Patient-reported outcome measures for systemic lupus erythematosus: an expert Delphi consensus to guide implementation in routine care.

BACKGROUND: Systemic lupus erythematosus (SLE) may result in great impact on patients' quality of life, social relationships, and work productivity. The use of patient-reported outcome measures (PROMs) in routine care could help capture disease burden to guide SLE management and optimize disease control. We aimed to explore the current situation, appropriateness, and feasibility of PROMs to monitor patients with SLE in routine care, from healthcare professionals' and patients' perspectives. METHODS: A scientific committee developed a Delphi questionnaire, based on a focus group with patients and a literature review, including 22 statements concerning: 1) Use of PROMs in routine care (n = 2); 2) PROMs in SLE management (n = 13); 3) Multidisciplinary management of patients with SLE (n = 4), and 4) Aspects on patient empowerment (n = 3). Statements included in Sects. 2-4 were assessed from three perspectives: current use, appropriateness, and feasibility (with currently available resources). For each statement, panellists specified their level of agreement using a 7-point Likert scale. A consensus was reached when ≥ 70% of the panellists agreed (6,7) or disagreed (1,2) on each statement. RESULTS: Fifty-nine healthcare professionals and 16 patients with SLE participated in the Delphi-rounds. A consensus was reached on the value of PROMs to improve SLE management (83%) and the key role of healthcare professionals (77%) and the need for a digital tool connected to the electronic medical record (85%) to promote and facilitate PROMs collection. PROMs most frequently used in clinical practice are pain (56%), patient's global assessment (44%) and fatigue (39%), all on visual analogue scales. Panellists agreed on the need to implement multidisciplinary consultation (79%), unify complementary tests (88%), incorporate pharmacists into the healthcare team (70%), and develop home medication dispensing and informed telepharmacy programmes (72%) to improve quality of care in patients with SLE. According to panellists, patient associations (82%) and nurses (80%) are critical to educate and train patients on PROMs to enhance patient empowerment. CONCLUSIONS: Although pain, fatigue, and global assessment were identified as the most feasible, PROMs are not widely used in routine care in Spain. The present Delphi consensus can provide a road map for their implementation being key for SLE management.

High rate of union of scaphoid pseudoarthrosis treated with arthroscopic olecranon bone graft using antegrade percutaneous headless compression screw.

PURPOSE: The primary aim of this prospective study was to assess the healing rate of scaphoid pseudoarthrosis treated with wrist arthroscopy, olecranon bone graft and anterograde screw fixation. Clinical, radiological outcomes and complications were included as secondary aims. METHODS: All patients with scaphoid nonunion were selected between January 2017 and December 2022. Inclusion criteria were patients between 18 and 60 years of age, diagnosis of scaphoid pseudoarthrosis, complete clinical patient-reported outcomes (PROs), radiographic measurements, and underwent at least 1-year follow-up. Scaphoid pseudoarthrosis was treated arthroscopically with olecranon bone graft and anterograde screw fixation. Clinical assessment was performed through visual analog scale (VAS) for pain, QuickDASH (disability of the arm, shoulder, and hand) questionnaire, wrist range of motion using a standard goniometer, and grip strength in Kilograms with a Jamar hydraulic hand dynamometer. Clinical relevance was measured with the minimal clinical important difference (MCID) for VAS and QuickDASH. Scapholunate angle was measured. Union was assessed on CT scan. RESULTS: Seventeen patients were included with a mean follow-up of 17.2 months. Mean age was 30.1 years old and average time from injury to arthroscopic surgery was 11.1 months. At latest follow-up, there was an improvement in VAS pain score and QuickDASH score. Range of motion and grip strength increased at last follow-up. MCID threshold for the VAS and DASH score was reached by 100% and 94.1%, respectively. Union was achieved in 16 patients (94.1%) after a median of 16 weeks (IQR 16-20). CONCLUSIONS: Arthroscopic treatment of scaphoid pseudoarthrosis with olecranon bone graft and antegrade percutaneous headless compression screw allows a high grade of union and improves in pain and function at short term follow-up. MCID threshold for the VAS and DASH score was reached by 100% and 94.1%, respectively.

