Closed Suction Drainage after Total Knee Arthroplasty with Concomitant Intravenous Tranexamic Acid Administration.

Drain use in total knee arthroplasty (TKA) remains controversial. Use has been associated with increased complications, particularly postoperative transfusion, infection, increased cost, and longer hospital stays. However, studies examining drain use were performed before widespread adoption of tranexamic acid (TXA), which markedly reduces transfusion without increasing venous thromboembolism events. We aim to investigate incidence of postoperative transfusion and 90-day return to the operating room (ROR) for hemarthrosis in TKA with use of drains and concomitant intravenous (IV) TXA. Primary TKAs from a single institution were identified from August 2012 to December 2018. Inclusion criteria were primary TKA, age 18 years and over where use of TXA, drains, anticoagulant, and pre- and postsurgical hemoglobin (Hb) were documented during the patient's admission. Primary outcomes were 90-day ROR specifically for hemarthrosis and rate of postoperative transfusion. A total of 2,008 patients were included. Sixteen patients required ROR, three of which were due to hemarthrosis. Drain output was statistically higher in the ROR group (269.3 vs. 152.4 mL, p = 0.05). Five patients required transfusion within 14 days (0.25%). Patients requiring transfusion had significantly lower presurgical Hb (10.2 g/dL, p = 0.01) and 24-hour postoperative Hb (7.7 g/dL, p < 0.001). Drain output between the transfusion and no transfusion groups varied significantly (p = 0.03), with transfusion patients having higher postoperative day 1 drain output of 362.6 mL and total drain output of 376.6 mL. In this series, postoperative drain use with concomitant weight-based IV TXA is shown to be safe and efficacious. We observed exceedingly low risk of postoperative transfusion compared with prior reports of drain use alone as well as preserved low rate of hemarthrosis that has previously been positively linked to drain use.

Role of the Coiled-Coil Domain in Allosteric Activity Regulation in Soluble Guanylate Cyclase.

Soluble guanylate cyclase (sGC) is the primary nitric oxide (NO) receptor in higher eukaryotes, including humans. NO-dependent signaling via sGC is associated with important physiological effects in the vascular, pulmonary, and neurological systems, and sGC itself is an established drug target for the treatment of pulmonary hypertension due to its central role in vasodilation. Despite isolation in the late 1970s, high-resolution structural information on full-length sGC remained elusive until recent cryo-electron microscopy structures were determined of the protein in both the basal unactivated state and the NO-activated state. These structures revealed large-scale conformational changes upon activation that appear to be centered on rearrangements within the coiled-coil (CC) domains in the enzyme. Here, a structure-guided approach was used to engineer constitutively unactivated and constitutively activated sGC variants through mutagenesis of the CC domains. These results demonstrate that the activation-induced conformational change in the CC domains is necessary and sufficient for determining the level of sGC activity.

Characterization of a unique polysaccharide monooxygenase from the plant pathogen Magnaporthe oryzae.

Blast disease in cereal plants is caused by the fungus Magnaporthe oryzae and accounts for a significant loss in food crops. At the outset of infection, expression of a putative polysaccharide monooxygenase (MoPMO9A) is increased. MoPMO9A contains a catalytic domain predicted to act on cellulose and a carbohydrate-binding domain that binds chitin. A sequence similarity network of the MoPMO9A family AA9 showed that 220 of the 223 sequences in the MoPMO9A-containing cluster of sequences have a conserved unannotated region with no assigned function. Expression and purification of the full length and two MoPMO9A truncations, one containing the catalytic domain and the domain of unknown function (DUF) and one with only the catalytic domain, were carried out. In contrast to other AA9 polysaccharide monooxygenases (PMOs), MoPMO9A is not active on cellulose but showed activity on cereal-derived mixed (1→3, 1→4)-ß-D-glucans (MBG). Moreover, the DUF is required for activity. MoPMO9A exhibits activity consistent with C4 oxidation of the polysaccharide and can utilize either oxygen or hydrogen peroxide as a cosubstrate. It contains a predicted 3-dimensional fold characteristic of other PMOs. The DUF is predicted to form a coiled-coil with six absolutely conserved cysteines acting as a zipper between the two α-helices. MoPMO9A substrate specificity and domain architecture are different from previously characterized AA9 PMOs. The results, including a gene ontology analysis, support a role for MoPMO9A in MBG degradation during plant infection. Consistent with this analysis, deletion of MoPMO9A results in reduced pathogenicity.

Batter's Shoulder: Clinical Outcomes and Return to Sport.

