RANDOMIZED COMPARATIVE STUDY OF DEFINITIVE EXTERNAL FIXATION VERSUS ORIF IN PILON FRACTURES: AN EARLY CLINICAL OUTCOME REPORT

Repairing Pilon fractures remains challenging. ORIF allows direct anatomical reduction, but at the expense of soft tissues dissection which are associated with recovery. On the other hand, External Fixation allows indirect reduction and causes less soft tissue damage. However, a few studies conclude that External Fixation is associated with high rates of malunion.The objectives were to evaluate and compare: primary outcome measure: ankle hindfoot function (AOFAS at 9 months) and secondary outcome measures: quality of reduction, bone union, arthritic changes, other potential complications and ultimately the optimum management for pilon fractures.A prospective randomized comparative clinical study. 40 Patients were included in the study with comminuted closed Pilon fracture. Patients were randomized by closed envelope technique into two groups: Group (1) Included 20 patients managed by external fixation with limited internal fixation. Group (2) Included 20 patients managed by open reduction and internal fixation. Skeletally immature, type 43A AO/OTA, Open fractures, compartment syndrome, Pathological fractures were excluded.There was no significant difference between External fixation and ORIF as methods of fixation for Pilon fracture in the functional activity of the patient after 9 months as evidenced by AOFAS score (P=0.547) and the development of complications (P=0.227). However, there was statistically significant difference (P<0.001) regarding the time to weight bearing between both groups, and statistically significant difference (P=0.042) regarding time to union.The best surgical modality to treat Pilon fractures is still debatable. While external fixation is used by many to avoid major complications, it has been associated with high rates of malunion, and osteoarthritis.

A case report of two Moroccan patients with hereditary neurological disorders and molecular modeling study on the S72L de novo PMP22 variant

Hereditary neurological disorders represent a wild group of hereditary illnesses affecting mainly the nervous system, the majority of which have a Mendelian inheritance pattern. Here we present the case of two Moroccan patients each affected by a different hereditary neurological disorder. In the first patient WES analysis revealed the presence of the p.Ser72Leu de novo mutation in the PMP22 gene reported for the first time in Africa, specifically in Morocco. This variant is predicted to be in a mutation "hot-spot" region causing Dejerine-Sottas syndrome called also Charcot-Marie-Tooth type 3. The molecular modeling study suggests an important alteration of hydrogen and hydrophobic interactions between the residue in position 72 of the PMP22 protein and its surrounding amino acids. On the other hand, the p.Ala177Thr mutation on the RNASEH2B gene, responsible of Aicardi-Goutières syndrome 2, was carried in a homozygous state by the second patient descending from a consanguineous family. This mutation is common among the Moroccan population as well as in other North African countries. The present results contributed to a better follow-up of both cases allowing better symptom management with convenient treatments.

Current concepts in the management of radial head fractures: a national survey and review of the literature

INTRODUCTION

This study aims to report on current practice in the management of radial head fractures (RHFs) in the United Kingdom and to review the literature to identify areas for future investigation.

METHODS

A 12-question online survey was sent to 500 surgeon members of the British Elbow and Shoulder Society in 2021. Questions focused on clinical assessment, indications for surgical treatment and willingness to participate in future studies. Descriptive statistical analysis summarised the responses.

RESULTS

The response rate was 20.4% (n = 102). For minimally displaced RHFs, non-operative management with immediate mobilisation was reported by 90.2% (n = 92) as opposed to 9.8% (n = 10) for initial immobilisation in plaster or brace. The most cited indication for radial head arthroplasty as opposed to fixation was increased patient age or low functional demand in 69.9% of responses (n = 71). In total, 41.2% (n = 42) indicated the need for a future randomised controlled trial (RCT) concerning the management of RHF. Only five RCTs were returned by the literature review.

DISCUSSION

There is considerable variability in the management of RHF among an experienced cohort of surgeons. With the interest declared by the participating surgeons, there is a call for a well-designed sufficiently powered RCT.

Use of photosensitizers activated by photodynamic therapy on the canal disinfection of radicular dentin bonded to Dimethacrylate-based glass fiber post: an assessment of pushout bond strength

OBJECTIVE

The present lab-based investigation aimed at evaluating the canal disinfectants using photodynamic therapy (PDT) using different photosensitizers, conventional NaOCl, a mixture of doxycycline, citric acid, and a detergent (MTAD) and their impact on the bond strength of glass fiber post to radicular dentin.

MATERIALS AND METHODS

Forty extracted human premolars were gathered and disinfected. The decoration was performed up to the cementoenamel junction. Using the crown down technique cleaning of the canal was done following rinse with distilled water. All canals were dried with paper points and obturated with gutta-percha. Post space was prepared using peso reamers and samples were randomly allocated into four groups following different disinfection regimes: Group 1 - Methylene blue photosensitizer (MBP) + MTAD; Group 2 - RBP (Rose Bengal photosensitizer) + MTAD; Group 3 - CP (curcumin photosensitizer) + MTAD and Group 4 - 2.25% NaOCl + MTAD (control). Following disinfection, the canals were dried and the post was placed and cemented within the canal. Samples were dissected at coronal, middle, and apical third and placed in a universal testing machine for push-out bond strength (PBS). Debonded surfaces were evaluated for failure modes. PBS was examined using a one-way analysis of variance (ANOVA). The means of PBS were compared using Tukey multiple comparison tests with a significance threshold of (p<0.05).