Plastid Phylogenomic Analysis of Tordylieae Tribe (Apiaceae, Apioideae).

Based on the nrDNA ITS sequence data, the Tordylieae tribe is recognized as monophyletic with three major lineages: the subtribe Tordyliinae, the Cymbocarpum clade, and the Lefebvrea clade. Recent phylogenomic investigations showed incongruence between the nuclear and plastid genome evolution in the tribe. To assess phylogenetic relations and structure evolution of plastomes in Tordylieae, we generated eleven complete plastome sequences using the genome skimming approach and compared them with the available data from this tribe and close relatives. Newly assembled plastomes had lengths ranging from 141,148 to 150,103 base pairs and contained 122-127 genes, including 79-82 protein-coding genes, 35-37 tRNAs, and 8 rRNAs. We observed substantial differences in the inverted repeat length and gene content, accompanied by a complex picture of multiple JLA and JLB shifts. In concatenated phylogenetic analyses, Tordylieae plastomes formed at least three not closely related lineages with plastomes of the Lefebvrea clade as a sister group to plastomes from the Selineae tribe. The newly obtained data have increased our knowledge on the range of plastome variability in Apiaceae.

Radiographic measurements have limited effect in dynamic plantar pressures in hallux valgus patients.

PURPOSE: Radiographic measurements are the gold standard in the management for preoperative surgical planning of hallux valgus deformity. Plantar pressure technology is a tool that is not commonly used to evaluate and manage hallux valgus patients, and few studies have reported the correlation of plantar pressure measurements and radiography. METHODS: A prospective cohort study was designed to analyze plantar pressure measurements and radiographic variables. The inclusion criteria were age over 18 years old, and diagnosis of hallux valgus requesting surgical correction because of discomfort, pain or difficulty with shoe wear. Plantar pressure measurements were performed using a platform. Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements. RESULTS: A total of 114 patients met the inclusion criteria. Mean age of the patients was 50 years, and 94 patients (82.5%) were women. We found significant correlations between dynamic plantar pressure measurements and HVA, DMAA, and MDA. Mean pressure under third metatarsal head was the most associated plantar pressure measurement with hallux valgus angle and metatarsal declination angle. However, this association showed signs of weakness. CONCLUSION: Hallux valgus angle and metatarsal declination angle had a minimal influence on plantar-loading parameters. Pressure values did not discriminate the magnitude of HV deformity. Others factors responsible for the observed plantar pressures pattern should be addressed.

Arthroscopic surgery for femoroacetabular impingement has limited effect in patients with Tönnis grade-2 at 4-year follow-up.

INTRODUCTION: This study evaluated intraoperative findings and outcomes in Tönnis grade-2 patients after hip arthroscopy and compared these results with patients with Tönnis grade-0 and grade-1. MATERIALS AND METHODS: Retrospective cohort study of patients undergoing hip arthroscopy between January 2013 and December 2017. Patients were divided into either Tönnis grade-2, grade-1, and grade-0 osteoarthritis groups. Labral and chondral status were evaluated. Radiographic analysis, modified Harris hip score (mHHS), a self-administered Hip Outcome Score (HOS) questionnaire, with activity of daily living (ADL) and sports subscale (SSS), and a self-administered short version of the International Hip Outcome Tool (IHOT-12) were assessed at 6, 12 months, and then yearly. Clinical meaningful outcomes were measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for mHHS, HOS-ADL and HOS-SSS, and IHOT-12. RESULTS: A total of 264 hip arthroscopic procedures met the inclusion criteria. There were 38 patients Tönnis grade-2, 91 patients Tönnis grade-1, and 135 patients Tönnis grade-0. Mean follow-up was 48.7 months in Tönnis grade-2 group, 48.6 months in Tönnis grade-0 group, and 48.1 months in Tönnis grade-1 group. Tönnis grade-2 patients had more extensive rim chondral damage, and a higher rate of labral debridement was performed in this group. There were no statistically significant differences in preoperative PROs among the groups. Tönnis grade-2 group had statistically significant improvement in mHHS, but not in HOS-AVD, HOS-SSS and IHOT-12. Between T1 and T2 groups there were no statistically significant differences in outcomes. Lower significant percentage values of Tönnis grade-2 patients achieved MCID, PASS, and SCB threshold. CONCLUSION: Improvements in PROs and rates of achieving clinical meaningful outcomes were limited for patients with Tönnis grade-2 after HA at 4-year follow-up. The outcomes of the Tönnis grade-2 cohort deteriorate over mid-term follow-up. Our results could be used in orthopedic practice to inform patients about the limited role of hip arthroscopy as a joint preservation procedure in these selected patients. LEVEL OF EVIDENCE: Cohort study, level 3.

