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Objectives: Early stages of osteochondral lesions with or without cystic changes are amenable to revitalization and cartilage restoration. In these cases, we assess the outcome using our standard technique and by eliminating the need for malleolar osteotomy. Materials and Methods: Seven cases of osteochondral lesion of talus were treated with retroarticular drilling under arthroscopy and fluoroscopy assistance. These cases were followed up for a minimum of 6 months (mean 20 ± 12.53 months). The functional outcome was assessed using American Orthopedic Foot and Ankle Score (AOFAS) hindfoot score. Results: The AOFAS increased from 49.28 (±6.7) points to 85 (±9.12) points and was noted to be statistically significant (P < 0.001). 2/7 ankles were lateral sided lesion and had a history of trauma. 6/7 cases had an intact intraoperative cartilage status, whereas one case had Grade C (fissures and fibrillation). However, the location of lesion or the grade of lesion did not influence the results. Conclusion: This treatment modality seems to be a feasible option for early lesions and can be considered before alternative cartilage replacement treatment strategies are employed.

The practice of arthroscopy in India had started as early as 1978; and during the same year, the Indian chapter of the International Arthroscopy Association was drafted alongside other countries such as Australia and Brazil. The subspecialty of arthroscopy has been a boon to both; the orthopedic surgeon and the patient. The advent of arthroscopy has enabled the orthopedic surgeon to clearly visualize and delineate the extent of disease, with minimal invasion. Moreover, the patient is benefited with rapid recovery and an early return to activities. The present-day arthroscopic surgeries include diagnostic arthroscopy, ligament reconstruction, cartilage repair, and labral repairs and have undoubtedly evolved into a glamorous subspecialty in orthopedics. However, before the technological advancements, the technique of arthroscopy had modest origins. This review traverses through the history of arthroscopy with special emphasis on the advances of arthroscopy in India.

Traumatic proximal tibiofibular joint dislocations occur infrequently and are typically the result of high-energy trauma. These injuries can be a marker of limb injury severity because patients often sustain vascular injury and are at high risk of amputation. The purpose of this study was to present a systematic review of traumatic proximal tibiofibular joint dislocations and compare rates of associated injuries with a retrospective series of patients at a level 1 trauma center. The secondary objective was to report rates and clinical predictors of limb amputation.A systematic review was conducted, identifying three studies meeting eligibility criteria. A retrospective chart review was conducted identifying 17 skeletally mature patients with proximal tibiofibular dislocation treated from January 2010 to February 2021. A chart review extracted patient demographics, fracture patterns, open fracture, preoprative and postoperative peroneal nerve injury, vascular injury, and amputation. Binary logistic regression analysis was used to identify clinical predictors of outcomes.Sixteen of 17 proximal tibiofibular injuries (94.1%) were associated with fracture, most commonly tibial shaft (n = 11, 68.75%). Twelve of 17 fractures (76.5%) were open. Five vascular injuries (29.4%) occurred requiring surgical intervention. Seven (41.2%) preoperative peroneal nerve deficits were noted; six had persistent deficits postoperatively or underwent amputation (average follow-up 31.3 ± 32.6 months). Two patients in the sample without preoperative peroneal nerve deficits were noted to exhibit them after fixation. Eight patients (47%) underwent an amputation, 7 (87.5%) of whom had an open fracture and 4 (50%) of whom had documented vascular injury.Traumatic proximal tibiofibular fractures indicate severe injury to the lower extremity with high risk for nerve injury and possible amputation. Patients who present with vascular injury and open fracture in association with proximal tibiofibular joint disruption may be at elevated risk of amputation.

Malaysia faces a high probability of experiencing landslide disasters, particularly during rainy weather. Copious rain would result in landslide prone areas with low slope strength; thus increasing the possibility of landslide disasters occurring and threatening the safety of surrounding communities. The locations of this study are in the state of Penang that has been listed as landslide prone areas, namely Mukim 17 at Batu Ferringhi, as well as Tanjung Bungah and Tanjung Tokong, two areas which are in Mukim 18. This research aims to map community slope risk areas and to evaluate the understanding, knowledge, and awareness of the community on slope risk and landslides. There are two methods involved, namely GIS and survey. The findings show that the estimated community slope risk mapping is 24.71% and 20.62% of inhabitants living in high risks landslide zones in Mukim 17 and 18. 62 respondents participated in the survey and the result analysis shows that more than 50% have a strong fundamental knowledge of slope risks, while less than 50% are aware of possible landslide risks, and 42.6% will always obey an evacuation order. Overall findings show that most of the community does have a general awareness of slope risks and landslides.

