Clinical practice guidelines: The good, the bad, and the ugly.

Clinical practices guidelines (CPGs) play a fundamental role in improving healthcare and patients' outcomes by helping clinicians make the best evidence-based decisions for their patients in a time-efficient manner. By following the available methods and criteria to create trustworthy CPGs, panel members can develop high-quality guidelines. However, despite the improvements over the years, CPGs are still subjected to biases and limitations, with conflicts of interest being the ugliest problem GCPs must face. In this review, we discuss the main characteristics of clinical practice guidelines, their pros and cons, and the future challenges they need to overcome.

Complications of standard versus long cephalomedullary nails in the treatment of unstable extracapsular proximal femoral fractures: A randomized controlled trial.

AIMS: To compare in a prospective randomized trial the mechanical complications in patients with unstable extracapsular proximal femur fractures without subtrochanteric extension (AO/OTA 31-A2 and 31-A3) METHODS: We prospectively studied 182 patients with unstable extracapsular proximal femur fractures without fractures lines extending more than 3 cm below the lesser trochanter, randomized to receive either a 'standard' (240 mm) nail or a long nail and followed them up for 1 year. RESULTS: We found no difference in the incidence of mechanical or general complications between the two groups, no cut-outs, no fractures of the tip the implant, 1 cut-through and 2 malrotations in the LN group, 2 non-unions that were reoperated, one on each group. The commonest complication was blade lateral migration, 13 (14%) patients in SN and 6 (9%) in the LN. The operating time was shorter in the SN group 51 minutes compared to 67 minutes in the LN group (p=0.000075). The mortality at 1,3 and 12 months in the SN group was of 2%, 6%, 12% while in the LN group was 12%, 18% and 22%. These differences where significative at 1 (p=0.007) and 3 months (p=0.013), but not at 12 months (p=0.075). CONCLUSIONS: We recommend the use of standard nails (240 mm) for this group of fractures, since it does not produce more mechanical complications, and it is faster, cheaper and easier to interlock distally.

Hybridization is strongly constrained by salinity during secondary contact between silverside fishes (Odontesthes, Atheriniformes).

This study investigates a contact zone between two silverside fish species (marine Odontesthes argentinensis and freshwater O. bonariensis) in the estuarine Mar Chiquita lagoon along the Atlantic coast in Argentina (MChL), in which intermediate morphs had been reported. It has been suggested that admixture and introgression occur in MChL between these two species, but direct genetic evidence is lacking. Leveraging samples collected over several years (n = 676), we document the spatial distribution of both species and intermediate morphs within this habitat and collect landmark-based morphometric and multilocus genetic data (9876 loci for n = 110 individuals) to test the hypothesis of hybridization. Our analysis unambiguously characterizes intermediate morphs as F1 or F2 hybrids. We show that the low frequency of hybrid individuals in MChL may be explained by uneven abundance of parental species, which in turn are strongly affected by water salinity, limiting the size of the contact zone. Although hybrids seem to be fertile, their fitness may be reduced by external and intrinsic factors that may limit their success and suggest that this is an unstable hybrid zone. Genetic distinctiveness of both parental species is strongly supported by genome-wide data, explaining a known pattern of mitonuclear discordance as a consequence of hybridization followed by mitochondrial introgression. A clear signature of population genetic structure was detected in O. argentinensis, distinguishing MChL residents from marine populations of this species, that also was supported by distinctive morphometric features among these groups. Previous hypotheses of speciation in these fishes are discussed in the light of the new findings.

Prejuveniles of Mugil liza (Actinopterygii; Fam. Mugilidae) show digestive and metabolic flexibility upon different postprandial times and refeeding.

