Enhancing the activity and succinyl-CoA specificity of 3-ketoacyl-CoA thiolase Tfu_0875 through rational binding pocket engineering.

The 3-ketoacyl-CoA thiolase is the rate-limiting enzyme for linear dicarboxylic acids production. However, the promiscuous substrate specificity and suboptimal catalytic performance have restricted its application. Here we present both biochemical and structural analyses of a high-efficiency 3-ketoacyl-CoA thiolase Tfu_0875. Notably, Tfu_0875 displayed heightened activity and substrate specificity for succinyl-CoA, a key precursor in adipic acid production. To enhance its performance, a deep learning approach (DLKcat) was employed to identify effective mutants, and a computational strategy, known as the greedy accumulated strategy for protein engineering (GRAPE), was used to accumulate these effective mutants. Among the mutants, Tfu_0875N249W/L163H/E217L exhibited the highest specific activity (320% of wild-type Tfu_0875), the greatest catalytic efficiency (kcat/KM = 1.00 min-1mM-1), the highest succinyl-CoA specificity (KM = 0.59 mM, 28.1% of Tfu_0875) and dramatically reduced substrate binding energy (-30.25 kcal mol-1v.s. -15.94 kcal mol-1). A structural comparison between Tfu_0875N249W/L163H/E217L and the wild type Tfu_0875 revealed that the increased interaction between the enzyme and succinyl-CoA was the primary reason for the enhanced enzyme activity. This interaction facilitated rapid substrate anchoring and stabilization. Furthermore, a reduced binding pocket volume improved substrate specificity by enhancing the complementarity between the binding pocket and the substrate in stereo conformation. Finally, our rationally designed mutant, Tfu_0875N249W/L163H/E217L, increased the adipic acid titer by 1.35-fold compared to the wild type Tfu_0875 in shake flask. The demonstrated enzymatic methods provide a promising enzyme variant for the adipic acid production. The above effective substrate binding pocket engineering strategy can be beneficial for the production of other industrially competitive biobased chemicals when be applied to other thiolases.

Improvement of Chalcone Synthase Activity and High-Efficiency Fermentative Production of (2S)-Naringenin via In Vivo Biosensor-Guided Directed Evolution.

Chalcone synthase (CHS) catalyzes the rate-limiting step of (2S)-naringenin (the essential flavonoid skeleton) biosynthesis. Improving the activity of the CHS by protein engineering enhances (2S)-naringenin production by microbial fermentation and can facilitate the production of valuable flavonoids. A (2S)-naringenin biosensor based on the TtgR operon was constructed in Escherichia coli and its detection range was expanded by promoter optimization to 0-300 mg/L, the widest range for (2S)-naringenin reported. The high-throughput screening scheme for CHS was established based on this biosensor. A mutant, SjCHS1S208N with a 2.34-fold increase in catalytic activity, was discovered by directed evolution and saturation mutagenesis. A pathway for de novo biosynthesis of (2S)-naringenin by SjCHS1S208N was constructed in Saccharomyces cerevisiae, combined with CHS precursor pathway optimization, increasing the (2S)-naringenin titer by 65.34% compared with the original strain. Fed-batch fermentation increased the titer of (2S)-naringenin to 2513 ± 105 mg/L, the highest reported so far. These findings will facilitate efficient flavonoid biosynthesis and further modification of the CHS in the future.

Metabolic Pathway Coupled with Fermentation Process Optimization for High-Level Production of Retinol in Yarrowia lipolytica.

Retinol is a lipid-soluble form of vitamin A that is crucial for human visual and immune functions. The production of retinol through microbial fermentation has been the focus of recent exploration. However, the obtained titer remains limited and the product is often a mixture of retinal, retinol, and retinoic acid, necessitating purification. To achieve efficient biosynthesis of retinol in Yarrowia lipolytica, we improved the metabolic flux of ß-carotene to provide sufficient precursors for retinol in this study. Coupled with the optimization of the expression level of ß-carotene 15,15'-dioxygenase, de novo production of retinol was achieved. Furthermore, Tween 80 was used as an extractant and butylated hydroxytoluene as an antioxidant to extract intracellular retinol and prevent retinol oxidation, respectively. This strategy significantly increased the level of retinol production. By optimizing the enzymes converting retinal to retinol, the proportion of extracellular retinol in the produced retinoids reached 100%, totaling 1042.3 mg/L. Finally, total retinol production reached 5.4 g/L through fed-batch fermentation in a 5 L bioreactor, comprising 4.2 g/L extracellular retinol and 1.2 g/L intracellular retinol. This achievement represents the highest reported titer so far and advances the industrial production of retinol.