RESULTS

Group 3 canals disinfected with CP and MTAD had the highest PBS at two levels: cervical (9.57±1.21 MPa), middle (6.37±0.79 MPa), and group 2 canal space disinfected by RBP and MTAD had the maximum PBS in apical portion (5.35±0.42 MPa). No significant difference at all root levels between group 2 (RBP + MTAD) and group 3 (p>0.05). Canal irrigation with group 1 (MBP + MTAD) and group 4 control (2.25% NaOCl + MTAD) exhibited comparable PBS at all three levels of the root.

CONCLUSIONS

CP, MTAD, RBP and MTAD for canal disinfection and bonding of glass fiber post to radicular dentin demonstrated comparable bond values at all three root levels and can be recommended in clinical settings after further investigations.

The correlation between coronary artery disease and left ventricular filling pressure: which correlates more LVEDP or LV pre-A wave?

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and Uneversity Heart Surgery Center, Damascus, Syrian Arab Republic.

Background

Coronary artery disease (CAD) affects left ventricular (LV) systolic and diastolic function. This  results in high filling pressure which expressed by different waves and may be assessed by invasive and noninvasive methods. Validation and comparing the correlation between CAD and different LV filling pressure waves may add a step forward in CAD diagnosis, prognosis and treatment.

Purpose

This study invasively validates the correlation between coronary artery disease (CAD) and left ventricular end-diastolic pressure (LVEDP) as well as left ventricular pre-A wave (LV pre-A wave) and compare the results.

Methods

124 patients who accepted to participate for this study underwent left heart catheterization for medical indications. This study obtained the results of LV filling pressures (LVEDP and LV pre-A wave), as well as, coronary angiography results with assessing the severity and extents (if CAD presents) by vessels number and Gensini Score (GS). Spearman r correlation were used for continuous/continuous or continuous/ordinal variables and Chi square test for nominal/nominal variables. Then we compared the results.

Results

CAD presence with elevated LVEDP incidence (OR = 4.29, relative risk = 1.85 P = 0.0123). Vessel number, plaque number and Gensini score correlations with LVEDP were (P = 0.0038 r = 0.34, P = 0.0002 r = 0.44, p = 0.0002 r = 0.43 and p = 0.0622 r = 0.22) respectively. In the same way, CAD presence with LV pre-a wave (OR = 2.75, relative risk = 1.5, P = 0.0447). Vessels number, plaque numbers and Gensini score relations with LV pre-A wave were (P = 0.0379 r = 0.23, P = 0.0004 r = 0.39, p = 0.0002 r = 0.40 and p = 0.0568 r = 0.21) respectively. All the results are summarized in Tables (1 + 2+3).

Conclusions

LV filling pressure had a significant correlation with CAD presence, vessel number and plaque number but it did not have a correlation with Gensini score. LVEDP had a stronger correlation with CAD presence, severity, sensitivity and extent but lower specificity than LV pre-A wave. Abstract Tables of results (1 + 2)  Abstract Table of result 3

A check of the grading system among the 2009 and 2016 EACVI/ASE left ventricular diastolic function guidelines statistically and invasively

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Left ventricular diastolic function assessment undergoes continuous updates. EACVI/ASE 2016 guidelines handles with this case, which is an expert consensus and simplified update of the 2009 recommendations. As stated in the latest guidelines, studies need to check that the simplicity does not affect much the accuracy.

Aim

This study compares the corresponding subgroups between the 2009 and 2016 EACVI/ASE guidelines, for the assessment of left ventricular diastolic function statistically. Furthermore, it invasively validates of the relation between the grading results of each guidelines and  the measured LV filling pressure during catheterization lab.

Methods

124 patients underwent transthoracic echocardiography just before angiography. A trained echo cardiographer obtained E/A mitral flow, Av E/e", LAVI, TR, septal and lateral e" and other supportive parameters to assess LV diastolic function and filling pressure according to 2009 and 2016 EACVI/ASE guidelines algorithms and we compared the results with LV pre-a wave during catheterization with a cut-off &gt;12mmhg considered elevated.

Results

EACVI/ASE 2016 resulted in {normal (46.77%), Grade I (29.03%), Grade II (10.48%), Grade III  (7.26%) and indeterminate (6.45%)}, while EACVI/ASE 2009 resulted in {normal (39.52%), Grade I (25%), Grade II (13.71%), Grade III  (7.26%) and indeterminate (14.52%)} with no statically significant difference between subgroups. EACVI/ASE 2016 vs. 2009 in assessment LV filling pressure (odds ratio =0.51 and p value = 0.034. EACVI/ASE 2016 sensitivity and specificity were (0.36, 0.94 ) respectively and EACVI/ASE 2009 sensitivity and specificity were (0.63, 0.80) respectively. All results are summarized in (tables: 1 + 2+3 + 4+5 + 6).