Significant improvement after hip arthroscopy for femoroacetabular impingement in women.

PURPOSE: This study was designed to evaluate outcomes in women after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) and compare these results with men. METHODS: Retrospective study of a prospective database of patients undergoing hip arthroscopy between 2015 and 2018. Inclusion criteria were patients between 18 and 50 years of age, diagnosis of FAIS, complete clinical patient-reported outcomes (PROs), radiographic measurements, and underwent at least a 2-year HA follow-up. For each woman, two men underwent HA were matched in a 1:2 ratio based on age within 5 years, and date of surgery within 6 months. Diagnostic arthroscopy was performed to evaluate labral and chondral status. Radiographic evaluation, a self-administered Hip Outcome Score (HOS) questionnaire, with activity of daily living (ADL) and sports subscale (SSS), and a self-administered short version of the International Hip Outcome Tool (iHOT-12) were assessed at 6 months, 12 months, and then yearly. Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for HOS-ADL, HOS-SSS, and iHOT-12. RESULTS: One hundred and eighty-five patients met the inclusion criteria. Fifty-two women were matched with 104 men. Significant differences in terms of demographics, radiographic results, intraoperative findings and arthroscopic procedures were found between women and men. Mean follow-up was 48.4 months in women and 50.2 months in men. Both groups showed significant improvement from preoperative PROs to the latest follow-up. There were no significant differences between groups in preoperative PROs, latest follow-up PROs and PROs improvements. The difference in frequency of patients achieving MCID, PASS, and SCB was only significant greater for iHOT-12 PASS in women compared with men. CONCLUSION: Significant improvements in PROs in women after HA for FAIS at 4-year follow-up were found. Differences between women and men in PROs and rates of achieving MCID, SCB and PASS were only significant for iHOT-12 PASS. LEVEL OF EVIDENCE: IV.

Hallux valgus with and without metatarsalgia in women: a matched-cohort study of plantar pressure measurements.

BACKGROUND: Few previous studies focused on plantar loading patterns in HV patients with metatarsalgia. Are there any differences in plantar pressure measurements in women with HV with and without metatarsalgia? METHODS: A prospective matched-cohort study was designed to analyze plantar pressure measurements in women with HV with and without metatarsalgia from January 2017 to December 2019. The inclusion criteria were age over 18 years old, women, diagnosis of HV with metatarsalgia. Control group had the same inclusion criteria, except metatarsalgia. Patient-reported outcomes scores included American Orthopedic Foot and Ankle Society Score (AOFAS), and Visual Analog Scale (VAS). Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements. Plantar pressure measurements were performed using a platform. RESULTS: Forty-seven patients met the inclusion criteria. An age-, BMI-, and hallux valgus angle-matched cohort of 47 patients were also selected. There were no statistically significant differences in demographic data and radiographic assessment. HV with metatarsalgia group showed greater values in peak and mean force, peak and mean pressure, and pressure-time integral under toes and metatarsal heads. These differences reached statistically significant in mean force (p = 0.009) and peak force (p = 0.003) under T1; mean pressure (p = 0.01) and peak pressure (p = 0.04) under T1; and mean force (p = 0.003) under MH1. The binary logistic regression analysis showed mean force under T1 as the most associated plantar pressure measurement with the presence of metatarsalgia. C-statistic was 0.66. Mean force > 35 N had a 70% of sensitivity and a 57% of specificity as a cut-off value for the presence of metatarsalgia. CONCLUSION: HV patients with metatarsalgia had greater values in plantar pressure measurements. Mean force under T1 could be used as a plantar pressure measurement to predict metatarsalgia.