Many animals face periods of feeding restrictions implying fasting and refeeding. The determination of digestive/metabolic and body condition parameters at different times of food deprivation and after refeeding allows to evaluate the postprandial dynamics, the transition from feeding to fasting and the capacity to reverse digestive and metabolic alterations. In spite of its physiological importance, studies on estuarine-dependent detritivore fish are lacking. We determined total mass (TM), relative intestine length (RIL), hepatosomatic index (HSI), digestive enzymes activities in the intestine and energy reserves in liver and muscle at 0, 24, 72, 144 and 240 h after feeding and at 72 h after refeeding in prejuveniles of Mugil liza (Mugilidae) as a model species. After feeding, a decrease occurred in: TM (144 h, 25%), RIL (144 h, 23%); amylase and maltase (72 h, 45 and 35%), sucrase (24 h, 40%) and lipase (24 h, 70%) in intestine; glycogen and free glucose (72 h, 90 and 92%) in liver. In muscle, glycogen (72-144 h) and free glucose (144 h) (170% and 165%, respectively) peak increased; triglycerides decreased at 24-240 h (50%). After refeeding TM, RIL, carbohydrases activities in intestine, glycogen and free glucose in liver were recovered. In muscle, glycogen and free glucose were similar to 0 h; lipase activity and triglycerides were not recovered. Trypsin and APN in intestine, triglycerides in liver, protein in liver and muscle and HSI did not change. The differential modulation of key components of carbohydrates and lipid metabolism after feeding/refeeding would allow to face fasting and recover body condition. Our results improve lacking knowledge about digestive and metabolic physiology of detritivore fish.

Is elective surgery during the COVID-19 pandemic safe? A multi-center prospective study in a high incidence area.

OBJECTIVE: The aim of this study was to describe the evolution of patients admitted for elective orthopaedic surgery during the immediate post-COVID-19 peak of the pandemic. METHODS: This is a multi-center, observational study conducted in 8 high complexity hospitals of Catalonia, one of the highest COVID-19 incidence areas in Spain. We included patients ≥18 years of age undergoing elective surgery (total knee or hip arthroplasty, knee or hip revision arthroplasty, shoulder or knee arthroscopy, hand or wrist surgery, forefoot surgery, or hardware removal) after the COVID-19 peak (between May 5th and June 30th, 2020). The main exclusion criterion was a positive result for SARS-CoV-2 PCR within the 7 days before the surgery. The primary outcomes were postoperative complications within 60 days (+/-30) or hospital readmission due to a COVID-19 infection. Following the recommendations of the International Consensus Group (ICM), elective surgeries were re-started when the nationwide lockdown was lifted. Before the surgery, patients were contacted by phone to rule out any exposure to confirmed COVID-19 cases, a reverse transcription-polymerase chain reaction (PCR) assay was performed in all patients 48-72 hours before hospital admission, and they were asked to maintain home confinement until the day of the surgery. RESULTS: 675 patients were included: 189 patients in the arthroplasty group (28%) and 486 in the ambulatory surgery group (72%). Mean [SD] age was 57.6 [15.3] years. The mean Charlson Comorbidity Index score was 2.21 (SD = 2.01, Min = 0, Max = 13). A total of 84 patients (12.75%) obtained an American Society of Anesthesiologists (ASA) score ≥ 3, showing no association between the ASA score and the risk of developing COVID-19 symptoms at follow-up (χ 2 (4) = 0.77, P = 0.94). The mean occupation rate of hospital beds for COVID-19 patients was 13% and the mean occupation rate of critical care beds for COVID-19 patients was 27% at the time of re-introducing elective surgeries. These were important rates to consider to decide when to reintroduce elective surgeries after lockdown. Surgical time, time of ischemia and intra-operative bleeding were not related with a higher risk of developing COVID-19 post-operatively (χ 2 (1) = 0.00, P = 0.98); (χ 2 (2) = 2.05, P = 0.36); (χ 2 (2) = 0.37, P = 0.83). Only 2 patients (0.3 %) presented with a suspected COVID-19 infection at follow-up. None of them presented with pneumonia or required confirmation by a reverse transcription PCR assay. Hospital re-admission was not needed for these patients. CONCLUSION: The risk of developing COVID-19 during the immediate post-COVID-19 peak in a region with a high incidence of COVID-19 has not been proved. These data suggest that elective orthopaedic surgeries can be resumed when assertive and strict protocols are followed.

A new species of Hoplias malabaricus species complex (Characiformes: Erythrinidae) from the Crepori River, Amazon basin, Brazil.

A new species belonging to the Hoplias malabaricus complex from the Amazon basin, Brazil, is described. The new species is characterized by 15-16 predorsal scales, 37-39 lateral-line scales, 5 scales from dorsal fin to lateral line, 38-39 vertebrae, iii-iv, 7-8 anal-fin rays, ii-iv, 12-15 caudal-fin rays, last vertical series of scales on the base of caudal-fin rays forming a straight line, 6-7 dark bands in anal fin and no distinctive dark bands or blotches on flanks. The new species is also distinguished from other congeners of the H. malabaricus species-group by means of landmark-based morphometrics and DNA Barcoding (Cytochrome c Oxidase I gene). An identification key to species of the H. malabaricus species complex is provided.