Conclusion

This study found that the updated and simplified 2016 EACVI/ASE guidelines algorithm did not affect statistically the grading results of 2009 EACVI/ASE. Even more, 2016 had a higher relation between diastolic subgroups and invasively measured LV filling pressure which reflects the higher specificity than 2009. On the other hand 2016 was less able to detect elevated LV filling pressure which reflects a lower sensitivity than 2009. 2016 was more specific but less sensitive than 2009. There were no statistically significant difference between the means of invasively measured LV filling pressures among both guidelines. Abstract Figure.  Abstract Figure.

Invasive validation of the different echo parameters and cut-offs among the trilogy of left ventricular filling pressure assessment guidelines: EACVI/ASE 2016, ESC 2016, HFA 2019

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Left ventricular filling pressure assessment is a challenge. Three guidelines concerned about this are: EACVI/ASE 2016, ESC 2016 and the HFA 2019 guidelines. Echo assessment is a corner stone in their algorithms with different cutoffs and different parameters used depending on expert consensus that should be validated in an invasive manner as the authors stated.

Aims

This study validates and tests the accuracy of the different cutoffs and parameters used in echo LV filling pressure assessment in the three guidelines: EACVI/ASE 2016, ESC 2016 and HFA 2019 by direct measure in the catheterization lab.

Methods

82 patients with EF ≥ 50%, signs and symptoms of HF underwent transthoracic echocardiography immediately before catheterization. Av E/e", TR, LAVI, LVMI, RWT, LV wall thickness, Septal, lateral and mean e" were used to assess LV filling pressure with respect to EACVI/ASE 2016, ESC 2016 and HFA guidelines algorithms" different cutoffs and  parameters used. This study used LV pre-A wave with a cutoff &gt;12mmhg defined high as a reference and then we compared the results.

Results

all the results of functional and structural echo parameters" diagnostic criteria (sensitivity, specificity, NPV, PPV and accuracy) are summarized in (Table:1 + 2).

Conclusion

From an echo view, each algorithm depends on  modest to high specific but low to modest sensitive echo parameters. There is no single parameter makes a guidelines superior to others. Although that the fact of combining more echo indices make the diagnosis and eventually the algorithm more reliable as in HFA 2019, that was for the cost of simplicity and ease of application. Av E/e"&gt;13 was the best cutoff (ESC 2016). Orientation for the cause of use (sensitivity, specificity, NPV or PPV) should employ the echo indices and cutoffs in best benefit, as for mitral (e"), although that septal &lt; 7 and lateral e"&lt;10 (EACVI/ASE 2016 and HFA 2019) had an overall more accuracy than mean e"&lt;9 (ESC 2016), sub analysis showed that the first is better used for specificity and NPV but the latter better for sensitivity and PPV. Same idea for LVMI≥145/122 (m/f)+RWT &gt; 0.42 (HFA 2019 major criteria) which had more specificity than LVMI≥115/95 (m/F) cutoffs (HFA2019 minor criteria and ESC2016) but in the cost of lower sensitivity, furthermore, sub analysis showed this LVMI high cutoffs were more benefit in female than in men after taking the NPV, PPV and accuracy in consideration. Abstract Figure.  Abstract Figure.

The correlation of ESC 2016 diastolic guidelines with invasively measured left ventricular filling pressure

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital, University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

left ventricular (LV) diastolic function and filling pressure assessment is a challenge. ESC 2016 diastolic guidelines handles with this issue. Validation of and comparing the correlation between this guidelines and invasively measured different waves may add a step forward in the assessment, prognosis and treatment of LV diastolic function by echo.

Purpose

this study validates of the correlation of ESC 2016 left ventricular filling pressure echo guidelines with invasively measured left ventricular end-diastolic pressure and left ventricular pre-a.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography immediately before left heart catheterization. This study obtained echo parameters to assess LV filling pressure according to ESC 2016 algorithms. It also obtained left ventricular end-diastolic pressure (LVEDP) and LV pre-a waves during catheterization. It analyzed the data and compared the results.

Results

Correlations of grading system (normal, abnormal parameters 1,2 and 3 present) with LV pre-a and LVEDP waves were (P= &lt; 0.0001 r = 0.47, P = 0.0027 r = 0.41), respectively. After excluding group of patients with only one abnormal parameter as indeterminate group, pressure assessment guidelines correlations with the presence of LV pre-a and LVEDP waves were (P = 0.0009 OR = 31.76, p= 0.0170 OR = 36.00), respectively. Means difference of LV pre-a and LVEDP waves between pressure guidelines presence and absence two groups were (LV pre-a: 12.72, 7.52, P &lt; 0.0001and LVEDP: 21.03 10.36, P = 0.0043), respectively. All results are summarized in (Table:1 + 2+3 + 4+5).

Conclusion

ESC 2016 guidelines pressure assessment correlated strongly with both LV pre-a and LVEDP waves which means that the higher the number of abnormal echo parameters is resulted by echo guidelines, the higher the LV pre-a or LVEDP is presented invasively. Different approaches had different diagnostic accuracy, the best specific was cutoff≥ 2 abnormal echo parameters and the best sensitive and overall accuracy was still cutoff≥2 but after excluding only one abnormal echo parameter group as indeterminate group. The difference between means between echo guidelines pressure assessment was more significant statistically in LV pre-a wave than in LVEDP. Abstract Figure. Abstract Figure.