Dynamic regulation and cofactor engineering of escherichia coli to enhance production of glycolate from corn stover hydrolysate.

Glycolic acid is widely employed in chemical cleaning, the production of polyglycolic acid-lactic acid, and polyglycolic acid. Currently, the bottleneck of glycolate biosynthesis lies on the imbalance of metabolic flux and the deficiency of NADPH. In this study, a dynamic regulation system was developed and optimized to enhance the metabolic flux from glucose to glycolate. Additionally, the knockout of transhydrogenase (sthA), along with the overexpression of pyridine nucleotide transhydrogenase (pntAB) and the implementation of the Entner-Doudoroff pathway, were performed to further increase the production of the NADPH, thereby increasing the titer of glycolate to 5.6 g/L. To produce glycolate from corn stover hydrolysate, carbon catabolite repression was alleviated and glucose utilization was accelerated. The final strain, E. coli Mgly10-245, is inducer-free, achieving a glycolate titer of 46.1 g/L using corn stover hydrolysate (77.1 % of theoretical yield). These findings will contribute to the advancement of industrial glycolate production.

High-Level De Novo Production of (2S)-Eriodictyol in Yarrowia Lipolytica by Metabolic Pathway and NADPH Regeneration Engineering.

(2S)-Eriodictyol, a polyphenolic flavonoid, has found widespread applications in health supplements and food additives. However, the limited availability of plant-derived (2S)-eriodictyol cannot meet the market demand. Microbial production of (2S)-eriodictyol faces challenges, including the low catalytic efficiency of flavone 3'-hydroxylase/cytochrome P450 reductase (F3'H/CPR), insufficient precursor supplementation, and inadequate NADPH regeneration. This study systematically engineered Yarrowia lipolytica for high-level (2S)-eriodictyol production. In doing this, the expression of F3'H/CPR was balanced, and the supply of precursors was enhanced by relieving feedback inhibition of the shikimate pathway, promoting fatty acid ß-oxidation, and increasing the copy number of synthetic pathway genes. These strategies, combined with NADPH regeneration, achieved an (2S)-eriodictyol titer of 423.6 mg/L. Finally, in fed-batch fermentation, a remarkable 6.8 g/L (2S)-eriodictyol was obtained, representing the highest de novo microbial titer reported to date and paving the way for industrial production.

Enhanced Selective Hydrogenation of Cinnamaldehyde to Cinnamyl Alcohol over Silica-Coated Pt-CoxOy Hybrid Nanoparticles.

Selective hydrogenation of cinnamaldehyde (CAL) to cinnamyl alcohol (COL) is difficult due to the intrinsic difficulty with thermodynamically easier hydrogenation of C═C bonds. In this work, Pt-CoxOy hybrid nanoparticles encapsulated in mesoporous silica nanospheres (Pt-CoxOy@mSiO2) were synthesized by a sol-gel method, which showed greatly improved COL selectivity for hydrogenation of CAL. At 80 °C and 1.0 MPa of H2, Pt-CoxOy@mSiO2 achieved a CAL conversion of 98.7% with a COL selectivity of 93.5%. In contrast, Pt@mSiO2 yields 3-phenylpropanol (HCOL) as the major product with HCOL selectivity of 67.2%, while PtCo@mSiO2 yields 3-phenylpropionaldehyde with selectivity of 51.8% under the same conditions. The enhanced catalytic performance of Pt-CoxOy@mSiO2 for hydrogenation of CAL to COL is ascribed to the Pt surface electron deficiency induced by metal-oxide interaction, and the protection of active NPs by silica shells results in good catalytic stability.

