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The modern management of open fractures was established after the foundational work of Gustilo and Anderson, but we continue to strive to determine the optimal treatment of open fractures to diminish the risk of infection. The ideal timing of antibiotics, presentation to the operating room, and timing of procedures such as flap coverage continue to be investigated with incremental changes recommended over the years. This article aims to provide the most recent review of the literature regarding the timing and management of both upper and lower extremity open fractures, pediatric open fractures, current topics of controversy, and the data supporting current treatment recommendations., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Tea, a globally popular beverage, contains various beneficial secondary metabolites. Tea plants (Camellia sinensis) exhibit diverse genetic traits across cultivars, impacting yield, adaptability, morphology, and secondary metabolite composition. Many tea cultivars have been the subject of much research interest, which have led to the accumulation of publicly available RNA-seq data. As such, it has become possible to systematically summarize the characteristics of different cultivars at the transcriptomic level, identify functional genes, and infer gene functions through co-expression analysis. Here, the transcriptomes of 9 tea cultivars were assembled, and comparative analysis was conducted on the coding sequences of 13 cultivars. To give access to this data, we present TeaNekT (https://teanekt.sbs.ntu.edu.sg/), a web resource that facilitates the prediction of gene functions of various tea cultivars. We used TeaNekT to perform a cross-cultivar comparison of co-expressed gene clusters and tissue-specific gene expression. We observed that 'Anji Baicha' possesses the highest number of cultivar-specific genes and the second-highest number of expanded genes. These genes in 'Anji Baicha' tend to be enriched in functions associated with cold stress response, chloroplast thylakoid structure, and nitrogen metabolism. Notably, we identified three significantly expanded homologous genes in 'Anji Baicha' encoding the ICE1, SIZ1, and MAPKK2, which are closely associated with the cold sensitivity of 'Anji Baicha'. Additionally, one significantly expanded homologous gene in 'Anji Baicha' encoding regulatory factor RIQ may play a crucial role in the abnormal chloroplast structure and absence of thylakoid membranes in 'Anji Baicha'., (© 2024 The Author(s). Physiologia Plantarum published by John Wiley & Sons Ltd on behalf of Scandinavian Plant Physiology Society.)

Despite the abundance of species with transcriptomic data, a significant number of species still lack sequenced genomes, making it difficult to study gene function and expression in these organisms. While de novo transcriptome assembly can be used to assemble protein-coding transcripts from RNA-sequencing (RNA-seq) data, the datasets used often only feature samples of arbitrarily selected or similar experimental conditions, which might fail to capture condition-specific transcripts. We developed the Large-Scale Transcriptome Assembly Pipeline for de novo assembled transcripts (LSTrAP-denovo) to automatically generate transcriptome atlases of eukaryotic species. Specifically, given an NCBI TaxID, LSTrAP-denovo can (1) filter undesirable RNA-seq accessions based on read data, (2) select RNA-seq accessions via unsupervised machine learning to construct a sample-balanced dataset for download, (3) assemble transcripts via over-assembly, (4) functionally annotate coding sequences (CDS) from assembled transcripts and (5) generate transcriptome atlases in the form of expression matrices for downstream transcriptomic analyses. LSTrAP-denovo is easy to implement, written in Python, and is freely available at https://github.com/pengkenlim/LSTrAP-denovo/., (© 2024 Scandinavian Plant Physiology Society.)

Background: As one of the world's most important beverage crops, tea plants (Camellia sinensis) are renowned for their unique flavors and numerous beneficial secondary metabolites, attracting researchers to investigate the formation of tea quality. With the increasing availability of transcriptome data on tea plants in public databases, conducting large-scale co-expression analyses has become feasible to meet the demand for functional characterization of tea plant genes. However, as the multidimensional noise increases, larger-scale co-expression analyses are not always effective. Analyzing a subset of samples generated by effectively downsampling and reorganizing the global sample set often leads to more accurate results in co-expression analysis. Meanwhile, global-based co-expression analyses are more likely to overlook condition-specific gene interactions, which may be more important and worthy of exploration and research., Results: Here, we employed the k-means clustering method to organize and classify the global samples of tea plants, resulting in clustered samples. Metadata annotations were then performed on these clustered samples to determine the "conditions" represented by each cluster. Subsequently, we conducted gene co-expression network analysis (WGCNA) separately on the global samples and the clustered samples, resulting in global modules and cluster-specific modules. Comparative analyses of global modules and cluster-specific modules have demonstrated that cluster-specific modules exhibit higher accuracy in co-expression analysis. To measure the degree of condition specificity of genes within condition-specific clusters, we introduced the correlation difference value (CDV). By incorporating the CDV into co-expression analyses, we can assess the condition specificity of genes. This approach proved instrumental in identifying a series of high CDV transcription factor encoding genes upregulated during sustained cold treatment in Camellia sinensis leaves and buds, and pinpointing a pair of genes that participate in the antioxidant defense system of tea plants under sustained cold stress., Conclusions: To summarize, downsampling and reorganizing the sample set improved the accuracy of co-expression analysis. Cluster-specific modules were more accurate in capturing condition-specific gene interactions. The introduction of CDV allowed for the assessment of condition specificity in gene co-expression analyses. Using this approach, we identified a series of high CDV transcription factor encoding genes related to sustained cold stress in Camellia sinensis. This study highlights the importance of considering condition specificity in co-expression analysis and provides insights into the regulation of the cold stress in Camellia sinensis., (© 2024. The Author(s).)