A comparison between left ventricular filling pressure two waves: end-diastolic and pre-a for the correlation with echocardiographic parameters

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital, University Heart Surgery Center Damascus, Syrian Arab Republic.

Background

left ventricular (LV) filling pressure has an important prognostic and therapeutic role. Echocardiography plays an essential noninvasive role in its assessment and diagnosis. Checking of the correlation between echo parameters and different LV filling pressure wave invasively measure may add a step forward in its diagnosis, prognosis and treatment.

Purpose

this study invasively measures left end-diastolic pressure (LVEDP) and left ventricular pre-a wave (LV pre-a wave) and validates the correlation of each wave with echo parameters obtained immediately before angiography.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography just before catheterization. E/A, Av E/e", lateral and septal e", TR. LAVI, S/D, AR-A and other parameters were obtained to validate and compare the correlation with LVEDP and LV pre-a wave.

Results

  Correlation of different echo parameters with LVEDP and LV pre-a wave are summarized in table.

Conclusion

Among these echo parameters of this study, there was a significant correlation between LVEDP and E, E/A, TR, S velocity, S/D, AR duration, AR-A duration and LVMI. LV pre-a wave had a significant correlation with LAVI, EF, FS, Av E/e", E velocity, A velocity, E/A, TR, S velocity, S/D, AR duration, AR-A duration, LVDd, RWT, LVDs and LVMI. LVEDP correlated more than LV pre-a wave with S velocity, S/D, AR duration, AR-A duration and LVMI. LV pre-a wave correlated more than LVEDP with TR and E velocity. E/A was equally correlated with LVEDP and LV pre-a wave. Abstract Table of results 1  Abstract Table of results 2

An echocardiographic algorithm for predicting coronary artery disease: is it time to establish one?

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Coronary artery disease (CAD) is a major clinical issue. CAD affects left ventricular systolic, diastolic function and LV filling pressure. Echocardiography has been known as the best noninvasive way for the assessment of systolic, diastolic function and LV filling pressure. Finding a correlation between CAD and echocardiographic parameters may help in the early assessment, prognosis and treatment of CAD.

Purpose

Finding a correlation between coronary artery disease and echocardiographic parameters with cutoffs to use in a diagnostic algorithm.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography immediately before their medically indicated left heart catheterization . An experienced echo cardiographer obtained mitral flow E velocity, A velocity, E/A, A duration, Av E/e", septal, lateral and mean e", pulmonary veins S velocity, D velocity, S/D, AR velocity, AR duration, AR-A duration, left atrial volume index (LAVI), tricuspid regurgitation (TR), inter ventricular septum (IVS), left inter ventricular diameter (LIVD), posterior wall diameter (PW) and some other echo parameters and assessed LV diastolic function and filling pressure according to EACVI/ASE 2016 guidelines. This study obtained angiography results and then analyzed and compared the results.

Results

Echo parameters that correlated with CAD were: EDT ≥ 160 (P = 0.0012 OR = 5.46), Av E/e" ≥ 7 (P = 0.0066 OR = 3.67), E ≥ 44 cm/s (P = 0.0026 OR = 10.00), A duration &gt; 140 (P = 0.0256 OR = 10.50), E/A ≥ 1 (P = 0.0036 OR = 4.17) and AR duration ≥ 210 (P = 0.0001 OR = 85.00). When Cutoffs ≥ 3 present, the correlation with CAD was (P= &lt; 0.0001 OR = 8.80) with diagnostic accuracy of (sensitivity = 0.76, specificity = 0.74, NPV = 0.68, PPV = 0.81). All the results are summarized in (Picture1:Tables 1 and 2).

Conclusion

Echo parameters (EDT, Av E/e", E velocity, A duration, E/A, AR duration) had strong correlations with the presence of coronary artery disease. The presence of three or more abnormal parameters had a significant diagnostic accuracy for CAD, and the more the abnormal parameters were positive, the higher the specificity and positive predictive value were for the diagnosis of CAD. The presence of only two abnormal parameters had a low specificity for CAD and the presence of 2016 EACVI/ASE diastolic dysfunction correlated with CAD with modest specificity which needs further assessment for the differential diagnosis. Furthermore, one or no abnormal parameters ruled out CAD with strong negative predictive value. Depending on the results of this study we kindly propose a resting echocardiographic algorithm for the diagnosis of CAD in (picture2: a proposed algorithm). Further studies should validate this algorithm and find other echo parameters especially strain echocardiography wether for resting or exercise algorithms. Abstract Tables of results  Abstract Figure. A proposed algorithm

Comparison between the British and the American/European guidelines for the assessment of left ventricular diastolic function with invasive validation of left ventricular filling pressure

Background

Left ventricle diastolic function and filling pressures assessment is still a major challenge to echocardiographer. There are two echo guidelines regarding this issue: the British Society of Echocardiography (BSE 2013) and the American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI 2016). The 2016 guidelines, which is an expert consensus and simplified update of 2009 guidelines, needs an invasive validation according to its authors. Recent studies raised questions about the diagnostic accuracy as sensitivity results varied very widely (34% to 87%) and also that of 2009 (43% to 79%). This study validated the diastolic pressure invasively in the cath lab and compared the results with the echo guidline algorithms were done immediately before the catheterization. When possible, it included additional assessment of S/D and Ar-A duration.