Metabolic engineering of Paracoccus denitrificans for dual degradation of sulfamethoxazole and ammonia nitrogen.

Sulfamethoxazole (SMX), as one of the most widely used sulfonamide antibiotics, has been frequently detected in the aqueous environment, posing potential risks to the environment and human health. Although microbial degradation methods have been widely applied, some issues remain, including low degradation efficiency and poor environmental adaptability. In this regard, constructing efficient degrading bacteria by metabolic engineering is an ideal solution to these challenges. In this study, we used Paracoccus denitrificans DYTN-1, a superior nitrogen removal environment strain, as chassis to construct an SMX degradation pathway, obtaining a new bacteria for simultaneous degradation of SMX and removal of ammonia nitrogen. In doing this, we first identified and characterized four native promoters of P. denitrificans DYTN-1 with gradient strength to control the expression of the SMX degradation pathway. After degradation pathway expression level optimization and FMN reductase optimization, SMX degradation efficiency was significantly improved. The constructed P. d-pIAB4-PCS-sutR strain exhibited superior co-degradation of SMX and ammonia nitrogen contaminants with degradation rates of 44% and 71%, respectively. This study could pave the way for SMX degradation engineered strain design and evolution of environmental bioremediation. IMPORTANCE The abuse of sulfamethoxazole (SMX) had led to an increased accumulation in the environment, resulting in the disruption of the structure of microbial communities, further disrupting the bio-degradation process of other pollutants, such as ammonia nitrogen. To solve this challenge, we first identified and characterized four native promoters of Paracoccus denitrificans DYTN-1 with gradient strength to control the expression of the SMX degradation pathway. Then SMX degradation efficiency was significantly improved with degradation pathway expression level optimization and FMN reductase optimization. Finally, the superior nitrogen removal environment strain, P. denitrificans DYTN-1, obtained an SMX degradation function. This pioneering study of metabolic engineering to enhance the SMX degradation in microorganisms could pave the way for designing the engineered strains of SMX and nitrogen co-degradation and the environmental bioremediation.

Genetically Encoded Biosensor Engineering for Application in Directed Evolution.

Although rational genetic engineering is nowadays the favored method for microbial strain improvement, building up mutant libraries based on directed evolution for improvement is still in many cases the better option. In this regard, the demand for precise and efficient screening methods for mutants with high performance has stimulated the development of biosensor-based high-throughput screening strategies. Genetically encoded biosensors provide powerful tools to couple the desired phenotype to a detectable signal, such as fluorescence and growth rate. Herein, we review recent advances in engineering several classes of biosensors and their applications in directed evolution. Furthermore, we compare and discuss the screening advantages and limitations of two-component biosensors, transcription-factor-based biosensors, and RNA-based biosensors. Engineering these biosensors has focused mainly on modifying the expression level or structure of the biosensor components to optimize the dynamic range, specificity, and detection range. Finally, the applications of biosensors in the evolution of proteins, metabolic pathways, and genome-scale metabolic networks are described. This review provides potential guidance in the design of biosensors and their applications in improving the bioproduction of microbial cell factories through directed evolution.

Ultrafine Vacancy-Rich Nb2O5 Semiconductors Confined in Carbon Nanosheets Boost Dielectric Polarization for High-Attenuation Microwave Absorption.