Understanding the early ontogenetic stages of Mugil liza (Mugilidae): Morphological traits and digestive/metabolic profile of pre-juveniles after recruitment.

The family Mugilidae consists mainly of diadromous species, whose reproduction occurs in offshore waters. Pre-juveniles shift their diet in the surf zone (zooplanktophagous to iliophagous). Later, during their recruitment into estuaries, huge changes take place in their digestive system. However, digestive and metabolic characteristics and some morphological traits at recruitment are unknown for Mugilidae. We performed comparative studies on early and late pre-juveniles of Mugil liza recruited in Mar Chiquita Coastal Lagoon (37°32'-37°45'S, 57°19'-57°26'W, Argentina). We determined digestive enzyme activities (intestine), energy reserves (liver/muscle), total/standard length, total weight, intestinal coefficient, hepatosomatic index and retroperitoneal fat. Pre-juveniles exhibited amylase, maltase, sucrase, lipase, trypsin and aminopeptidase-N (APN) activities, which were maintained over a wide range of pH and temperature, and exhibited Michaelis-Menten kinetics. In late pre-juveniles, amylase (422 ± 131 µmol maltose min-1 mgprot-1 ), sucrase (86 ± 14 mg glucose min-1 mgprot-1 ), trypsin (84 ± 9 µmoles min-1 mgprot-1 ) and APN (0.58 ± 0.08 µmoles min-1 mgprot-1 ) activities were higher (42%, 28%, 35% and 28%, respectively) than in the early stage. Also, the intestinal coefficient was higher in late (3.04) compared to early (2.06) pre-juveniles. Moreover, the liver appeared to be a main site of glycogen and triglyceride storage in late pre-juveniles, muscle being the site of storage in early pre-juveniles, exhibiting higher glycogen, free glucose and protein concentrations (92%, 82%, 32%, respectively). The results suggest that pre-juveniles of M. liza exhibit an adequate digestive battery to perform complete hydrolysis of various dietary substrates, availability of energy reserves and morphological characteristics to support their feeding habit and growth after recruitment. Our results represent an important contribution to knowledge of the ecology and digestive physiology of pre-juveniles of Mugilidae in the wild.

"Can patients learn how to reduce their shoulder dislocation?" A one-year follow-up of the randomized clinical trial between the Boss-Holzach-Matter self-assisted technique and the Spaso method.

OBJECTIVE: The aim of this study was to assess the effectiveness and reproducibility of self-assisted Boss-Holzach-Matter (BHM) technique compared with the Spaso (Sp) method for shoulder dislocation. METHODS: We conducted a follow-up at 1 year from the randomization of 60 patients with shoulder dislocation enrolled in the study "Teaching patients to reduce a shoulder dislocation." Half of these patients had been taught the self-assisted technique, whereas the other half had been treated by a physician's manipulative maneuver for reduction. We surveyed all the enrolled patients to describe recurrence rates and reproducibility for both the techniques without supervision as well as the number of emergency visits. RESULTS: In total, 52 patients (age range: 18-44 years) answered the survey from the 60 patients enrolled in the study. The total rate of recurrence was 38.5% (20 patients). For the Sp group, 4 of the 30 patients were lost. There were 9 recurrent patients (30%), and 7 were treated in the emergency department (ED). For the BHM group, 4 of the 30 patients were lost. There were 11 recurrent patients (37%), and 2 were treated in the ED. The difference in self-reduction rates and ED visits for both the groups was statistically significant (p=0.025). CONCLUSION: Teaching the BHM technique to the patients is effective and reproducible without direct supervision. It can decrease the number of visits to the ED and is a valid option to teach the patients at risk of recurrence when not being able to get immediate help. LEVEL OF EVIDENCE: Level I, Therapeutic study.

¿Podemos ayudar? Nuestra experiencia como cirujanos ortopédicos durante la pandemia por COVID / Can we help? Our experience as orthopedic surgeons during the COVID-19 pandemic

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All-Arthroscopic Nanofractured Autologous Matrix-Induced Chondrogenesis (A-NAMIC) Technique for the Treatment of Focal Chondral Lesions of the Knee.