Purpose

Validation of the diagnostic accuracy of the 2009, the updated 2016 ASE/EACVI and 2013 BSE echocardiographic LV filling pressure predicting algorithms, as well as pulmonary veins flow (S/D) and (Ar-A) durations with invasively measured LV-pre-A wave.

Methods

124 patients (58.06% males) underwent transthoracic echocardiography immediately before left heart catheterization. A trained echocardiographer obtained E/A mitral flow, E/e', left atrial volume index, TR, EDT, lateral and septal e' to estimate LV filling pressure as normal, elevated or indeterminate using the 2009, 2016

ASE/EACVI algorithms and 2013 BSE algorithm. He also obtained Secondary parameters as (S/D) and (Ar-A) duration. Invasive LV pre-A pressure was the reference of this study, with &gt;12 mm Hg defined as elevated.

Results

Invasive LV pre-A pressure was elevated in 60 (48.38%) patients. When they could determine LV filling pressure, 2016 sensitivity was 0.36 and specificity 0.94, 2009 had 0.56 sensitivity and 0.90 specificity and 2013 resulted in 0.63 sensitivity and 0.80 specificity. Results of diagnostic accuracy of each algorithm as well as (S/D) and (Ar-A) summarized in tables associated in (picture 1: Tables of results). EDT≥150 msec raised NPV in normal, grade one diastolic dysfunction and indeterminate pressure.

Conclusion

2016 was the most specific but the least sensitive with modest NPV and PPV between the 2013 and 2009. 2013 was the most sensitive with the highest indeterminate pressure rate to execlude. Adding S/D or Ar-A duration markedly improved the sensitivity and reduced class indeterminate among all algorithms with more benefit when both combined. EDT had a rule out role in normal, grade one diastolic dysfunction and indeterminate pressure patients. We kindly propose a modification of 2016 algorithm by adding S/D, Ar-A and EDT as optional parameters to increase sensitivity and reduce indeterminate class without affecting simplicity or specificity (picture 2: Proposed algorithms A+B). We recommend future studies to validate the diagnostic accuracy of the proposed algorithms.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Al mouwasat University Hospital and University Heart Surgery Center at Damascus, Syrian Arab Republic. Tables of resultsProposed Algorithms A+B

DSPECT-specific normal limits for LV measurements: a new approach to derivation

Funding Acknowledgements

Type of funding sources: None.

Background

Differences in spatial resolution and image filtering between the solid-state DSPECT and traditional Anger SPECT (A-SPECT) cameras are likely to result in differences in LV measurements. However, DSPECT- specific normal values have not been systematically derived. We used healthy organ-donor subjects from our high-volume solid organ transplant center for derivation of normal values.

Purpose

To report DSPECT-specific LV measurements normal limits derived from a unique cohort of donor subjects.

Methods

Subjects were 92 consecutive kidney or liver donors who underwent single day rest (5 mCi)- stress (15mCi) Tc-99m sestamibi gated SPECT myocardial perfusion imaging (MPI) on the DSPECT for pre-operative evaluation. Exclusion criteria included any cardiac disease or medications. LV measurements were made on the post-stress supine stress images using QGS®.

Results

Of 92 subjects (mean age 54.4 ± 15.0 and 39% men), mean EF for women and men were 77.2 ± 14.1% and 70.0 ± 14.7%, respectively. Mean end-diastolic volume for women and men were 67.0 ± 32.2 ml and 99.6 ± 51.6 ml (indexed 38.3 ± 17.2 ml/m2 and 48.1 ± 25.9 ml/m2), respectively. Mean LV wall volume for women and men were 95.9 ± 26.0 ml and 112.0 ± 48.8 ml (indexed 55.0 ± 13.8 ml/m2 and 54.1 ± 24.6 ml/m2), respectively.

Conclusion

We report DSPECT-specific LV measurements from normal subjects from which limits of normality can be derived for clinic use. Organ-donors who undergo pre-operative MPI are a suitable cohort for the derivation of normal values.

Thalamic versus midbrain tremor; two distinct types of Holmes' Tremor: a review of 17 cases

INTRODUCTION

Holmes Tremor (HT) is a unique and debilitating movement disorder. It usually results from lesions of the midbrain and its connection but can also result from posterior thalamic injury. Clinical examination can help lesion localization between these two areas. We studied the clinical features and their radiological correlations to distinguish midbrain HT (HT-m) from thalamic HT (HT-t).

METHODS

Retrospective review of 17 patients with a HT-type presentation was conducted. Tremor characteristics, associated clinical signs and radiological findings were studied.