The integration of nano-semiconductors into electromagnetic wave absorption materials is a highly desirable strategy for intensifying dielectric polarization loss; achieving high-attenuation microwave absorption and realizing in-depth comprehension of dielectric loss mechanisms remain challenges. Herein, ultrafine oxygen vacancy-rich Nb2O5 semiconductors are confined in carbon nanosheets (ov-Nb2O5/CNS) to boost dielectric polarization and achieve high attenuation. The polarization relaxation, electromagnetic response, and impedance matching of the ov-Nb2O5/CNS are significantly facilitated by the Nb2O5 semiconductors with rich oxygen vacancies, which consequently realizes an extremely high attenuation performance of - 80.8 dB (> 99.999999% wave absorption) at 2.76 mm. As a dielectric polarization center, abundant Nb2O5-carbon heterointerfaces can intensify interfacial polarization loss to strengthen dielectric polarization, and the presence of oxygen vacancies endows Nb2O5 semiconductors with abundant charge separation sites to reinforce electric dipole polarization. Moreover, the three-dimensional reconstruction of the absorber using microcomputer tomography technology provides insight into the intensification of the unique lamellar morphology regarding multiple reflection and scattering dissipation characteristics. Additionally, ov-Nb2O5/CNS demonstrates excellent application potential by curing into a microwave-absorbing, machinable, and heat-dissipating plate. This work provides insight into the dielectric polarization loss mechanisms of nano-semiconductor/carbon composites and inspires the design of high-performance microwave absorption materials.

Malignant transformation of an aneurysmal bone cyst of the femoral neck: A case report.

Aneurysmal bone cyst (ABC) is a benign, distending, osteolytic and locally aggressive bone tumor that is mostly associated with trauma. Approximately 1% of bone tumors are ABCs, which are most prevalent in adolescents and are usually detected in the spine and long tubular bones. The diagnosis of ABC mainly relies on histopathology, malignant transformation is rare, and the chance of malignancy increases if there are multiple recurrences. Due to the rarity of reports of malignant transformation of ABCs into osteosarcoma, there is still considerable debate on the appropriate treatment strategy. The current paper presents a case of aneurysmal bone cyst malignant to osteosarcoma and the therapeutic measures to provide expertise for the diagnosis and treatment of ABCs that are malignant to osteosarcoma.

A systematic review and meta-analysis comparing outcomes following total knee arthroplasty for rheumatoid arthritis versus for osteoarthritis.

PURPOSE: Total knee arthroplasty (TKA) in patients with osteoarthritis (OA) are considered to be a successful procedure, but with little being known about outcomes in patients with rheumatoid arthritis (RA). The aim of this study was to compare the outcomes of TKA in patients with RA versus OA. METHODS: Data were obtained from PubMed, Cochrane Library, EBSCO and Scopus for all available studies comparing the outcomes of THA in RA and OA patients (From January 1, 2000 to October 15, 2022). Outcomes of interest included infection, revision, venous thromboembolism (VTE), mortality, periprosthetic fractures, prosthetic loosening, length of stay, and satisfaction. Two reviewers independently assessed each study for quality and extracted data. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS). RESULTS: Twenty-four articles with a total 8,033,554 patients were included in this review. The results found strong evidence for increased risk of overall infection (OR = 1.61, 95% CI, 1.24-2.07; P = 0.0003), deep infection (OR = 2.06, 95% CI, 1.37-3.09; P = 0.0005), VTE (OR = 0.76, 95% CI, 0.61-0.93; P = 0.008), pulmonary embolism (PE) (OR = 0.84, 95% CI, 0.78-0.90; P<0.00001), periprosthetic fractures (OR = 1.87, 95% CI, 1.60-2.17; P<0.00001); and reasonable evidence for increased risk of deep venous thrombosis (DVT) (OR = 0.74, 95% CI, 0.54-0.99; P = 0.05), and length of stay (OR = 0.07, 95% CI, 0.01-0.14; P = 0.03) after TKA in patients with RA versus OA. There were no significant differences in superficial site infection (OR = 0.84,95% CI, 0.47-1.52; P = 0.57), revision (OR = 1.33,95% CI, 0.79-2.23; P = 0.28), mortality (OR = 1.16,95% CI, 0.87-1.55; P = 0.32), and prosthetic loosening (OR = 1.75, 95% CI, 0.56-5.48; P = 0.34) between the groups. CONCLUSION: Our study demonstrated that patients with RA have a higher risk of postoperative infection, VTE, periprosthetic fracture, and lengths of stay, but did not increase revision rate, prosthetic loosening and mortality compared to patients with OA following TKA. In conclusion, despite RA increased incidence of postoperative complications, TKA should continue to be presented as an effective surgical procedure for patients whose conditions are intractable to conservative and medical management of RA.