Background Batter's shoulder has been defined as an acute posterior subluxation of the lead shoulder during a baseball swing causing a traumatic tear of the posterior labrum. There are limited data correlating repair techniques with return-to-play information but none utilizing standardized outcome measures. The purpose of this study is to examine a case series of patients for postoperative return-to-play and obtain follow-up using standardized outcome measures. Methods We retrospectively identified 10 patients with a batter's shoulder injury. Patients were included if they met the criteria for batter's shoulder injury. We attempted contact via telephone to complete Western Ontario Shoulder Instability (WOSI) and Disability of Arm Shoulder and Hand (QuickDASH) evaluations. We successfully reached five of the patients. The minimum follow-up was one year and the maximum was 11 years. Results All five patients in our cohort were able to return to play at the previous level without limitation. Patients reported a very low percentage limitation on the WOSI and QuickDASH questionnaires and results are detailed further on. Range of motion (ROM) and strength were not affected. Conclusion Batter's shoulder is an infrequent cause of posterior labral tearing, leading to a painful swing that can limit sports activity. In our limited series, all patients treated with arthroscopic repair were able to return to play at the previous level, confirming a significantly improved prognosis for a batter's shoulder injury in contrast to return to play after other causes of posterior labral tears.

Convergent allostery in ribonucleotide reductase.

Ribonucleotide reductases (RNRs) use a conserved radical-based mechanism to catalyze the conversion of ribonucleotides to deoxyribonucleotides. Within the RNR family, class Ib RNRs are notable for being largely restricted to bacteria, including many pathogens, and for lacking an evolutionarily mobile ATP-cone domain that allosterically controls overall activity. In this study, we report the emergence of a distinct and unexpected mechanism of activity regulation in the sole RNR of the model organism Bacillus subtilis. Using a hypothesis-driven structural approach that combines the strengths of small-angle X-ray scattering (SAXS), crystallography, and cryo-electron microscopy (cryo-EM), we describe the reversible interconversion of six unique structures, including a flexible active tetramer and two inhibited helical filaments. These structures reveal the conformational gymnastics necessary for RNR activity and the molecular basis for its control via an evolutionarily convergent form of allostery.

An endogenous dAMP ligand in Bacillus subtilis class Ib RNR promotes assembly of a noncanonical dimer for regulation by dATP.

The high fidelity of DNA replication and repair is attributable, in part, to the allosteric regulation of ribonucleotide reductases (RNRs) that maintains proper deoxynucleotide pool sizes and ratios in vivo. In class Ia RNRs, ATP (stimulatory) and dATP (inhibitory) regulate activity by binding to the ATP-cone domain at the N terminus of the large α subunit and altering the enzyme's quaternary structure. Class Ib RNRs, in contrast, have a partial cone domain and have generally been found to be insensitive to dATP inhibition. An exception is the Bacillus subtilis Ib RNR, which we recently reported to be inhibited by physiological concentrations of dATP. Here, we demonstrate that the α subunit of this RNR contains tightly bound deoxyadenosine 5'-monophosphate (dAMP) in its N-terminal domain and that dATP inhibition of CDP reduction is enhanced by its presence. X-ray crystallography reveals a previously unobserved (noncanonical) α2 dimer with its entire interface composed of the partial N-terminal cone domains, each binding a dAMP molecule. Using small-angle X-ray scattering (SAXS), we show that this noncanonical α2 dimer is the predominant form of the dAMP-bound α in solution and further show that addition of dATP leads to the formation of larger oligomers. Based on this information, we propose a model to describe the mechanism by which the noncanonical α2 inhibits the activity of the B. subtilis Ib RNR in a dATP- and dAMP-dependent manner.

Transient Thermal Response of a Guarded-Hot-Plate Apparatus for Operation Over an Extended Temperature Range.

A mathematical model is presented for a new-generation guarded-hot-plate apparatus to measure the thermal conductivity of insulation materials. This apparatus will be used to provide standard reference materials for greater ranges of temperature and pressure than have been previously available. The apparatus requires precise control of 16 interacting heated components to achieve the steady temperature and one-dimensional heat-transfer conditions specified in standardized test methods. Achieving these criteria requires deriving gain settings for the 16 proportional-integral-derivative (PID) controllers, comprising potentially 48 parameters. Traditional tuning procedures based on trial-and-error operation of the actual apparatus impose unacceptably lengthy test times and expense. A primary objective of the present investigation is to describe and confirm the incremental control algorithm for this application and determine satisfactory gain settings using a mathematical model that simulates in seconds test runs that would require days to complete using the apparatus. The first of two steps to achieve precise temperature control is to create and validate a model that accounts for heating rates in the various components and interactions with their surroundings. The next step is to simulate dynamic performance and control with the model and determine settings for the PID controllers. A key criterion in deriving the model is to account for effects that significantly impact thermal conductivity measurements while maintaining a tractable model that meets the simulation time constraint. The mathematical model presented here demonstrates how an intricate apparatus can be represented by many interconnected aggregated-capacity masses to depict overall thermal response for control simulations. The major assemblies are the hot plate with four subcomponents, two cold plates with three subcomponents each, and two edge guards with three subcomponents each. Using symmetry about the hot plate, the number of components in the simulation model is reduced to 12 or 15, depending on the mode of operation for the apparatus. Configurations of the main components with embedded heating elements were carefully designed earlier using detailed finite-element analyses to give essentially isothermal surfaces and one-dimensional heat flow through test specimens. It is not tractable, or perhaps justified, to extend these prior analyses to simulate the controlled transient responses of the apparatus. The earlier design criterion does, however, support the aggregated-capacity simplification implemented in the present thermal model. The governing equations follow from dynamic energy balances on components with controlled heating elements and additional intermediate ("floating") components. Thermal bridges comprise conduction paths, with and without surface convection and radiation, between components and fixed-temperature "heat sinks." An implicit finite-difference numerical method was used to solve the resulting system of first-order differential equations. The mathematical model was initially validated using measurement data from test runs where a step change in heating rate was applied to single elements in turn, and component temperatures were recorded up to a nearly steady condition. Thermocouples and standard platinum resistance thermometers were used to measure temperatures, and thermopiles were used to measure temperature differences. Next, extensive simulations were conducted with the mathematical model to estimate suitable gain settings for the various controllers. The criteria were tight temperature control after reaching set points and acceptable times to achieve quasi-steady-state operation. Comparisons between measurements and predicted temperatures for heated components are presented. The results show that the model incorporating the above simplifying approximations is satisfactory for components comprising the hot-plate and cold-plate assemblies. For the edge guards, however, the conventional aggregated-capacity criteria are not as fully satisfied because of their configuration. Temperature variations in the edge guards, fortunately, have a lesser effect on the accuracy of the thermal conductivity measurements. Therefore, the thermal response model is deemed satisfactory for simulating PID feedback to investigate "closed-loop" control of the apparatus, thus meeting the primary objective.

