The Dog Bite, the Acrometastasis and the Disappearing Hamate.

In this case report, we describe a peculiar case of basaloid squamous cell carcinoma of the lung that was first diagnosed from a hamate metastasis. Acrometastases are bony metastases that are located distal to the elbow and knee. They generally become symptomatic only when a primary tumour has been identified. However, in this instance, the patient first sought medical attention following a dog bite to the ulnar side of the wrist, and thus the acrometastasis was diagnosed first, which is uncommon. We discuss the learning points relating to the unusual presentation of this case, classical acrometastatic features and a review of the literature.

Range-wide genetic analysis of an endangered bumble bee (Bombus affinis, Hymenoptera: Apidae) reveals population structure, isolation by distance, and low colony abundance.

Declines in bumble bee species range and abundances are documented across multiple continents and have prompted the need for research to aid species recovery and conservation. The rusty patched bumble bee (Bombus affinis) is the first federally listed bumble bee species in North America. We conducted a range-wide population genetics study of B. affinis from across all extant conservation units to inform conservation efforts. To understand the species' vulnerability and help establish recovery targets, we examined population structure, patterns of genetic diversity, and population differentiation. Additionally, we conducted a site-level analysis of colony abundance to inform prioritizing areas for conservation, translocation, and other recovery actions. We find substantial evidence of population structuring along an east-to-west gradient. Putative populations show evidence of isolation by distance, high inbreeding coefficients, and a range-wide male diploidy rate of ~15%. Our results suggest the Appalachians represent a genetically distinct cluster with high levels of private alleles and substantial differentiation from the rest of the extant range. Site-level analyses suggest low colony abundance estimates for B. affinis compared to similar datasets of stable, co-occurring species. These results lend genetic support to trends from observational studies, suggesting that B. affinis has undergone a recent decline and exhibit substantial spatial structure. The low colony abundances observed here suggest caution in overinterpreting the stability of populations even where B. affinis is reliably detected interannually. These results help delineate informed management units, provide context for the potential risks of translocation programs, and help set clear recovery targets for this and other threatened bumble bee species.

Topical Negative Pressure Wound Dressing and Its Applications in the Hand-A Review of the Literature.

The use of topical negative pressure wound therapy (NPWT) has become increasingly popular in the management of complex wounds. There are many theories as to the mechanism of action of NPWT, but the essential components of the various systems remain consistent. There are many attractive potential properties of negative pressure dressings that lend themselves to the management of upper limb injuries. This article explores the technique of negative pressure wound dressing, the theories pertaining to mechanism of action, and the increasingly broad indications described for the use of NPWT in the hand. The literature pertaining to the efficacy of NPWT in general is also discussed.

Predicting factors for better outcomes of stable supination external rotation type 2 ankle fractures.

PURPOSE: Stable Weber B ankle fractures are treated by a walking boot for 6 weeks and bearing full weight through the boot as tolerated. The aim of the present study was to assess the outcome parameters of this treatment protocol, evaluate the efficacy of using the walking boot, and investigate any possible predicting factors that could affect the outcomes. METHODS: All the patients with stable Weber B ankle fractures, treated in our hospital between January 2018 and December 2018, were prospectively included to the study. The patients were evaluated clinically, and the patient-reported outcome measures data were collected at the 2 and 6 weeks post-injury. Chi square, Spearman's rho test, independent samples and paired sample t-tests were used for the monovariant analysis. RESULTS: A total of 128 consecutive patients (aged 52.2 ± 19.1 years) with supination external rotation type 2 fracture were finally included to the study. At the 2 weeks follow-up, the reported outcome measures scores were in moderate levels, but improved significantly at the 6 weeks follow-up (p < 0.0001). Multivariant analysis revealed that the ability to bear full weight without the boot at the 2 weeks after diagnosis was the only variable, which made statistically unique contribution to the foot and ankle disability index score at the 6 weeks (p = 0.005). CONCLUSION: Conservative treatment using a walking boot with advice to bear full weight of stable ankle Weber B fractures can bring to good functional outcomes. The ability to bear full weight without the aid of the walking boot at 2 weeks after diagnosis was the only significant predicting factor for better outcomes at 6 weeks after diagnosis.

A Systematic Review of Arthroscopic Versus Open Debridement of the Arthritic Elbow.