Screening and Constructing a Library of Promoter-5'-UTR Complexes with Gradient Strength in Pediococcus acidilactici.

The GRAS (generally recognized as safe) strain Pediococcus acidilactici is well known for its antibacterial and probiotic functions. Furthermore, as P. acidilactici has excellent high temperature and salt resistance, it is an ideal host for the production of food enzymes, food additives, and pharmaceuticals. In this regard, it is desirable and feasible to enhance the production of these products through the metabolic engineering of P. acidilactici. However, the rare gene expression elements greatly obstruct the development of engineering P. acidilactici. In this study, we screened and constructed a library of promoter-5'-UTR (PUTR) complexes in P. acidilactici DY15 for regulating gene expression at the transcription and translation levels. In the post-log phase, the mRNA and protein expression level ranges of the 90 screened native PUTRs were 0.059-2010% and 0.77-245%, respectively, of the P32 promoter. Besides, several PUTRs exhibited great expression stability under high temperature, salt, and ethanol stress. We analyzed the structure of PUTRs and obtained the conserved regions of the promoter and 5'-UTR. Based on the identified core regions of PUTRs, we constructed a panel of combinatorial PUTRs with higher and stable protein expression levels. The strongest combinatorial PUTR was 853% of the P32 promoter in the protein expression level. Finally, the obtained PUTRs were applied to optimize the expression level of aminotransferase and improve the phenyllactic acid (PLA) production in P. acidilactici DY15. The achieved yield was 950.6 mg/L, which was 79.2% higher than the wild-type strain. These results indicated that the obtained PUTRs with gradient strength had great potential for precisely regulating gene expression to achieve various goals in P. acidilactici.

Synthesis of Mesoporous Silica-Supported NiCo Bimetallic Nanocatalysts and Their Enhanced Catalytic Hydrogenation Performance.

In this work, mesoporous silica SBA-16-supported NiCo bimetallic nanocatalysts were synthesized by coimpregnation of Ni and Co precursors followed by calcination and reduction, and various characterization techniques confirm the formation of NiCo bimetallic nanostructures in the catalysts. The synthesized NiCo/SBA-16 shows enhanced catalytic performance for hydrogenation of a series of nitroaromatics. Under the reaction conditions of 80 °C and 1.0 MPa of H2, the yields of aniline for nitrobenzene hydrogenation over NiCo0.3/SBA-16 can reach more than 99% at 2.0 h. The enhanced catalytic performance can be ascribed to the formation of NiCo bimetallic nanostructures, where the synergistic effect between Ni and Co improves their catalytic activities for hydrogenation of nitroaromatics.

Osteoblastoma of the patella, a rare benign bone tumor with an uncommon site: A case report.

Osteoblastoma is a rare, benign, bone-forming tumor that is frequently observed in the spine and long tubular bones. There are very few reports available on osteoblastoma of the patella. The present study reported an extremely rare case of a 22-year-old male adult who presented with an osteoblastoma of the patella. He was treated via intralesional curettage of the patella with subsequent bone grafting. After the intervention, he made an uneventful recovery with no recurrence after a follow-up of 2 years. Making an accurate diagnosis of osteoblastoma of the patella is challenging and important for determining the correct treatment modality and prognosis, therefore, the present case may be helpful in the diagnosis and treatment of osteoblastoma of the patella.

Cementless total hip arthroplasty for treatment of acetabular protrusion secondary to rheumatoid arthritis.