Two centuries from species discovery to diagnostic characters: molecular and morphological evidence for narrower species limits in the widespread SW Australian Anarthria gracilis complex (Restionaceae s.l./Anarthriaceae, Poales).

BACKGROUND: The extreme southwest of Australia is a biodiversity hotspot region that has a Mediterranean-type climate and numerous endemic plant and animal species, many of which remain to be properly delimited. We refine species limits in Anarthria, a Western Australian endemic genus characterised by the occurrence of the greatest number of plesiomorphic character states in the restiid clade of Poales. In contrast to many other groups of wind-pollinated Australian Poales, Anarthria was traditionally viewed as having well-established species limits. All six currently recognised species, which are conspicuous members of some Western Australian plant communities, were described in the first half of the 19th century. They are traditionally distinguished from each other mainly using quantitative characters. METHODS: We examined extensive existing herbarium specimens and made new collections of Anarthria in nature. Scanning electron microscopy and light microscopy were used to study leaf micromorphology. Molecular diversity of Anarthria was examined using a plastid (trnL-F) and a low-copy nuclear marker (at103). This is the first study of species-level molecular diversity in the restiid clade using a nuclear marker. RESULTS: Material historically classified as Anarthria gracilis R.Br. actually belongs to three distinct species, A. gracilis s.str., A. grandiflora Nees and A. dioica (Steud.) C.I.Fomichev, each of which forms a well-supported clade in phylogenetic analyses. Both segregate species were described in the first half of the 19th century but not recognised as such in subsequent taxonomic accounts. Anarthria dioica was first collected in 1826, then wrongly interpreted as a species of Juncus (Juncaceae) and described as Juncus dioicus. We provide a formal transfer of the name to Anarthria and for the first time report its clear and qualitative diagnostic characters: an extremely short leaf ligule and distinctive pattern of leaf epidermal micromorphology. A long ligule is present in A. gracilis s.str. and A. grandiflora. These species differ from each other in leaf lamina morphology and anatomy and have mostly non-overlapping distribution ranges. The narrower definition of species provides a basis for future phylogeographic analyses in Anarthria. Our study highlights a need for more extensive use of nuclear DNA markers in Restionaceae. The use of the low copy nuclear marker at103 allowed a clade comprising all three ligulate species of Anarthria to be recognised. The ligule character is used here for the first time in the taxonomy of Anarthria and merits special attention in studies of other restiids. In general, our study uncovered a superficially hidden but, in reality, conspicuous diversity in a common group of wind-pollinated plants in the southwest of Western Australia.