Study Design Retrospective comparative study. Objectives This study compares supine vs bending flexibility radiographs and evaluates their ability to predict residual postoperative lumbar curvature after selective thoracic fusion for Lenke 1 and 2 curves across different lumbar modifiers (A, B, and C) in adolescent idiopathic scoliosis (AIS). Methods This was a retrospective review of AIS Lenke 1 and 2 patients who underwent posterior fusion. All patients had preoperative flexibility radiographs including side-bending and supine posteroanterior (PA) films, in addition to pre- and post-operative standing PA and lateral radiographs. We used SurgiMap 2.0 software for all radiographic measurements. Pearson correlations and linear regression models were developed in SAS. Results A total of 86 patients were included mean age 14.9 years and follow-up 72.3 months. Preoperative supine lumbar Cobb angle and preoperative side-bending Cobb angles had similar, positive correlations with postoperative lumbar Cobb angle, r = .55 ( P < .001) and r = .54 ( P < .001), respectively. Three regression models were built to predict postoperative lumbar Cobb angles from preoperative information: Model S (R2 = .39) uses preoperative supine lumbar curve; Model B (R2 = .44) uses preoperative side-bending lumbar curve; Model SB (R2 = .49) uses both preoperative supine and side-bending lumbar curves. Model S and B performed just as well as Model SB. Conclusion Either supine or side-bending radiographs alone may be used to estimate mean residual postoperative lumbar curvature after selective posterior thoracic fusion, but little is to be gained by taking both supine and side-bending radiographs.

BACKGROUNDVaccine-elicited adaptive immunity is a prerequisite for control of SARS-CoV-2 infection. Multiple sclerosis (MS) disease-modifying therapies (DMTs) differentially target humoral and cellular immunity. A comprehensive comparison of the effects of MS DMTs on SARS-CoV-2 vaccine-specific immunity is needed, including quantitative and functional B and T cell responses.METHODSSpike-specific Ab and T cell responses were measured before and following SARS-CoV-2 vaccination in a cohort of 80 study participants, including healthy controls and patients with MS in 6 DMT groups: untreated and treated with glatiramer acetate (GA), dimethyl fumarate (DMF), natalizumab (NTZ), sphingosine-1-phosphate (S1P) receptor modulators, and anti-CD20 mAbs. Anti-spike-Ab responses were assessed by Luminex assay, VirScan, and pseudovirus neutralization. Spike-specific CD4+ and CD8+ T cell responses were characterized by activation-induced marker and cytokine expression and tetramer.RESULTSAnti-spike IgG levels were similar between healthy control participants and patients with untreated MS and those receiving GA, DMF, or NTZ but were reduced in anti-CD20 mAb- and S1P-treated patients. Anti-spike seropositivity in anti-CD20 mAb-treated patients was correlated with CD19+ B cell levels and inversely correlated with cumulative treatment duration. Spike epitope reactivity and pseudovirus neutralization were reduced in anti-CD20 mAb- and S1P-treated patients. Spike-specific CD4+ and CD8+ T cell reactivity remained robust across all groups, except in S1P-treated patients, in whom postvaccine CD4+ T cell responses were attenuated.CONCLUSIONThese findings from a large cohort of patients with MS exposed to a wide spectrum of MS immunotherapies have important implications for treatment-specific COVID-19 clinical guidelines.FUNDINGNIH grants 1K08NS107619, K08NS096117, R01AI159260, R01NS092835, R01AI131624, and R21NS108159; NMSS grants TA-1903-33713 and RG1701-26628; Westridge Foundation; Chan Zuckerberg Biohub; Maisin Foundation.

High tibial osteotomy (HTO) is a popular joint preserving option for medial compartmental osteoarthritis, especially in younger individuals. This procedure is however associated with alterations in the patellar height and tibial slope (TS). In this article, we have described the ascending and descending HTO and evaluated their effect on radiological parameters postoperatively.