Nanofractured autologous matrix-induced chondrogenesis (NAMIC©) is a 1-step technique that combines nanofracture needling to induce bone marrow stimulation (BMS) and the use of cell-free collagen matrix to optimize cartilage regeneration. In this Technical Note, we describe a modification of the NAMIC procedure using mosaicplasty trephines to prepare the lesion surface and to shape collagen implants in an all-arthroscopic approach (A-NAMIC). This technique is indicated for the treatment of International Cartilage Repair Society grade III to IV knee chondral lesions of ≤4 cm2. After damaged cartilage is debrided, trephines are used to create a flat, circular lesion surfaces. Subsequently, BMS is performed with nanofracture, eliciting reproducible and stop-controlled subchondral bone perforations of 9-mm depth and 1-mm width. The collagen membrane is then cut to size with the trephine, placed over the prepared defect, and secured with fibrin glue, preventing loss of regenerating cells and growth factors to the joint space. Using trephines allows the rapid and precise creation of smooth defect surfaces with known dimensions, ensuring optimal lesion coverage. Additionally, nanofracture reduces trabecular compaction and allows for a deeper access to subchondral bone in comparison with conventional microfracture, improving lesion filling and production of cartilage with higher hyaline content.

Biogeography, habitat transitions and hybridization in a radiation of South American silverside fishes revealed by mitochondrial and genomic RAD data.

Rivers and lake systems in the southern cone of South America have been widely influenced by historical glaciations, carrying important implications for the evolution of aquatic organisms, including prompting transitions between marine and freshwater habitats and by triggering hybridization among incipient species via waterway connectivity and stream capture events. Silverside fishes (Odontesthes) in the region comprise a radiation of 19 marine and freshwater species that have been hypothesized on the basis of morphological or mitochondrial DNA data to have either transitioned repeatedly into continental waters from the sea or colonized marine habitats following freshwater diversification. New double digest restriction-site associated DNA data presented here provide a robust framework to investigate the biogeographical history of and habitat transitions in Odontesthes. We show that Odontesthes silversides originally diversified in the Pacific but independently colonized the Atlantic three times, producing three independent marine-to-freshwater transitions. Our results also indicate recent introgression of marine mitochondrial haplotypes into two freshwater clades, with more recurring instances of hybridization among Atlantic- versus Pacific-slope species. In Pacific freshwater drainages, hybridization with a marine species appears to be geographically isolated and may be related to glaciation events. Substantial structural differences of estuarine gradients between these two geographical areas may have influenced the frequency, intensity and evolutionary effects of hybridization events.

Evidence of a landlocked reproducing population of the marine pejerrey Odontesthes argentinensis (Actinopterygii; Atherinopsidae).

In South America, the order Atheriniformes includes the monophyletic genus Odontesthes with 20 species that inhabit freshwater, estuarine and coastal environments. Pejerrey Odontesthes argentinensis is widely distributed in coastal and estuarine areas of the Atlantic Ocean and is known to foray into estuaries of river systems, particularly in conditions of elevated salinity. However, to our knowledge, a landlocked self-sustaining population has never been recorded. In this study, we examined the pejerrey population of Salada de Pedro Luro Lake (south-east of Buenos Aires Province, Argentina) to clarify its taxonomic identity. An integrative taxonomic analysis based on traditional meristic, landmark-based morphometrics and genetic techniques suggests that the Salada de Pedro Luro pejerrey population represents a novel case of physiological and morphological adaptation of a marine pejerrey species to a landlocked environment and emphasises the environmental plasticity of this group of fishes.

Reproductive biology of Parona signata (Actinopterygii: Carangidae), a valuable economic resource, in the coastal area of Mar del Plata, Buenos Aires, Argentina

The reproductive biology and life cycle of Parona leatherjacket, Parona signata, present in Mar del Plata (38º 00'S 57º 33'W) coast, was studied. Samples were obtained monthly since January 2018 to February 2019 from the artisanal fishermen and the commercial fleet of Mar del Plata. A histological analysis was carried out and the main biologic-reproductive parameters were estimated: fecundity, oocyte frequency distribution and gonadosomatic index (GSI). Both the macroscopic and microscopic analyses showed reproductive activity in March and November. Mature females were recorded, which showed hydrated oocytes, as was evidenced by the histological procedures. Both, the histological and the oocyte diameter distribution analyses showed the presence of all oocyte maturation stages in ovaries in active-spawning subphase, indicating that P. signata is a multiple spawner with indeterminate annual fecundity. Batch fecundity ranged between 36,426 and 126,035 hydrated oocytes/ female. Relative fecundity ranged between 42 and 150 oocytes/ g female ovary free.(AU)