RESULTS

Eleven patients had a myorythmic rest tremor, large amplitude proximal tremor with goal-directed worsening, with or without mild distal dystonic posturing, representing HT-m. Six patients had slow, large amplitude proximal tremors and distal choreathetoid movements, significant proximal/distal dystonic posturing, associated with proprioceptive sensory loss, representing HT-t. Haemorrhagic lesions were the predominant cause of HT-m; whereas, ischaemia was more commonly associated with HT-t.

CONCLUSION

When assessing patients with HT, attentiveness to the presence of associated signs in the affected limb, such as a proprioceptive sensory deficits and additional movement disorders, can aid lesion localisation, which can have implications for management.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS)

Background

There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems.

Methods

Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence.

Results

Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1).

Conclusions

Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

Intensive home treatment in comparison with care as usual: Cost-utility analysis from a pre-randomized controlled trial in the netherlands

Introduction

The implementation of Intensive Home Treatment (IHT) aims to decrease the pressure on acute inpatient services that could lead to prevent hospitalization and reduce the number of hospitalization days and, ultimately, reduce cost in the mental health services. Although there are studies assessing the effectiveness of IHT, there is a shortage of research studying the cost-effectiveness.

Objectives

The aim of this study is to present an cost-utility analysis of IHT compared to care as usual (CAU)

Methods

Patients between 18 and 65 years of age whose mental health professionals considered hospitalization were included. These patients were pre-randomized in either IHT or CAU and followed up for 12-months. For this study, the base case analysis was performed from the societal and healthcare perspective. For the cost-utility analyses the Euroqol 5D was used to calculate quality adjusted life years (QALYs) as a generic measure of health gains.

Results

Data of 198 patients were used. From a sociatal perspective, the cost-utility analysis resulted in an incremental cost-effectiveness ratios (ICERs) of €58 730, and a 37% likelihood that IHT leads to higher QALYs at lower costs. The probability of IHT being cost-effective was >50% if there was no willingness to pay more for extra QALY than in the current situation under CAU.

Conclusions

Professionals working in crisis care are able to offer IHT with the same effect as other crisis care interventions at lower costs. IHT seem to be cost-effective compared with CAU over 52 weeks follow-up for patients who experience psychiatric crises.

Disclosure

No significant relationships.

In vitro haemostatic efficacy of aqueous, methanol and ethanol plant extracts of three medicinal plant species in Palestine

Abstract The haemostatic efficacy of different extract types of Satureja thymbra L., Thymbra spicata L. (Lamiaceae) and Verbascum fruticulosum Post. (Scrophulariaceae) was evaluated in this study via the Prothrombin time (PT) and Activated partial thromboplastin time (aPTT) analysis. Aqueous, methanol and ethanol extracts of the examined plant species leaves were prepared to a final concentration 50 mg/mL. In vitro PT and aPTT assays were conducted on normal platelet poor plasma blood samples by a digital coagulation analyzer. The obtained results revealed anticoagulation activity of all investigated plant species with observed variations among them. The aqueous and ethanol extracts of T. spicata as well as the aqueous extract of S. thymbra prolonged PT values significantly (p < 0.05). While, all V. fruticulosum extract types have had no significant effect on the PT values. The recorded aPTT data showed that all aqueous extracts have had a significant effect on the blood haemostasis as they increased aPTT values in all plant species under study. Out of which, both the ethanol and methanol extracts of T. spicata and methanol extract of S. thymbra showed similar effect. Of great concern, it was clearly noticed that the aqueous and ethanol extract of T. spicata and the aqueous extract of S. thymbra possess the strongest anticoagulation effect as they increased both PT and aPTT values significantly relative to the control (p < 0.05). The variable anticoagulation bioactivity among the studied plant species could be referred to the various solvents degrees of solubility of different phyto-constituents. Thus, the efficacy of the plant species extracts evaluation as anticoagulants or coagulants were related to the plant species and to the solvent of extraction.

Are positive-pressure ventilation lobby rooms effective for protective and source isolation?

High-efficiency particulate air supplied to a positive-pressure ventilation lobby (PPVL) in isolation rooms offers the dual advantage of protective and source isolation. This study demonstrates the in-use validity of PPVL rooms for protective isolation of patients. Of the 48 PPVL air samples investigated, Aspergillus fumigatus was detected from only one (2%) sample. Local and remote monitoring of the PPVL rooms is essential for the safety of patients and healthcare workers. Remote and point-of-use engineering controls are essential for ongoing ventilation monitoring, but this should be complemented by visual inspection of the isolation suite. Periodic microbiological monitoring should also be considered with other control measures.

Computational studies of 2-(4-oxo-3-phenylthiazolidin-2-ylidene)malononitrile

The molecular structure of the 2-(4-oxo-3-phenylthiazolidin-2-ylidene) malononitrile (3) is calculated using DFT B3LYP/6-311G(d, p) method. The calculated geometric parameters are in good agreement with the experimental data. The NBO calculations were performed to predict the natural atomic charges at the different atomic sites and study the different intramolecular charge transfer (ICT) interactions occurring in the studied system. The BD(2)C17-C19 → BD*(2)C14-C15, LP(2)O2 → BD*(1)N5-C9 and LP(1)N5 → BD*(2)C10-C11 ICT interactions causing stabilization of the system by 23.30, 30.63 and 52.48 kcal/mol, respectively. The two intense electronic transition bands observed experimentally at 249 nm and 296 nm are predicted using the TD-DFT calculations at 237.9 nm (f = 0.1618) and 276.4 nm (f = 0.3408), respectively. These electronic transitions are due to H-3 → L (94%) and H → L (95%) excitations, respectively.