Recreational Sports and Intra-articular Hip Injuries in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: We aimed to determine the relationship between recreational sports and intra-articular hip injuries in an active population that had undergone hip arthroscopy for femoroacetabular impingement syndrome. METHODS: A retrospective review was performed of prospectively collected data from patients undergoing hip arthroscopy between January 2015 and December 2016. Inclusion criteria included patients between 18 and 50 years of age who had participated in recreational sports prior to surgery and had a minimum of a 2-year follow-up. Labral injury was evaluated using the Multicenter Arthroscopic Hip Outcome Research Network classification, and rim chondral injuries were evaluated using the Acetabular Labral Articular Disruptions system. Ligamentum teres tear and psoas impingement were also recorded. Sports were classified as rotational running (soccer, basketball, handball), flexibility (martial arts, dance), asymmetric-overhead (racquet), or endurance (running, swimming, cycling). Primary univariate analysis of sports' independent associations, demographic characteristics, intra-articular hip injuries, and outcomes was performed. RESULTS: Patients included 185 people with a mean age of 36.7 years. Patients participating in rotational running sports and flexibility sports had a significantly greater proportion of rim chondral injuries than those participating in endurance sports or asymmetric overhead sports (P = 0.02). Ligamentum teres tears were significantly associated with flexibility sports (P < 0.001). A total of 84.7%, 67.7%, 67.2%, and 71.2% of patients met minimal clinically important difference levels for the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)10 questionnaire with activities of daily living (HOS-ADL), the sports subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-12), respectively; 94.9%, 66.2% and 62.7% met the patient acceptable symptom state for mHHS, HOS-ADL, and HOS-SSS, respectively; 86.7%, 48.5%, 47.8%, and 32.4% found substantial clinical benefit for mHHS, HOS-ADL, HOS-SSS, and iHOT-12, respectively. CONCLUSIONS: Rotational running sports were significantly associated with rim chondral injuries. Flexibility sports were significantly associated with rim chondral injuries and ligamentum teres tears. Athletes participating in these sports are more likely to have intra-articular hip injuries than those in the other sports categories. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Arthroscopic management with labral preservation, femoral osteoplasty, and capsular plication in patients with borderline hip dysplasia. Results of a matched-cohort study at minimum two year follow-up.

PURPOSE: The purpose of this study was to assess intra-operative findings, surgical procedures, and outcomes in a cohort of patients with borderline hip dysplasia treated with arthroscopic labral repair, femoral osteoplasty, and capsular plication, and compare these outcomes with those of a rigorously matched control group without dysplasia. METHODS: Data were prospectively collected and retrospectively reviewed for patients with a lateral center-edge angle between 20 and 24° who underwent hip arthroscopy surgery between 2014 and 2018. Labral, chondral status, psoas impingement, ligamentum teres, and cam morphology were evaluated. Patient-reported outcomes (PROs) scores included modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living Subscale (HOS-AVD) and Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (IHOT-12). Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB). RESULTS: Twenty patients met the inclusion criteria. An age- and sex-matched control group of 40 patients was also selected. Arthroscopic intra-operative findings were similar between cohorts. At a mean follow-up of 50 months in the borderline hip dysplasia cohort, and 52 months in the control cohort, there was a significant improvement in PROs in both cohorts, and no significant differences could be detected at the latest follow-up. The difference in frequency of patients achieving the MCID, PASS, and SCB was not statistically significant between cohorts. CONCLUSION: With strict patient selection criteria, hip arthroscopy may be a beneficial approach in patients with borderline hip dysplasia.

Topical tranexamic acid in cemented primary total knee arthroplasty without tourniquet: a prospective randomized study.

PURPOSE: Tranexamic acid (TXA) has been shown to be effective in reducing blood loss after total knee replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use, to reduce blood loss after primary total knee replacement without tourniquet, and to compare these outcomes with a control group that did not receive tranexamic acid. METHODS: This is a prospective, randomized study to assess the effect of a 2-g topical tranexamic acid in 50 mL physiological saline solution in total knee replacement without tourniquet and drain. Primary outcomes were total blood loss. Secondary outcomes were hemoglobin and hematocrit level, hemoglobin and hematocrit drop, transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events. RESULTS: Preoperative and intraoperative data were similar between the two groups. The mean total blood loss was 620 mL in the topical tranexamic acid group and 1094 mL in the control group with significant differences (p = 0.001), which meant 43% reduction in total blood loss. The hemoglobin and hematocrit postoperative value was significantly higher in the topical tranexamic acid group than in the control group (p = 0.002). Transfusion rates were 0% in the topical tranexamic group and 4.3% in the control group. The length of stay was significantly lower in the topical tranexamic acid group (p = 0.01). There were no DVT or PE in any group. CONCLUSION: A single dose of 2-g TXA in 50 mL topical administration significantly reduces blood loss and improves postoperative blood chemistries in patients undergoing unilateral primary cemented TKA without tourniquet and drain compared to a control group, without increasing the risk of thromboembolic complications.