BACKGROUNDVaccine-elicited adaptive immunity is a prerequisite for control of SARS-CoV-2 infection. Multiple sclerosis (MS) disease-modifying therapies (DMTs) differentially target humoral and cellular immunity. A comprehensive comparison of the effects of MS DMTs on SARS-CoV-2 vaccine-specific immunity is needed, including quantitative and functional B and T cell responses.METHODSSpike-specific Ab and T cell responses were measured before and following SARS-CoV-2 vaccination in a cohort of 80 study participants, including healthy controls and patients with MS in 6 DMT groups: untreated and treated with glatiramer acetate (GA), dimethyl fumarate (DMF), natalizumab (NTZ), sphingosine-1-phosphate (S1P) receptor modulators, and anti-CD20 mAbs. Anti-spike-Ab responses were assessed by Luminex assay, VirScan, and pseudovirus neutralization. Spike-specific CD4+ and CD8+ T cell responses were characterized by activation-induced marker and cytokine expression and tetramer.RESULTSAnti-spike IgG levels were similar between healthy control participants and patients with untreated MS and those receiving GA, DMF, or NTZ but were reduced in anti-CD20 mAb- and S1P-treated patients. Anti-spike seropositivity in anti-CD20 mAb-treated patients was correlated with CD19+ B cell levels and inversely correlated with cumulative treatment duration. Spike epitope reactivity and pseudovirus neutralization were reduced in anti-CD20 mAb- and S1P-treated patients. Spike-specific CD4+ and CD8+ T cell reactivity remained robust across all groups, except in S1P-treated patients, in whom postvaccine CD4+ T cell responses were attenuated.CONCLUSIONThese findings from a large cohort of patients with MS exposed to a wide spectrum of MS immunotherapies have important implications for treatment-specific COVID-19 clinical guidelines.FUNDINGNIH grants 1K08NS107619, K08NS096117, R01AI159260, R01NS092835, R01AI131624, and R21NS108159; NMSS grants TA-1903-33713 and RG1701-26628; Westridge Foundation; Chan Zuckerberg Biohub; Maisin Foundation.

BACKGROUND: Anterolateral ligament (ALL) reconstruction provides rotational stability in patients undergoing anterior cruciate ligament (ACL) reconstruction. The aim of this study was to assess the outcome of patients who underwent combined ACL and ALL reconstruction with a novel anatomic technique using hamstring tendon autograft and fixed loop suspensory device. METHODS: From 2016 to 2018, 25 patients who underwent combined reconstruction of ACL and ALL in our Institution were evaluated retrospectively. International Knee Documentation Committee (IKDC) Score, Tegner Lysholm Knee Score, grade of pivot shift was assessed at a final follow-up. RESULTS: Mean follow-up was 31.5 months (28–42). Mean IKDC (81.5) and Tegner Lysholm (82.8) Knee Scores improved significantly at a final follow-up, with all knees demonstrating negative pivot shift. All patients had good outcomes at 2 years follow-up with no graft failure and with no residual instability. CONCLUSION: ACL and ALL reconstruction using this technique described for the anterolateral instability of the knee was satisfactory in our patients. This technique is simple, easily reproducible and avoids additional implants for ALL in the tibia. LEVEL OF EVIDENCE: IV.

Background: Human growth is susceptible to damage from insults, particularly during periods of rapid growth. Identifying those periods and the normative limits that are compatible with adequate growth and development are the first key steps toward preventing impaired growth. Objective: This study aimed to construct international fetal growth velocity increment and conditional velocity standards from 14 to 40 weeks’ gestation based on the same cohort that contributed to the INTERGROWTH-21st Fetal Growth Standards. Study Design: This study was a prospective, longitudinal study of 4321 low-risk pregnancies from 8 geographically diverse populations in the INTERGROWTH-21st Project with rigorous standardization of all study procedures, equipment, and measurements that were performed by trained ultrasonographers. Gestational age was accurately determined clinically and confirmed by ultrasound measurement of crown-rump length at Results: Peak velocity was observed at a similar gestational age: 16 and 17 weeks’ gestation for head circumference (12.2 mm/wk), and 16 weeks’ gestation for abdominal circumference (11.8 mm/wk) and femur length (3.2 mm/wk). However, velocity growth slowed down rapidly for head circumference, biparietal diameter, occipitofrontal diameter, and femur length, with an almost linear reduction toward term that was more marked for femur length. Conversely, abdominal circumference velocity remained relatively steady throughout pregnancy. The change in velocity with gestational age was more evident for head circumference, biparietal diameter, occipitofrontal diameter, and femur length than for abdominal circumference when the change was expressed as a percentage of fetal size at 40 weeks’ gestation. We have also shown how to obtain accurate conditional fetal velocity based on our previous methodological work. Conclusion: The fetal skeleton and abdomen have different velocity growth patterns during intrauterine life. Accordingly, we have produced international Fetal Growth Velocity Increment Standards to complement the INTERGROWTH-21st Fetal Growth Standards so as to monitor fetal well-being comprehensively worldwide. Fetal growth velocity curves may be valuable if one wants to study the pathophysiology of fetal growth. We provide an application that can be used easily in clinical practice to evaluate changes in fetal size as conditional velocity for a more refined assessment of fetal growth than is possible at present (https://lxiao5.shinyapps.io/fetal_growth/). The application is freely available with the other INTERGROWTH-21st tools at https://intergrowth21.tghn.org/standards-tools/.