Two year outcome in treatment-naive patients with neovascular age-related macular degeneration (nAMD) using an individualized regimen of Aflibercept

PURPOSE

To evaluate the 2 year visual and anatomical results of intravitreal aflibercept injection (IAI) in nAMD in treatment-naive eyes in real life using a flexible regimen combining a PRN and modified treat-and-extend (TAE) regimen.

PATIENTS AND METHODS

This is a retrospective study including 48 eyes of 38 patients with nAMD treated with aflibercept as first line therapy. The modified T&E protocol consisted of a loading phase with 3 monthly IAI followed by an adaptation phase during which patients were monitored and treated as needed at the same visit from week 12 to week 32, then a T&E phase per se, for which the treatment interval was determined based on history of disease recurrence.

RESULTS

A total of 48 eyes were included. Visual acuity at baseline was 57.3±16 letters. Visual gain was 6±12 letters at 1 year and 5.2±11 letters at 2 years. At the 2-year end point, 94.3% of eyes maintained visual acuity and 71.4% of eyes had ≥70 letters. Reduction of central macular thickness, macular volume and pigment epithelium detachment height was observed after the loading phase, at 1 and 2 years compared to baseline. Complete resolution of fluid was obtained in 78% of eyes after the loading phase, in 68% of eyes at 1 year and in 62.8% of eyes at 2 years. Subfoveal choroidal thickness remained stable during the study. The surface area of the neovascular lesion was reduced at 1 year. The mean number of IAI was 6 IVT (3-11) during the first year and 3.2 IVT (0-13) during the second year.

CONCLUSION

Aflibercept is effective in real life in treatment-naive eyes at two years. A personalized regimen of IAI for neovascular AMD produced good functional and anatomical outcome over 2 years, with a lower number of injections than in the pivotal studies.

Synthesis of CoFeO mixed oxides via an alginate gelation process as efficient heterogeneous catalysts for lignin depolymerization in water

CoFeO mixed oxide, an efficient catalyst for lignin depolymerization in water to functional phenols.

Valorization of algal waste via pyrolysis in a fixed-bed reactor: Production and characterization of bio-oil and bio-char

The aim of the present work is to develop processes for the production of bio-oil and bio-char from algae waste using the pyrolysis at controlled conditions. The pyrolysis was carried out at different temperatures 400-600°C and different heating rates 5-50°C/min. The algal waste, bio-oil and bio-char were successfully characterized using Elemental analysis, Chemical composition, TGA, FTIR, ¹H NMR, GC-MS and SEM. At a temperature of 500°C and a heating rate of 10°C/min, the maximum yield of bio-oil and bio-char was found to be 24.10 and 44.01wt%, respectively, which was found to be strongly influenced by the temperature variation, and weakly affected by the heating rate variation. Results show that the bio-oil cannot be used as bio-fuel, but can be used as a source of value-added chemicals. On the other hand, the bio-char is a promising candidate for solid fuel applications and for the production of carbon materials.

Simultaneous detoxification and bioethanol fermentation of furans-rich synthetic hydrolysate by digestate-based pyrochar

Pyrolysis is a sustainable pathway to transform renewable biomasses into both biofuels and advanced carbonaceous materials (i.e. pyrochar) which can be used as adsorbent of furan compounds. In particular, the aim of this study was to: i) evaluate the effect of vibro-ball milling on physical characteristics of pyrochar and its consequent performance on solely detoxification of a synthetic medium, containing furans and soluble sugars; ii) study the simultaneous detoxification and bioethanol fermentation, by adding activated pyrochar into fermentation medium. Results demonstrated that, compared to untreated pyrochar, the use of milled pyrochar increased by 52% furfural removal from the synthetic medium. Furfural removal rate was also increased (adsorption kinetic constant increased from 0.015 min^-1 up to 0.215 min^-1), at a pyrochar loading of 40 g L^-1. Although, the simultaneous addition of pyrochar into the fermentation medium did not improve the bioethanol yield of the synthetic medium, it has significantly increased the bioethanol production rate.

Detection of influenza B viruses with reduced sensitivity to neuraminidase inhibitor in Morocco during 2014/15 season

We monitored phenotypic and genotypic susceptibility of influenza viruses circulating in Morocco during 2014-2015 to oseltamivir and zanamivir. Throat and nasal swab specimens were collected from outpatients (with influenza-like illness) and inpatients (with severe acute respiratory illness) and tested for influenza viruses using real-time reverse transcription polymerase chain reaction. Positive samples were inoculated in MDCK cells and virus phenotypic susceptibility to neuraminidase inhibitors (NAIs) was assessed using fluorescent NA inhibition. Of 440 specimens, 135 were positive for influenza B Yamagata-like virus, 38 were A(H1N1)pdm09 and 25 were A(H3N2). Sixty influenza B viruses isolated from MDCK cells showed no significant resistance to NAIs. However, two of these strains, B/Morocco/176H/2015 and B/Morocco/CP10/2015, showed reduced susceptibility to oseltamivir. The two influenza B viruses with reduced susceptibility to oseltamivir show that ongoing NAI susceptibility surveillance is essential.

