management of septic arthritis in children

We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children.

Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.

Delaying treatment of supracondylar fractures in children

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure.

This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.