Massive cellular necrosis in acute liver failure (ALF) is dominantly immune mediated and innate immune cells are major pathophysiological determinants in liver damage. In fifty ALF and fifteen healthy, immune cells phenotyping by flow-cytometry, DAMPs using ELISA were analysed and correlated with clinical and biochemical parameters. ALF patients (aged 27 ± 9 yr, 56% males, 78% viral aetiology) showed no difference in neutrophils and classical monocytes, but significantly increased intermediate monocytes (CD14+CD16+) (p In conclusion, Combination of NK cell frequency among lymphocytes and lactate levels at admission can reliably predict survival of ALF patients.

PURPOSE: Lateral epicondylitis or lateral elbow tendinopathy is a common condition which needs to be addressed appropriately. This condition usually responds well to non-operative treatment. However, an orthopaedic physician needs to be aware of the recalcitrant cases and equip surgical armamentarium to provide adequate care. METHODOLOGY: The literature search was performed on PubMed, Medline and Google scholar using the keywords Tennis elbow, recalcitrant, thorntons technique, surgical options, for this narrative review. CONCLUSION: This article focuses on the causes for recalcitrant tendinopathy and review of its surgical options.

Background and AimLymphatic vessels (LVs) are crucial for maintaining abdominal fluid homeostasis and immunity. In liver cirrhosis, mesenteric LVs (mLVs) are dilated and dysfunctional. Given an established protective role of VEGF-C in LVs, we hypothesized that VEGF-C treatment could improve functions of mLVs in cirrhosis.MethodIn this study, we developed a nanoformulation comprising LV-specific growth-factor, recombinant human VEGF-C(Cys156Ser) protein(E-VEGF-C) and delivered it orally in rat models of liver cirrhosis to target mLVs. Nanoformulation without VEGF-C served as vehicle. Drainage of mLVs was analyzed using tracer dye. Portal and systemic physiological assessments and computed-tomography were performed to measure portal pressures and ascites. Gene expression of mesenteric lymphatic endothelial cells (LyECs) was studied. Immune cell subsets in mesenteric lymph nodes (MLNs) were quantified by flow-cytometry. Gut bacterial translocation to MLNs was examined using GFP-labelled bacteria.ResultsIn cirrhotic rats, mLVs were dilated and leaky with impaired drainage. Treatment with E-VEGF-C induced proliferation of VEGFR3+ mLVs, reduced their diameter and improved functional drainage. Ascites and portal pressures were significantly reduced in E-VEGF-C treated rats compared to vehicle. At molecular level, E-VEGF-C treatment upregulated the expression of cell adhesion and permeability genes (VCAM1, VE-Cad) in LyECs. In MLNs of E-VEGF-C rats, there was an increased percentage of CD8+CD134+ T-cells and decreased CD25+Treg-cells. Bacterial translocation was also limited to MLNs only in E-VEGF-C treated rats with reduced levels of endotoxins in ascites in comparison to vehicle.ConclusionE-VEGF-C treatment ameliorates mesenteric lymph drainage, portal pressure, and strengthens cytotoxic immune responses in MLNs in experimental cirrhosis. It may thus serve as a promising therapy to manage ascites and portal pressure and reduce gut bacterial translocation in patients with cirrhosis.Lay SummaryA human recombinant pro-lymphangiogenic growth factor, VEGF-C, was encapsulated in nanolipocarriers (E-VEGF-C) and orally delivered in rat models of decompensated liver cirrhosis to facilitate its gut lymphatic vessel uptake. E-VEGF-C administration significantly increased mesenteric lymphatic vessel proliferation and improved lymph drainage, attenuating abdominal ascites and portal pressures in the animal models. E-VEGF-C treatment limits bacterial translocation to MLNs only with reduced gut bacterial load and ascitic endotoxins. E-VEGF-C therapy holds the potential to manage ascites and portal pressure and reduce gut bacterial translocation in patients with decompensated cirrhosis.Graphical Abstract