Plantar pressure improvement in moderate hallux valgus with modified chevron osteotomy: Clinical and radiographic outcomes.

BACKGROUND: Hallux valgus (HV) is widely treated by Chevron osteotomy (CO); however, a modified CO may improve patient outcomes and recovery. METHODS: A prospective study was designed to analyze plantar pressure measurements and clinical and radiographic outcomes of a modified CO for HV. Recruitment was between February 2016 and February 2017. INCLUSION CRITERIA: diagnosis of moderate HV; an indication for surgical correction due to discomfort, pain or difficulty with shoe wear; and age over 18 years. Clinical and radiographic outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) guidelines and a visual analog scale (VAS). RESULTS: Forty-four patients met inclusion criteria. After surgery, the highest percentage in mean pressure was in the first and fifth metatarsal heads. At 12 months' follow-up, the AOFAS score improved, but differences in VAS scale were only significant at baseline. CONCLUSIONS: Modified CO is a good option for people with HV, improving foot activity compared to preoperative levels while limiting the time needed for recovery.

Progressive Akin Osteotomy.

The most common complication associated to Akin osteotomy is the intraoperative fracture of the lateral cortex of the proximal phalanx. We present a progressive Akin osteotomy that preserves the lateral cortex of the proximal phalanx and allows to remove the exact wedge size to achieve the preoperative planned correction.

Femoroacetabular impingement: prospective study of rate and factors related for nerve injury after hip arthroscopy.

Prospective, longitudinal, descriptive study was conducted from January 2016 to January 2018 to detect nerve dysfunction after hip arthroscopy. A total of 110 patients were included. Twenty-four hours after surgery, 62.7% reported symptoms of abnormal sensation at least in one area. The most common was the perineal area. Three weeks after hip arthroscopy, 42.6% still experienced abnormal sensation. Six months after hip arthroscopy, only one patient remained with symptoms. Nerve dysfunction after HA was more common than has been reported in the literature within large populations. Traction time was a significant factor for the development of perineal nerve dysfunction.

Indirect Scapholunate Ligament Repair: All Arthroscopic.

The arthroscopic technique most frequently used in acute scapholunate instability is reduction and fixation with Kirschner wires. To repair the injured ligament, open surgery and dorsal capsular plication are recommended, but this procedure has the risk of damaging secondary dorsal stabilizers, the dorsal blood supply, and the proprioceptive innervation of the posterior interosseous nerve. In this report, we present an all-arthroscopic technique of a dorsal reconstruction of the scapholunate interosseous ligament for scapholunate instability using a tape by tethering the scaphoid to the lunate.

Matched cohort study of topical tranexamic acid in cementless primary total hip replacement.

PURPOSE: Tranexamic acid has been shown to be effective in reducing blood loss after total hip replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use to reduce blood loss after primary total hip replacement and to compare these outcomes with those of a matched control group from a similar cohort that did not have received tranexamic acid. METHODS: This is a prospective matched control study to assess the effect of a 2 g topical tranexamic acid in 50 mL physiological saline solution in total hip replacement. Primary outcomes were hemoglobin and hematocrit drop, and total blood loss. Secondary outcomes were transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events. RESULTS: We could match 100 patients to a control group. There were no statistical significantly differences between the two groups. The hemoglobin and hematocrit postoperative values were significantly higher in topical tranexamic acid group than in control group (P < 0.001). The mean total blood loss was 769 in topical tranexamic acid group and 1163 in control group with significant differences (P = 0.001), which meant 34% reduction in total blood loss. Length of stay was lower in topical tranexamic acid group. The risk of deep vein thrombosis and pulmonary events did not increase. CONCLUSIONS: A single dose of 2 g tranexamic acid in 50 mL physiological saline solution topical administration was effective and safe in reducing bleeding in patients undergoing unilateral primary non-cemented total hip replacement compared to a matched control group.