X-ray Scattering Studies of Protein Structural Dynamics.

X-ray scattering is uniquely suited to the study of disordered systems and thus has the potential to provide insight into dynamic processes where diffraction methods fail. In particular, while X-ray crystallography has been a staple of structural biology for more than half a century and will continue to remain so, a major limitation of this technique has been the lack of dynamic information. Solution X-ray scattering has become an invaluable tool in structural and mechanistic studies of biological macromolecules where large conformational changes are involved. Such systems include allosteric enzymes that play key roles in directing metabolic fluxes of biochemical pathways, as well as large, assembly-line type enzymes that synthesize secondary metabolites with pharmaceutical applications. Furthermore, crystallography has the potential to provide information on protein dynamics via the diffuse scattering patterns that are overlaid with Bragg diffraction. Historically, these patterns have been very difficult to interpret, but recent advances in X-ray detection have led to a renewed interest in diffuse scattering analysis as a way to probe correlated motions. Here, we will review X-ray scattering theory and highlight recent advances in scattering-based investigations of protein solutions and crystals, with a particular focus on complex enzymes.

Gas Phase Oxidation of Campholenic Aldehyde and Solution Phase Reactivity of its Epoxide Derivative.

The rate constant for the OH reaction with campholenic aldehyde (CA) was measured using the flow tube-chemical ionization mass spectrometry method with a relative rate kinetics technique and was found to be (6.54 ± 0.52) × 10-11 cm3 molecule-1 s-1 at 100 Torr pressure and 298 K. A mechanism for the formation of the observed products was developed for both NO-free and NO-present conditions. On the basis of measurements of the pressure dependent yields of the products, between 5 and 20% of the CA oxidation at atmospheric pressure is predicted to lead to campholenic aldehyde epoxide (CAE). The aqueous solution reaction rate constants for CAE were determined via NMR spectroscopy and were found to be (2.241 ± 0.036) × 10-5 s-1 for neutral conditions and 0.0989 ± 0.0053 M-1 s-1 for acid-catalyzed conditions at 298 K. The products of the CAE aqueous solution reaction were identified as an isomer of CAE and the aldehyde group hydrated form of this isomer. Unlike the isoprene-derived epoxide, IEPOX, a nucleophilic addition mechanism was not observed. On the basis of the rate constants determined for CA and CAE, it is likely that these species are reactive on atmospherically relevant time scales in the gas and aerosol phases, respectively. The results of the present study largely support a previous supposition that α-pinene-derived secondary organic aerosol may be influenced by the multiphase processing of various intermediate species, including those with epoxide functionality.

Thermal response simulation for tuning PID controllers in a 1016 mm guarded hot plate apparatus.

A mathematical model has been developed and used to simulate the controlled thermal performance of a large guarded hot-plate apparatus. This highly specialized apparatus comprises three interdependent components whose temperatures are closely controlled in order to measure the thermal conductivity of insulation materials. The simulation model was used to investigate control strategies and derive controller gain parameters that are directly transferable to the actual instrument. The simulations take orders-of-magnitude less time to carry out when compared to traditional tuning methods based on operating the actual apparatus. The control system consists primarily of a PC-based PID control algorithm that regulates the output voltage of programmable power amplifiers. Feedback parameters in the form of controller gains are required for the three heating circuits. An objective is to determine an improved set of gains that meet temperature control criteria for testing insulation materials of interest. The analytical model is based on aggregated thermal capacity representations of the primary components and includes the same control algorithm as used in the actual hot-plate apparatus. The model, accounting for both thermal characteristics and temperature control, was validated by comparisons with test data. The tuning methodology used with the simulation model is described and results are presented. The resulting control algorithm and gain parameters have been used in the actual apparatus without modification during several years of testing materials over wide ranges of thermal conductivity, thickness, and insulation resistance values.