Circulation of Respiratory Syncytial Virus in Morocco during 2014-2016: Findings from a sentinel-based virological surveillance system for influenza

Respiratory syncytial virus (RSV) is a leading cause of mortality and morbidity in young infants, little was known on its circulation types and patterns in Morocco. We conducted a prospective study using sentinel-based influenza surveillance to detect RSV by real time PCR in patients with acute respiratory infections, enrolled during two seasons (2014/15, 2015/16). During September 2014-April 2016, we obtained 1450 specimens, of which 267(18.4%) tested positive for RSV. The proportion of positive RSV infection was higher in patients hospitalized with acute respiratory infection compared to those with mild symptoms in out-patient clinics. The proportion of RSV infection was highest in children aged 0-6 months (45%; P < 0.001). Higher positivity rate was observed between months of December and March. RSV remains important viral etiological agent causing influenza-like illness and severe acute respiratory infections especially among infants in Morocco. Further surveillance, is required to understand better the risk factors of RSV infections.

Association analysis of APOA5 rs662799 and rs3135506 polymorphisms with obesity in Moroccan patients

The aim of the present study is to explore the association between the APOA5 polymorphisms and haplotypes with obesity in Moroccan patients. The study was performed in 459 subjects, Obese (n=164) and non-obese (n=295). All subjects were genotyped for the APOA5 -1131T>C (rs662799) and c.56C>G (rs3135506) polymorphisms. The contribution of APOA5 polymorphisms and haplotypes in the increased risk of obesity were explored using logistic regression analyses. The -1131T>C and c.56C>G polymorphisms were significantly associated with obesity. Both polymorphisms were strongly associated with increased BMI. Analysis of constructed haplotypes showed a significant association between CG haplotype and susceptibility to obesity (OR [95%CI]=3.09 [1.93-4.97]; P<0.001). These results support a potential role for APOA5 common variants and related haplotypes as risk factors for obesity.

Bioethanol fermentation as alternative valorization route of agricultural digestate according to a biorefinery approach

This study investigates the feasibility of producing bioethanol from solid digestate after a mechanical fractionation (i.e. centrifugal milling), in order to improve the energy recovery from agricultural wastes and the sustainability of anaerobic digestion plants. A bioethanol yield of 37gkg(-1)TS was evaluated for the solid digestate fraction. Mass and energetic balances were performed and compared between two scenarios: (A) one-stage bioethanol fermentation and (B) two-stage anaerobic digestion-bioethanol fermentation, in order to evaluate the feasibility and the advantages of the two-stage process. Results revealed that, compared to the one-stage process, the dual anaerobic digestion-bioethanol process permitted: (i) to diversify biofuels production; (ii) to provide the thermal energy sufficient for drying digestate (13,351kWhthday(-1)), for the subsequent milling step; (iii) to reduce the electric energy requirement for the milling step (from 23,880 to 3580kWhelday(-1)); (iv) to produce extra electrical energy of 8483kWhelday(-1); (v) to improve the reduction of waste streams generated (from 13% to 54% of organic matter removal).

Compound heterozygous SLC29A3 mutation causes H syndrome in a Moroccan patient: A case report

H syndrome is an autosomal recessive syndrome, which affects the skin and some vital organs, it is caused by mutations in the SLC29A3 gene, encoding the human equilibrative nucleoside transporter hENT3. This report describes a patient with typical features of H syndrome. Based on the patient's clinical features, SLC29A3 was selected for molecular investigation. Through direct sequencing, a compound heterozygous alteration in the SLC29A3 gene was found. The c.243delA frameshift mutation leading to a premature termination, resulting in a truncated protein, and a splice site mutation c.300+1G>C predicted to cause a splicing error. This contribution extends the clinical variability of compound heterozygous SLC29A3 mutations resulting in an additional multisystemic manifestation of the clinical spectrum of SLC29A3 disorders.

Correction: Temporal Patterns of Influenza A and B in Tropical and Temperate Countries: What Are the Lessons for Influenza Vaccination?

[This corrects the article DOI: 10.1371/journal.pone.0152310.].

Regioselective synthesis and crystal structure of ethyl-4-acetyl-5-((2- ethoxy-2-oxoethyl)thio)-3-hydroxythiophene-2-carboxylate, C13H16O6S2

C13H16O6S2, triclinic, P1̅ (no. 2), a = 7.979(1) Å, b = 9.189(1) Å, c = 10.263(1) Å, ɑ = 72.876(2)°, β = 71.485(2)°, γ = 76.655(2)°, V = 674.0 Å3, Z = 2, Rgt(F) = 0.0360, wRref(F2) = 0.0962, T = 273 K.