PURPOSE: To systematically review the available data with regard to clinical and functional outcomes of arthroscopic and open debridement for elbow arthritis to determine the complication rate with transition to arthroscopic surgery. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta Analyses protocol, a systematic review was performed including studies reporting clinical and functional outcomes following open or arthroscopic debridement of elbow arthritis. The primary outcome measures analyzed were functional outcome (Mayo Elbow Performance Score), range of motion, and complication rate. Data were extracted for the whole group and then compared between the techniques using ranges and forest plots. RESULTS: In total, 39 level IV and 3 level III studies with 1097 elbows were eligible for inclusion; 684 elbows were treated using an open technique and 413 using an arthroscopic technique. Regarding functional outcome scores, mean Mayo Elbow Performance Score improved significantly with comparable magnitude of improvement in both groups (arthroscopic group: range 28-34, open group: range 25-31). Regarding range of motion, mean flexion-extension arc improved significantly in both groups (arthroscopic group: range 8-26°, open group: range 13-49°). The open group had a lower preoperative flexion-extension arc (range 63-96) in comparison with the arthroscopic group (range 84-119). The overall incidence of complications was 5.7% (range 0%-19%) in the arthroscopic group and 6.1% (range 0%-25%) in the open group. The most common complication type was neurologic, with an incidence of 2.1% (range 0%-8%) in the arthroscopic group and 1.9% (range 0%-12%) in the open group. The deep infection rate was 0.7% (range 0%-10%) in the open group with no reported incidence in the arthroscopic group. CONCLUSIONS: This systematic review demonstrated good mid-term functional outcomes following debridement arthroplasty of the arthritic elbow. There was no increase in complications with an arthroscopic technique confirming its safety and efficacy. LEVEL OF EVIDENCE: IV, Systematic Review of Level III and IV articles.

Indications, Outcomes, and Complications of Lateral Ulnar Collateral Ligament Reconstruction of the Elbow for Chronic Posterolateral Rotatory Instability: A Systematic Review.

BACKGROUND: Posterolateral rotatory instability (PLRI) of the elbow can lead to pain, recurrent dislocations, and, in the worst-case scenario, disability. PURPOSE: To report the indications, outcomes, and complication rates of lateral ulnar collateral ligament (LUCL) reconstruction for chronic PLRI of the elbow. STUDY DESIGN: Systematic review. METHODS: This systematic review was registered with PROSPERO and performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The review entailed 17 studies that included 168 patients with isolated LUCL reconstruction for chronic PLRI. Patients with concurrent medial collateral ligament reconstruction were excluded. The primary outcome measures were patient characteristics, indication for surgery, surgical technique, functional outcomes, and complications. RESULTS: Chronic PLRI commonly occurred after a previous traumatic injury (n = 168). Of these, there were 119 simple instabilities (no fracture) and 33 complex instabilities (associated fracture). In 11 patients, PLRI was iatrogenic. The cause was unknown in 5 patients. Grafts used were autograft (n = 102; 61%), allograft (n = 18; 11%), synthetic graft (n = 15; 9%), and unknown (n = 33; 20%). The most common surgical technique was a docking procedure or a modification of this (n = 145; 86%). Other techniques included suture anchors (n = 18; 11%), nonanatomic (n = 1; 0.6%), and unknown (n = 4; 2%). There were 45 complications reported in 37 patients (22%). The most frequent complication was recurrent instability (21/138; 15%). No other major complications were reported. The rate of recurrent instability was significantly higher in revision reconstructions (6/15 elbows; 40%) compared with primary reconstructions (15/123 elbows; 12.2%) (P = .005). The mean Mayo Elbow Performance Score and abbreviated Disabilities of the Arm, Shoulder and Hand score were 87.5 (range, 40-100) and 18.8 (range, 0-77), respectively. Of the patients in whom range of motion was measured, 134 of 144 patients (93%) regained a functional range (30L-130L). CONCLUSION: LUCL reconstruction for chronic PLRI proved a reliable method of reconstruction, save for the moderate rate of recurrent instability, which was highest in revision reconstructions.

Comparison of all suture fixation with tension band wiring and plate fixation of the olecranon.

BACKGROUND: Tension band wiring and plate fixation are common techniques used to stabilize simple olecranon fractures and osteotomies of the olecranon. All suture fixation is an alternative technique but has not been compared previously to these traditional methods. The aim of this study was to compare the clinical and radiographic outcomes of the three techniques. METHODS: One hundred and sixty-eight consecutive Mayo type 1 and 2 olecranon fractures (n = 138) and olecranon osteotomies (n = 30) with a minimum follow-up time of one year were compared. The primary outcome measure was the rate of re-operation. Secondary outcome measures were the incidence of complications, rate of radiographic union and incidence of radiographic reduction loss. RESULTS: Fixation was performed using tension band wiring in 89 patients, plating in 38 patients and suture fixation in 41 patients. There was no significant difference in the fracture type according to the Mayo classification between the groups. The re-operation rate was significantly higher in the tension band wiring group (36%) compared with both the plate group (11%, p = 0.03) and the suture group (2%, p = 0.002). There were two revision fixations in the tension band wiring group and one in the suture group. There was one asymptomatic non-union in the suture group. All other fractures and osteotomies achieved radiographic union. CONCLUSION: Suture fixation of simple olecranon fractures and osteotomies was reliable in providing stable union and had a significantly lower re-operation rate when compared with tension band wiring.

Coronal shear fractures of the distal humerus: Current concepts and surgical techniques.

Coronal shear fractures of the distal humerus are a unique subset of distal humeral fractures which entail partial or complete articular fractures of the distal humerus without involvement of the columns. The very distal nature of these fragments, their small size and propensity for comminution render them challenging to treat surgically. The purpose of this article is to describe the classification, outcomes and surgical techniques currently used for the treatment of these fractures using the available literature and authors' clinical experience.

Oats-From Farm to Fork.