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

The Orthopaedic Interview Spreadsheet (OIS) is an annual, open-source Google sheet used by prospective orthopaedic surgery applicants to share applicant statistics, interview data, and program information. The purpose of the current study was to determine whether self-reported applicant statistics within the OIS were representative of the official orthopaedic applicant pool, as reported by the National Resident Matching Program (NRMP).A total of 243 self-reported applicants from the 2017-2018 (n=136) and 2019-20 (n=107) orthopaedic surgery residency application cycles who used the OIS were identified.Step1 scores, Step2 scores, total research items reported on the Electronic Residency Application Service® (ERAS), and Alpha Omega Alpha (AOA) status were compared to NRMP weighted means from the 2018 and 2020 Charting Outcomes in the Match reports using one-sampled t-tests and one-sample binomial tests.According to the 2017-2018 OIS data, the self-reported Step 1 score (n=126) (M:251.3 ±10.5, p0.001), Step 2 score (n=113) (M:259.4 ±8.5, p0.001), and total research items (n=129) (M:8.9 ±8.6, p=0.019) were all statistically different from their respective NRMP weighted means. The NRMP cohort of applicants with AOA membership (36.4%) was significantly different than the OIS cohort (53.7%), (p0.001). Similarly, for 2019-2020, the OIS Step 1 score (n=105) (M: 248.8 ±0.7, p=0.016) and Step 2 score (n=93) (M:257.4 ±9.4, p0.001) were statistically different from their respective NRMP weighted means. OIS total research items (n=102) (M: 15.0 ±15.2, p=0.656) was not statistically different from its NRMP weighted mean. The NRMP cohort of applicants with AOA membership (36.4%) was significantly different than the OIS cohort (53.7%), (p=0.040).Prospective applicants should be cautious about using this document to solely gauge their competitiveness during the application process. The real value of the OIS is its non-quantifiable message board functions that provide peer-to-peer mentorship and the collaborative, uncensored community it fosters.

SARS-CoV-2 / COVID 19 is the largest health emergency and a global pandemic of recent times. Orthopaedic surgery involves procedures involving routine reaming and drilling the bones that generate substantially high volumes of aerosols and microdroplets creating a huge concern among the operating surgeons, anaesthetists and the supporting staff. We aimed at reducing the amount of aerosol generation and microdroplet spread by a simple and cost-effective technique which can be very well reproducible by anyone, thereby reducing the infection/viral load.

Summary Background Preterm birth is a major global health challenge, the leading cause of death in children under 5 years of age, and a key measure of a population's general health and nutritional status. Current clinical methods of estimating fetal gestational age are often inaccurate. For example, between 20 and 30 weeks of gestation, the width of the 95% prediction interval around the actual gestational age is estimated to be 18–36 days, even when the best ultrasound estimates are used. The aims of this study are to improve estimates of fetal gestational age and provide personalised predictions of future growth. Methods Using ultrasound-derived, fetal biometric data, we developed a machine learning approach to accurately estimate gestational age. The accuracy of the method is determined by reference to exactly known facts pertaining to each fetus—specifically, intervals between ultrasound visits—rather than the date of the mother's last menstrual period. The data stem from a sample of healthy, well-nourished participants in a large, multicentre, population-based study, the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st). The generalisability of the algorithm is shown with data from a different and more heterogeneous population (INTERBIO-21st Fetal Study). Findings In the context of two large datasets, we estimated gestational age between 20 and 30 weeks of gestation with 95% confidence to within 3 days, using measurements made in a 10-week window spanning the second and third trimesters. Fetal gestational age can thus be estimated in the 20–30 weeks gestational age window with a prediction interval 3–5 times better than with any previous algorithm. This will enable improved management of individual pregnancies. 6-week forecasts of the growth trajectory for a given fetus are accurate to within 7 days. This will help identify at-risk fetuses more accurately than currently possible. At population level, the higher accuracy is expected to improve fetal growth charts and population health assessments. Interpretation Machine learning can circumvent long-standing limitations in determining fetal gestational age and future growth trajectory, without recourse to often inaccurately known information, such as the date of the mother's last menstrual period. Using this algorithm in clinical practice could facilitate the management of individual pregnancies and improve population-level health. Upon publication of this study, the algorithm for gestational age estimates will be provided for research purposes free of charge via a web portal. Funding Bill & Melinda Gates Foundation, Office of Science (US Department of Energy), US National Science Foundation, and National Institute for Health Research Oxford Biomedical Research Centre.