BACKGROUND: To explore the surgical technique and clinical outcomes of cementless total hip arthroplasty (THA) combined with impacted bone grafting for the treatment of moderate and severe acetabular protrusion with rheumatoid arthritis (RA). METHODS: From January 2010 to October 2020, 45 patients (56 hips), including 17 men (22 hips) and 28 women (34 hips) with acetabular impingement secondary to RA, were treated with bioprosthetic THA combined with autologous bone grafting at our hospital. According to the Sotello-Garza and Charnley classification criteria, there were 40 cases (49 hips) of type II (protrusio acetabuli 6-15 mm) and 5 cases (7 hips) of type III (protrusio acetabuli > 15 mm). At the postoperative follow-up, the ROM of the hip joint, the VAS score, and the Harris score were evaluated. The healing of the bone graft, the restoration of the hip rotation center, and the prosthesis loosening were assessed by plain anteroposterior radiographs. RESULTS: The average operation time was 95.53 ± 22.45 min, and the mean blood loss was 156.16 ± 69.25 mL. There were no neurovascular complications during the operation. The mean follow-up duration was 5.20 ± 1.20 years. The horizontal distance of the hip rotation center increased from preoperative 10.40 ± 2.50 mm to postoperative 24.03 ± 1.77 mm, and the vertical distance increased from preoperative 72.36 ± 3.10 mm to postoperative 92.48 ± 5.31 mm. The range of flexion motion of the hip joint increased from 39.48 ± 8.36° preoperatively to 103.07 ± 7.64° postoperatively, and the range of abduction motion increased from 10.86 ± 4.34° preoperatively to 36.75 ± 3.99° postoperatively. At the last follow-up, the Harris score increased from 37.84 ± 4.74 to 89.55 ± 4.05. All patients were able to move independently without assistance. CONCLUSIONS: Cementless THA combined with impacted grafting granule bone of the autogenous femoral head and biological acetabular cup can reconstruct the acetabulum, restore the rotation center of the hip joint, and achieve good medium-term outcomes in the treatment of moderate to severe acetabular herniation secondary to RA.

Metabolic engineering and fermentation optimization strategies for producing organic acids of the tricarboxylic acid cycle by microbial cell factories.

The organic acids of the tricarboxylic acid (TCA) pathway are important platform compounds and are widely used in many areas. The high-productivity strains and high-efficient and low-cost fermentation are required to satisfy a huge market size. The high metabolic flux of the TCA pathway endows microorganisms potential to produce high titers of these organic acids. Coupled with metabolic engineering and fermentation optimization, the titer of the organic acids has been significantly improved in recent years. Herein, we discuss and compare the recent advances in synthetic pathway engineering, cofactor engineering, transporter engineering, and fermentation optimization strategies to maximize the biosynthesis of organic acids. Such engineering strategies were mainly based on the TCA pathway and glyoxylate pathway. Furthermore, organic-acid-secretion enhancement and renewable-substrate-based fermentation are often performed to assist the biosynthesis of organic acids. Further strategies are also discussed to construct high-productivity and acid-resistant strains for industrial large-scale production.

Comparable clinical outcomes of culture-negative and culture-positive periprosthetic joint infections: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to compare the clinical outcomes of culture-negative periprosthetic joint infection (CN PJI) with those of culture-positive periprosthetic joint infection (CP PJI). METHODS: Data were obtained from Embase, Web of Science and EBSCO for all available studies comparing the clinical outcomes of CN PJI with those of CP PJI. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess clinical outcomes. Subgroup analyses were performed to explain heterogeneity among the included studies. Publication bias was estimated using Begg's funnel plot. Sensitivity analysis was performed to test the stability of pooled results. RESULTS: Thirty studies with 1630 (38.7%) CN PJI and 2577 (61.3%) CP PJI were included in this meta-analysis. The pooled results of the included studies showed that overall failure rate in CN PJI group (19.0%, 309/1630) was significantly lower than that in CP PJI group (23.4%, 604/2577) (OR 0.63, 95% CI 0.47-0.84, P = 0.002). We performed the subgroup analysis based on the surgical strategies, the pooled results of nine studies for patients undergoing debridement, antibiotics and implant retention (DAIR) revealed that failure rate in CN PJI group (22.2%, 53/239) was significantly lower than that in CP PJI group (29.3%, 227/775) (OR 0.62, 95% CI 0.43-0.90, P = 0.01), the pooled results of four studies for patients undergoing one-stage revision revealed that failure rate between CN PJI group (11.5%, 11/96) and CP PJI group (7.6%, 27/355) had no significant difference (OR 1.57, 95% CI 0.75-3.26, P = 0.23), and the pooled results of 19 studies for patients undergoing two-stage revision revealed that failure rate in CN PJI group (16.1%, 171/1062) was significantly lower than that in CP PJI group (20.4%, 206/1010) (OR 0.52, 95% CI 0.34-0.79, P = 0.002). CONCLUSIONS: CN PJI group had similar or better survival rate when compared with CP PJI group for patients who underwent DAIR, one-stage or two-stage revision. Negative culture was not a worse prognostic factor for PJI.