Objective: To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures., Design: Retrospective cohort study., Setting: 3 Level 1 tertiary academic trauma centers., Patients/participants: The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures., Main Outcome Measurements: Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal., Results: The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating., Conclusions: While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Antibacterial resistance poses a significant global threat, necessitating the discovery of new therapeutic agents. Plants are a valuable source of secondary metabolites with demonstrated anticancer and antibacterial properties. In this study, we reveal that Melastoma dodecandrum exhibits both bacteriostatic and bactericidal effects against Pseudomonas aeruginosa and Staphylococcus aureus . Treatment with plant extracts results in membrane damage and a reduction in P.aeruginosa swimming and swarming motility. A comparative analysis of bacterial transcriptomes exposed to M.dodecandrum extracts and four distinct antibiotics indicates that the extracts may trigger similar transcriptomic responses as triclosan, a fatty acid synthesis inhibitor. Activity-guided fractionation suggests that the antibacterial activity is not attributable to hydrolyzable tannins, but to unidentified minor compounds. Additionally, we identified 104 specialized metabolic pathways and demonstrated a high level of transcriptional coordination between these biosynthetic pathways and phytohormones, highlighting potential regulatory mechanisms of antibacterial metabolites in M.dodecandrum., Competing Interests: Author DS was employed by the company ACM Biolabs Pte Ltd. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Poh, Ruhazat, Yang, Shivhare, Lim, Kanagasundaram, Rice and Mutwil.)

Background: There is significant variability both in how proximal humerus fractures (PHFs) are treated and the ensuing patient outcomes. The purpose of this study was to investigate which surgeon- and patient-specific factors contribute to decision-making in the treatment of adult PHFs. We hypothesized that orthopedic sub-specialty training creates inherent bias and plays an important role in management algorithms for PHFs., Methods: We performed a prospective cohort investigation in 2 groups of surgeons-traumatologists (N = 25) and shoulder & elbow/sports surgeons (SES) (N = 26)-and asked them to provide treatment recommendations for 30 distinct clinical cases with standardized radiographic and clinical data. This is a population-based sample of surgeons who take trauma call and treat PHFs with different sub-specializations and practice settings including academic, hospital-employed, and private. Surgeons characterized based on subspecialty (trauma vs. SES), experience level (>10 vs. ≤10-years), and employment type (hospital- vs. non-hospital-employed). Chi-square analyses, logistic mixed-effects modeling, and relative importance analysis were used to evaluate the data., Results: Of the patient-specific factors, we found that the management of PHFs is largely dependent on initial radiographs obtained. Traumatologists were more likely to offer open reduction internal fixation (ORIF) and less likely to offer arthroplasty: 69% ORIF (traumatologists) vs. 51% ORIF (SES, P < .001), 8% arthroplasty (traumatologists) vs. 17% (SES, P < .001). Traumatologists were less likely to change from operative (either ORIF or arthroplasty) to non-operative management compared to SES surgeons when presented with additional patient demographic data. Surgeon-specific factors contributed to more than one-half of the variability in decision-making of PHF management while patient-specific factors contributed to about one-third of the variability in decision-making., Conclusions: As physicians strive to advance the treatment for PHFs and optimize patient outcomes, our findings highlight the complex overlap between surgeon-, fracture-, and patient-specific factors in the final decision-making process., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe disease. During the coronavirus disease 2019 (COVID-19) pandemic, numerous reports of AP have been published, with most authors concluding a causal relationship between COVID-19 and AP. Retrospective case reports or small case series are unable to accurately determine the cause-effect relationship between COVID-19 and AP., Aim: To establish whether COVID-19 is a cause of AP using the modified Naranjo scoring system., Methods: A systematic review was conducted on PubMed, World of Science and Embase for articles reporting COVID-19 and AP from inception to August 2021. Exclusion criteria were cases of AP which were not reported to be due to COVID-19 infection, age < 18 years old, review articles and retrospective cohort studies. The original 10-item Naranjo scoring system (total score 13) was devised to approximate the likelihood of a clinical presentation to be secondary to an adverse drug reaction. We modified the original scoring system into a 8-item modified Naranjo scoring system (total score 9) to determine the cause-effect relationship between COVID-19 and AP. A cumulative score was decided for each case presented in the included articles. Interpretation of the modified Naranjo scoring system is as follows: ≤ 3: Doubtful, 4-6: Possible, ≥ 7: Probable cause., Results: The initial search resulted in 909 articles, with 740 articles after removal of duplicates. A total of 67 articles were included in the final analysis, with 76 patients which had AP reported to be due to COVID-19. The mean age was 47.8 (range 18-94) years. Majority of patients (73.3%) had ≤ 7 d between onset of COVID-19 infection and diagnosis of AP. There were only 45 (59.2%) patients who had adequate investigations to rule out common aetiologies (gallstones, choledocholithiasis, alcohol, hypertriglyceridemia, hypercalcemia and trauma) of AP. Immunoglobulin G4 testing was conducted in 9 (13.5%) patients to rule out autoimmune AP. Only 5 (6.6%) patients underwent endoscopic ultrasound and/or magnetic resonance cholangiopancreatogram to rule out occult microlithiasis, pancreatic malignancy and pancreas divisum. None of the patients had other recently diagnosed viral infections apart from COVID-19 infection, or underwent genetic testing to rule out hereditary AP. There were 32 (42.1%), 39 (51.3%) and 5 (6.6%) patients with doubtful, possible, and probable cause-effect relationship respectively between COVID-19 and AP., Conclusion: Current evidence is weak to establish a strong link between COVID-19 and AP. Investigations should be performed to rule out other causes of AP before establishing COVID-19 as an aetiology., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: The aim of the study is to investigate the differences between the extensile lateral (EL) and sinus tarsi (ST) approaches for the treatment of displaced intra-articular calcaneus fractures as treated by a single surgeon., Methods: A retrospective cohort study performed at a Level 1 trauma center. One hundred twenty-nine consecutive intra-articular calcaneus fractures from 2011 to 2018 that were surgically treated by a single surgeon. Primary outcomes were time to surgery, operative time, postoperative restoration of the critical angle of Gissane, postoperative wound complications, and need for unplanned re-operation., Results: Patient characteristics, including demographics, mechanism of injury, and fracture patterns were similar between the EL and ST approach groups. There was a significant decrease in unplanned secondary procedures (P = .008), shorter time to definitive fixation (P = .00001), and shorter average operative time in the ST group (P = .00001). Postoperative measurement of the critical angle of Gissane between the two groups was significantly different, but minute with an average difference of approximately 3 degrees (P = .025). Measurements in both groups were within the expected range of normal., Conclusions: For displaced intra-articular calcaneus fractures, a limited open ST approach is associated with a significant reduction in the time to definitive fixation and decreased operative time. The EL approach was associated with a small, but significant improvement in the restoration of the critical angle of Gissane compared with the ST approach. Therefore, an ST approach may allow for earlier surgical intervention and result in equivalent quality of reduction compared with an EL approach., Level of Evidence: Level III.