Better triage tests for screening tuberculosis (TB) disease are needed for people living with HIV (PLHIV). We performed the first evaluation of a previously-validated 8-antigen serological panel to screen PLHIV for pulmonary TB in Kampala, Uganda. We selected a random 1:1 sample with and without TB (defined by sputum culture) from a cohort of PLHIV initiating antiretroviral therapy. We used a multiplex microbead immunoassay and an ensemble machine learning classifier to determine the area under the receiver operating characteristic curve (AUC) for Ag85A, Ag85B, Ag85C, Rv0934-P38, Rv3881, Rv3841-BfrB, Rv3873, and Rv2878c. We then assessed the performance with the addition of four TB-specific antigens ESAT-6, CFP-10, Rv1980-MPT64, and Rv2031-HSPX, and every antigen combination. Of 262 participants (median CD4 cell-count 152 cells/μL [IQR 65-279]), 138 (53%) had culture-confirmed TB. The 8-antigen panel had an AUC of 0.53 (95% CI 0.40-0.66), and the additional 4 antigens did not improve performance (AUC 0.51, 95% CI 0.39-0.64). When sensitivity was restricted to ≥90% for the 8- and 12-antigen panel, specificity was 2.2% (95% CI 0-17.7%) and 8.1% (95% CI 0-23.9%), respectively. A three-antigen combination (Rv0934-P38, Ag85A, and Rv2031-HSPX) outperformed both panels, with an AUC of 0.60 (95% CI 0.48-0.73), 90% sensitivity (95% CI 78.2-96.7%) and 29.7% specificity (95% CI 15.9-47%). The multi-antigen panels did not achieve the target accuracy for a TB triage test among PLHIV. We identified a new combination that improved performance for TB screening in an HIV-positive sample compared to an existing serological panel in Uganda, and suggests an approach to identify novel antigen combinations specifically for screening TB in PLHIV.

Hepatorenal syndrome (HRS) carries a high short-term mortality in patients with cirrhosis and acute on chronic liver failure (ACLF). Terlipressin and noradrenaline are routinely used in cirrhosis with HRS and have been found to be equally effective. There are no data comparing the efficacy of terlipressin with noradrenaline in ACLF patients with HRS. In an open-label, randomized controlled trial (RCT), consecutive patients with ACLF diagnosed with HRS acute kidney injury (AKI) were randomized to albumin with infusion of terlipressin (2-12 mg/day; n = 60) or noradrenaline (0.5-3.0 mg/h; n = 60). Response to treatment, course of AKI, and outcome were studied. Baseline characteristics, including AKI stage and sepsis-related HRS-AKI, were comparable between groups. Compared to noradrenaline, terlipressin achieved greater day 4 (26.1% vs. 11.7%; P = 0.03) and day 7 (41.7% vs. 20%; P = 0.01) response. Reversal of HRS was also better with terlipressin (40% vs. 16.7%; P = 0.004), with a significant reduction in the requirement of renal replacement therapy (RRT; 56.6% vs. 80%; P = 0.006) and improved 28-day survival (48.3% vs. 20%; P = 0.001). Adverse events limiting use of drugs were higher with terlipressin than noradrenaline (23.3% vs. 8.3%; P = 0.02), but were reversible. On multivariate analysis, high Model for End-Stage Liver Disease (MELD; odds ratio [OR], 1.10; confidence interval [CI] = 1.009-1.20; P = 0.03) and noradrenaline compared to terlipressin (OR, 3.05; CI = 1.27-7.33; P = 0.01) predicted nonresponse to therapy. Use of noradrenaline compared to terlipressin was also predictive of higher mortality (hazard ratio [HR], 2.08; CI = 1.32-3.30; P = 0.002). Conclusion: AKI in ACLF carries a high mortality. Infusion of terlipressin gives earlier and higher response than noradrenaline, with improved survival in ACLF patients with HRS-AKI.