Effect of a reused insulin needle remaining in a patient's body.

Diabetes is one of the most common chronic diseases at present, and insulin pen injection therapy plays an important role in the treatment of diabetes. However, the majority of patients might reuse disposable insulin pen needles for various reasons, which leads to related complications. As far as we know, this article is the first to describe a patient whose needle remained in the right upper limb while reusing a disposable insulin injection needle for subcutaneous insulin injection with the non-dominant hand. The patient went to the doctor 1 week later. The needle moved from the lateral area of the proximal upper arm (the injection site) to the posterolateral area of the distal upper arm. The needle was then successfully removed by surgery. The reuse of disposable insulin pen needles might lead to serious complications. It is suggested to strengthen the education of people living with diabetes to help them use insulin pen needles safely.

Clinical effects of interspace between the popliteal artery and capsule of the posterior knee block with multimodal analgesia for total knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: Combination of regional anaesthesia technique that is most effective in analgesia and postoperative functional outcome with the fewest complications needs investigation. Interspace between the popliteal artery and the capsule of the posterior knee block (IPACK) has been introduced clinically. We evaluated the efficacy of IPACK in combination with other nerve blocks after total knee arthroplasty. METHODS: Data were obtained from PubMed, Cochrane Library, Web of Science, and Sciencedirect. Studies that compared outcomes using IPACK combined with other regional nerve blocks after total knee arthroplasty with other analgesic modalities and those which used pain scores or opioid consumption as primary or secondary outcomes were included. RESULTS: Seventeen articles (20 trials, 1652 patients) were included. IPACK supplementation significantly reduced rest pain scores after total knee arthroplasty at postoperative hours 8-12(95%CI - 0.85 [- 1.36, - 0.34], I2 = 94%, p = 0.001), postoperative day 1 (95% CI - 0.49 [- 0.85, - 0.14], I2 = 87%, p = 0.006), and postoperative day 2 (95% CI - 0.28 [- 0.51, -0.05], I2 = 72%, p = 0.02); there was no significant difference at postoperative day 3 or discharge (95% CI - 0.14 [- 0.33, 0.05], I2 = 0%, p = 0.14). Combination treatment resulted in reduced dynamic pain scores at postoperative hours 8-12 (95%CI - 0.52 [- 0.92, - 0.12], I2 = 86%, p = 0.01) and postoperative day 1(95% CI - 0.49 [- 0.87, - 0.11], I2 = 88%, p = 0.01). There was no difference between postoperative day 2(95% CI - 0.29 [- 0.63, 0.05], I2 = 80%, p = 0.09), postoperative day 3 or discharge (95% CI - 0.45 [- 0.92, 0.02], I2 = 83%, p = 0.06). In addition, it strongly reduced postoperative opioid consumption within 24 H (95% CI - 0.76 [- 1.13, - 0.39], I2 = 85%, p < 0.00001), 24-48 H (95% CI - 0.43 [- 0.85, - 0.01], I2 = 83%, p = 0.04), and total opioid use (95% CI - 0.64 [- 1.07, - 0.22], I2 = 86%, p = 0.003). Although IPACK supplementation improved timed up and go test and walking distance at postoperative day 2, there was no statistically significant difference at other time periods or obvious improvement in knee range of motion and quadriceps strength. IPACK block supplementation could shorten the length of stay (LOS) (95% CI - 0.40 [- 0.64, - 0.15], I2 = 70%, p = 0.001) and improve patient satisfaction (95% CI 0.43 [0.01, 0.84], I2 = 87%, p = 0.04). CONCLUSION: Based on these results, IPACK supplementation, in addition to standard postoperative analgesia, can be used effectively and safely to relieve early postoperative pain after total knee arthroplasty.