Se estudió la biología reproductiva y el ciclo de vida de la palometa pintada, Parona signata en Mar del Plata (38°00'S 57°33'O). Las muestras fueron obtenidas mensualmente desde enero de 2018, hasta febrero de 2019, provenientes de la pesca artesanal y/o de la flota comercial de la localidad Mar del Plata. Además, se llevó a cabo un análisis histológico y se estimaron los principales parámetros reproductivos tales como: la fecundidad, análisis de la distribución de la frecuencia de diámetros ovocitarios e índice gonadosomático (GSI) mensual. Tanto el análisis macroscópico como el microscópico permitieron afirmar que en los meses de marzo y noviembre existe actividad reproductiva. Se encontraron hembras en puesta, las cuales presentaron ovocitos hidratados en los cortes histológicos. Ambos, los análisis histológicos y de distribución de la frecuencia de diámetros oocitarios mostraron la presencia de todas las fases de maduración oocitaria en ovarios correspondientes a la sub-fase de desove activo, indicando que P. signata es un desovante parcial con fecundidad anual indeterminada. La fecundidad parcial osciló entre 36.426 y 126.035 oocitos hidratados/hembra. La fecundidad relativa varió entre 42 y 150 ovocitos por gramo de hembra libre de ovario.(AU)

Effects of accelerated versus standard care surgery on the risk of acute kidney injury in patients with a hip fracture: a substudy protocol of the hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) international randomised controlled trial.

INTRODUCTION: Inflammation, dehydration, hypotension and bleeding may all contribute to the development of acute kidney injury (AKI). Accelerated surgery after a hip fracture can decrease the exposure time to such contributors and may reduce the risk of AKI. METHODS AND ANALYSIS: Hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) is a multicentre, international, parallel-group randomised controlled trial (RCT). Patients who suffer a hip fracture are randomly allocated to either accelerated medical assessment and surgical repair with a goal of surgery within 6 hours of diagnosis or standard care where a repair typically occurs 24 to 48 hours after diagnosis. The primary outcome of this substudy is the development of AKI within 7 days of randomisation. We anticipate at least 1998 patients will participate in this substudy. ETHICS AND DISSEMINATION: We obtained ethics approval for additional serum creatinine recordings in consecutive patients enrolled at 70 participating centres. All patients provide consent before randomisation. We anticipate reporting substudy results by 2021. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients.

INTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

Inferring boundaries among fish species of the new world silversides (Atherinopsidae; genus Odontesthes): new evidences of incipient speciation between marine and brackish populations of Odontesthes argentinensis.

Species of new world silversides (Actinopterygii; Atherinopsidae; genus Odontesthes) possess economic relevance, biological interest and ecological importance. In the present paper we: (A) investigate the molecular diversity in marine species of Odontesthes from the South West Atlantic Ocean (SWAO), and analyse their interspecific relationships and divergence by means of DNA Barcoding, including its freshwater congeners, as well. (B) Explore the suitability of DNA Barcoding to analyse the diversity and distribution of haplotypes in Odontesthes argentinensis, the only well documented marine species from the SWAO that exhibit putative estuarine and marine populations. Molecular analysis revealed 100% of agreement between morphological identification and molecular identity. Odontesthes argentinensis, Odontesthes platensis, Odontesthes smitti, Odontesthes nigricans and Odontesthes incisa were assigned to five different barcode index numbers (BINs). Maximum-likelihood analysis showed that all marine species of Odontesthes clustered separately in a unique monophyletic phylogroup, comprising five well defined haplogroups, with genetic divergence between groups ranging from 2.75 to 7.11%. The genetic analysis including freshwater congeners showed that O. incisa clustered alone occupying a basal position. The Fst pairwise comparisons within O. argentinensis support the existence of three population groups: one conformed by Mar Chiquita Lagoon (MCh) specimens, and the others by Mar del Plata/Mar Chiquita coast and San Blas Bay coastal specimens, respectively. The AMOVA showed significant overall differentiation (Fst = 0.238; p = 0.00001) for the entire data set. The previous/present evidence is discussed, and strongly suggests that incipient speciation is occurring in O. argentinensis argentinean populations, and specimens from MCh would be considered at present as the leading candidate of a marine to freshwater incipient speciation event.