Serologic assays are needed to determine SARS-CoV-2 seroprevalence, but poor specificity can overestimate exposures. Here, we built a pan-human coronavirus proteome-wide programmable phage display assay (VirScan) to profile coronavirus antigens specifically enriched by 20 COVID-19 patient serum IgG. With ReScan, a new diagnostic development workflow which combines the isolation of phage expressing the most immunogenic peptides with paper-based microarrays manufactured via acoustic liquid handling, we identified 9 candidate antigens from a library of 534 SARS-CoV-2 peptides. These arrays could form the basis of a multiplexed COVID-19 serologic assay with enhanced specificity. ReScan has broad applicability for serologic assay development.

Concomitant meniscal injuries are common in patients with anterior cruciate ligament (ACL) insufficiency. Along with ACL reconstruction, meniscal repair offers better outcomes. This requires multiple incisions for both procedures. We present a novel technique of medial meniscus inside out repair using only the tibial tunnel wound without making an additional posteromedial incision. This is the first such description of this novel technique in a 21 year old male who underwent ACL reconstruction along with bucket handle medial meniscal repair.

Anterior cruciate ligament (ACL) insufficiency in combination with patellar instability are rare occurrences and are difficult to treat. Failure to address patellar instability in such cases may place excessive strain on ACL graft leading to graft rupture. We present three such cases treated by concurrent ACL and medial patellofemoral ligament (MPFL) reconstruction with hamstring tendon autografts. Two patients had MRI evidence of MPFL injury and one patient had intact MPFL on MRI. All patients had good outcome without any residual instability at final follow-up.

Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.

Single crystal of l -Histidine Nitrate monohydrate (LHNM) has been grown from aqueous solution by evaporation technique. A comprehensive investigation of the NIR FT-Raman and FT-IR spectra was carried out with the aid of normal coordinate analysis following the scaled quantum mechanical force field methodology supported by the density functional theory (DFT) computations to analyze the effects of intramolecular charge transfer on the geometries and the vibrational modes contributing to the linear electro-optic effect of the organic NLO material. Effect of protonation and hydrogen bonding interactions has been analyzed using structural analysis, natural bond orbital analysis, and spectral analysis. The HOMO-LUMO energy gap value suggests the possibility of charge transfer within the molecule. Hyperconjugative interactions responsible for second hyperpolarizabilities have been described by NBO and AIM analyses. Hirshfeld surface analysis reveals that the van der Waals H⋯H (32.3%) contact plays a significant role in crystal packing and that a variety of N H⋯O intermolecular contacts and hydrogen bonds leads to the formation of intermolecular charge transfer occurring in LHNM. The nonlinear refractive index (n2), nonlinear absorption coefficient (β) and third-order nonlinear susceptibility (χ3) of LHNM have been determined by Z-scan technique, which points to its potential application in the field of optical limiting. The calculated value of laser damage threshold was 2.04 GW/cm2.

BACKGROUND: Gene-expression profiles have been reported to distinguish between patients with and without active tuberculosis (TB), but no prior study has been conducted in the context of TB screening. METHODS: We included all the patients (n = 40) with culture-confirmed TB and time-matched controls (n = 80) enrolled between July 2013 and April 2015 in a TB screening study among people living with human immunodeficiency virus (PLHIV) in Kampala, Uganda. We randomly split the patients into training (n = 80) and test (n = 40) datasets. We used the training dataset to derive candidate signatures that consisted of 1 to 5 differentially-expressed transcripts (P ≤ .10) and compared the performance of our candidate signatures with 4 published TB gene-expression signatures, both on the independent test dataset and in 2 external datasets. RESULTS: We identified a novel, 5-transcript signature that met the accuracy thresholds recommended for a TB screening test. On the independent test dataset, our signature had an area under the curve (AUC) of 0.87 (95% confidence interval [CI] 0.72–0.98), with sensitivity of 94% and specificity of 75%. None of the 4 published TB signatures achieved desired accuracy thresholds. Our novel signature performed well in external datasets from both high (AUC 0.81, 95% CI 0.74–0.88) and low (0.81, 95% CI 0.77–0.85) TB burden settings. CONCLUSIONS: We identified the first gene-expression signature for TB screening. Our signature has the potential to be translated into a point-of-care test to facilitate systematic TB screening among PLHIV and other high-risk populations.