Oats have a long history of use as human food and animal feed. From its origins in the Fertile Crescent, the oat has adapted to a wide range of climatic conditions and geographic regions. Its unique macro-, micro-, and phytonutrient composition, high nutritional value, and relatively low agricultural input requirements makes oats unique among cereal crops. The health benefits of the oats are becoming well established. While the connection between oat ß-glucan fiber in reducing the risk of cardiovascular disease and controlling glycemia have been unequivocally established, other potential benefits including modulation of intestinal microbiota and inflammation continue to be explored. Advances in food technology are continuing to expand the diversity of oat-based foods, creating opportunities to deliver the health benefits of oats to a larger segment of the population.

Factors associated with adherence to phosphodiesterase type 5 inhibitors for the treatment of pulmonary arterial hypertension.

OBJECTIVES: To assess factors associated with adherence to phosphodiesterase type 5 inhibitors (PDE5Is) in the management of pulmonary arterial hypertension (PAH). METHODS: This study analyzed pharmacy benefit claims of naïve Adcirca and Revatio users between January 1, 2008 and December 31, 2010. Patients were considered adherent if their proportion of days covered (PDC) was ≥ 80% over a 6-month period. Logistic regressions were estimated to assess the factors associated with adherence. Analyses were stratified by use of a specialty pharmacy or retail pharmacy. A sensitivity analysis was performed by excluding individuals with 90-day supply. RESULTS: Of the total of 2143 patients included, 46.8% were adherent. Adherence was higher among 930 specialty pharmacy users (65.6%) than 1213 retail pharmacy users (32.3%, p < 0.001). Adherence was higher among Adcirca users (60.7%; approved dose 40 mg once-daily) than Revatio users (44.3%, p < 0.001; approved dose 20 mg thrice-daily). Among retail pharmacy users, adherence was higher in patients using Adcirca (OR = 2.59; 95% CI = 1.60-4.22) and patients with an index prescription given by pulmonologists (OR = 1.70; 95% CI = 1.15-2.50), while lower in patients with higher copayment ($51-$250: OR = 0.61, 95% CI = 0.42-0.90; $251+: OR = 0.57, 95% CI = 0.39-0.83). Among specialty pharmacy users, only high copayment ($251+: OR = 0.56, 95% CI = 0.35-0.90) was found to be a significant factor for non-adherence. After excluding individuals with 90-day supply, adherence rate was 29.6% in retail pharmacy and 57.9% in specialty pharmacy (p < 0.001), and regression results were similar. LIMITATIONS: Diagnosis of PAH was not confirmed without access to medical claims. Pharmacy refill records might not reflect actual consumption. Adherence evaluated for 6 months might not be generalizable to longer periods. CONCLUSION: Adherence to PDE5Is for PAH is sub-optimal. The findings suggest that adherence to PDE5Is in patients with PAH is associated with the use of specialty pharmacy, simpler dosing frequency, a lower financial barrier, and a prescription given by pulmonologists.

Angiopoietin-1 variant reduces LPS-induced microvascular dysfunction in a murine model of sepsis.

INTRODUCTION: Severe sepsis is characterised by intravascular or extravascular infection with microbial agents, systemic inflammation and microcirculatory dysfunction, leading to tissue damage, organ failure and death. The growth factor angiopoietin (Ang-1) has therapeutic potential but recombinant Ang-1 tends to aggregate and has a short half-life in vivo. This study aimed to investigate the acute effects of the more stable Ang-1 variant matrilin-1-angiopoietin-1 (MAT.Ang-1) on the function of the microcirculation in an experimental model of sepsis, and whether any protection by MAT-Ang-1 was associated with modulation of inflammatory cytokines, angiogenic factors or the endothelial nitric oxide synthase (eNOS)-Akt and vascular endothelial (VE)-cadherin pathways. METHODS: Aluminium window chambers were implanted into the dorsal skinfold of male C3H/HeN mice (7 to 10 weeks old) to expose the striated muscle microcirculation. Endotoxemia was induced by intraperitoneal injection of lipopolysaccharide (LPS, 1 mg/kg at 0 and 19 hours). MAT.Ang-1 was administered intravenously 20 hours after the onset of sepsis. Microcirculatory function was evaluated by intravital microscopy and Doppler fluximetry. RESULTS: Endotoxemia resulted in macromolecular leak, which was ameliorated by MAT.Ang-1 post-treatment. LPS induced a dramatic reduction in tissue perfusion, which was improved by MAT.Ang-1. Proteome profiler array analysis of skeletal muscle also demonstrated increased inflammatory and reduced angiogenic factors during endotoxemia. MAT.Ang-1 post-treatment reduced the level of IL-1ß but did not significantly induce the expression of angiogenic factors. MAT.Ang-1 alone did not induce leak or increase angiogenic factors but did reduce vascular endothelial growth factor expression in controls. CONCLUSION: Administration of MAT.Ang-1 after the onset of sepsis protects the microcirculation from endotoxemia-induced vascular dysfunction through reducing inflammation but without pro-angiogenic actions, thus representing a novel, potential pharmacotherapeutic agent for the treatment of sepsis.