Complete plastome sequence of Paeonia lactiflora Pall. (Paeoniaceae: Saxifragales).

Paeonia lactiflora has been listed as an Endangered species in Russian Federation. The complete plastome was assembled from Next-Generation Sequencing data. It is 152,747 bp in length. It consists of a pair of Inverted Repeat regions (25,651 bp), separated by a small single copy region of 17,033 bp and a large single copy region of 84,412 bp. The plastome encoded 128 genes, including 83 protein coding genes, 37 tRNA, eight rRNA genes, four pseudogenes, and is characterized by loss of the rpl32 and infA genes. Phylogenetic analysis of Paeoniaceae plastomes revealed that P. lactiflora clustered with Eurasian peonies (section Paeoniae).

Meta-analysis of validity of echogenic intracardiac foci for calculating the risk of Down syndrome in the second trimester of pregnancy.

Echogenic intracardiac foci are a second trimester marker associated with aneuploidy in high-risk populations. The objective of this study is to assess the validity of echogenic intracardiac foci for Down syndrome detection in the second trimester ultrasound scan. A systematic search in major bibliographic databases was carried out (MEDLINE, EMBASE, CINAHL). Twenty-five studies about echogenic intracardiac foci were selected for statistical synthesis in this systematic review. Those 25 considered to be relevant were then subjected to critical reading, following the Critical Appraisal Skills Programme criteria, by at least three independent observers. Then, the published articles were subjected to a meta-analysis. A global sensitivity of 21.8% and a 4.1% false positive rate were obtained. The positive likelihood ratio was 5.08 (95% confidence interval, 4.04-6.41). The subgroups analysis did not reveal statistically significant differences. In conclusion, echogenic intracardiac foci as an isolated marker could be a tool to identify-rather than exclude-the high-risk group of Down syndrome, although it should be noted that it shows low sensitivity.

Arthroscopic Treatment of a Malunion of a Posteromedial Tubercle Fracture of the Talus.

Posteromedial ankle impingement is rare and uncommonly associated with a fracture. Bone resection of the fragment is the recommended treatment. In this report, we describe the step-by-step surgical technique of arthroscopic resection of a malunion of a posteromedial talus fracture to correct the impingement.

Gradual vs. abrupt reduction of carpels in syncarpous gynoecia: A case study from Polyscias subg. Arthrophyllum (Araliaceae: Apiales).

PREMISE OF THE STUDY: Revealing the relative roles of gradual and abrupt transformations of morphological characters is an important topic of evolutionary biology. Gynoecia apparently consisting of one carpel have evolved from pluricarpellate syncarpous gynoecia in several angiosperm clades. The process of reduction can involve intermediate stages, with one fertile and one or more sterile carpels (pseudomonomery). The possible origin of monomery directly via an abrupt change of gynoecium merism has been a matter of dispute. We explore the nature of gynoecium reduction in a clade of Araliaceae. METHODS: The anatomy and development of unilocular gynoecia are investigated using light and scanning electron microscopy in two members of Polyscias subg. Arthrophyllum. Gynoecium diversity in the genus is discussed in a phylogenetic framework. KEY RESULTS: Unilocular gynoecia with one fertile ovule have evolved at least four times in Polyscias, including one newly discovered case. The two unilocular taxa investigated are unicarpellate, without any traces of reduced sterile carpels. Carpel orientation is unstable, and the ovary roof and style contain numerous vascular bundles without clearly recognizable dorsals or ventrals. In contrast to pluricarpellate Araliaceae and Apiaceae, the cross zone is apparently oblique in the unicarpellate species. CONCLUSIONS: No support was found for gradual gynoecium reduction via pseudomonomery. The abrupt origin of monomery via direct change of gynoecium merism and the unstable carpel orientation observed are related to the general lability of the flower groundplan in Polyscias. The apparent occurrence of the unusual oblique cross zone in unicarpellate Araliaceae can be explained by developmental constraints.