Aims The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery. Materials and Methods We conducted a systematic review of MEDLINE and the CEA Registry to identify CEAs that were conducted on or after 1 January 1997, that studied a procedure pertaining to the field of hand and upper extremity surgery, that were clinical studies, and that reported outcomes in terms of quality-adjusted life-years. We identified a total of 33 studies that met our inclusion criteria. The quality of these studies was assessed using the Quality of Health Economic Analysis (QHES) scale. Results The mean total QHES score was 82 (high-quality). Over time, a greater proportion of these studies have demonstrated poorer QHES quality (scores < 75). Lower-scoring studies demonstrated several deficits, including failures in identifying reference perspectives, incorporating comparators and sensitivity analyses, discounting costs and utilities, and disclosing funding. Conclusion It will be important to monitor the ongoing quality of CEA studies in orthopaedics and ensure standards of reporting and comparability in accordance with Second Panel recommendations. Cite this article: Bone Joint J 2018;100-B:1416–23.

Introduction: Mucoid degeneration of the Anterior Cruciate Ligament is a rare degenerative condition affecting the middle age population (16 to 50 years). The infiltration of glycosaminoglycan into the substance of the ACL causes the ligament to swell up and impinge on the intercondylar notch and Posterior Cruciate Ligament. This results in posterior knee pain and restriction of terminal movements. The current trend of management is debulking the ligament by stripping the degenerated part and preserving the native thin ACL. This poses two problems - 1. Difficulty in identifying the degenerated parts by the arthroscope. Stripping is done with the aid of pre-op MRI; 2. Chances of under stripping (recurrence of the symptoms) or over stripping (laxity and ACL failure). Studies have shown high incidence of grade 1/grade 2 laxity by Lachman test 6 months post-op and a requirement of Secondary ACL reconstruction in many patients. Goal: The goal of this study is to assess the functional outcome of Primary ACL reconstruction with autologous quadrupled hamstring tendon graft after complete excision of the native degenerated ACL. Materials and Methods: This is a prospective study of 13 patient (7 male, 6 female) of average age 41 (25-63) years presenting with posterior knee pain and restriction of flexion for an average period of 6 months (15 days – 36 months) diagnosed with Mucoid degeneration of ACL by MRI, arthroscopy and by histo-pathological examination. They were operated by ACL reconstruction following complete excision of degenerated ACL, as a single stage procedure. Evaluation: The patients were evaluated both pre-operatively and post-operatively by Lysholm knee scoring system and VAS (visual analog score) pain scoring system. Results: Postoperatively, patients were followed up for a minimum of 1 year (average of 14.9 months). There was no evidence of recurrence or instability at the end of follow-up. There was significant improvement in Lysholm score (34.6 to 83.2) and VAS (5.76 to 0.54). Conclusion: Treatment of ACL mucoid degeneration by this modality is effective in preventing recurrence, post-operative laxity and provides better functional outcome compared to the classical partial resection of the degenerated ACL.

This study defines reporting conservatism as a higher verification standard for probable gains compared to losses and builds a model that endogenously generates optimal behavior resembling an asymmetric preference for gains versus losses. Our model considers the setting where one party produces a resource and another tries to expropriate it. The key factor determining the extent of the gain-loss asymmetry is the level of information asymmetry or trust between the two parties. The information asymmetry-based results of our model provide a simpler explanation for the vast empirical literature on conservatism, where the bulk of the economic relationships among the parties appear to be information-based with little direct relation to explicit debt contracts, a factor that has been the focus of theoretical arguments. We also suggest new empirical analyzes.

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the “APASL ACLF Research Consortium (AARC)” was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the ‘Golden Therapeutic Window’, extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here., Article Highlights Updated on the basis of AARC data of >3300 cases enrolled into AARC registry prospectivelyACLF is distinct form Acute Decompensation of cirrhosisNewer sections on DILI-ACLF, AIH-ACLF, PVT/HVOTO–ACLFReversibility of Chronic Liver Disease in ACLFPortal and systemic hemodynamics and their relevance in ACLFAcute Portal Hypertension and Variceal progression in ACLFAARC score as a guide for treatment strategies in ACLFACLF in Children-first consensus on pediatric ACLF