Introduction: It is our hypothesis that physician-specific variables affect the management of distal radius (DR) fractures in addition to patient-specific factors., Methods: A prospective cohort study was conducted evaluating treatment differences between Certificate of Additional Qualification hand surgeons (CAQh) and board-certified orthopaedic surgeons who treat patients at level 1 or level 2 trauma centers (non-CAQh). After institutional review board approval, 30 DR fractures were selected and classified (15 AO/OTA type A and B and 15 AO/OTA type C) to create a standardized patient data set. The patient-specific demographics and surgeon's information regarding the volume of DR fractures treated per year, practice setting, and years posttraining were obtained. Statistical analysis was done using chi-square analysis with a postanalysis regression model., Results: A notable difference was observed between CAQh and non-CAQh surgeons. Surgeons in practice longer than 10 years or who treat >100 DR fractures/year were more likely to choose surgical intervention and obtain a preoperative CT scan. The two most influential factors in decision making were the patients' age and medical comorbidities, with physician-specific factors being the third most influential in medical decision making., Discussion: Physician-specific variables have a notable effect on decision making and are critical for the development of consistent treatment algorithms for DR fractures., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Abiotic stresses negatively impact ecosystems and the yield of crops, and climate change will increase their frequency and intensity. Despite progress in understanding how plants respond to individual stresses, our knowledge of plant acclimatization to combined stresses typically occurring in nature is still lacking. Here, we used a plant with minimal regulatory network redundancy, Marchantia polymorpha, to study how seven abiotic stresses, alone and in 19 pairwise combinations, affect the phenotype, gene expression, and activity of cellular pathways. While the transcriptomic responses show a conserved differential gene expression between Arabidopsis and Marchantia, we also observe a strong functional and transcriptional divergence between the two species. The reconstructed high-confidence gene regulatory network demonstrates that the response to specific stresses dominates those of others by relying on a large ensemble of transcription factors. We also show that a regression model could accurately predict the gene expression under combined stresses, indicating that Marchantia performs arithmetic multiplication to respond to multiple stresses. Lastly, two online resources ( https://conekt.plant.tools and http://bar.utoronto.ca/efp&#95;marchantia/cgi-bin/efpWeb.cgi ) are provided to facilitate the study of gene expression in Marchantia exposed to abiotic stresses., (© 2023. The Author(s).)

The immense structural diversity of products and intermediates of plant specialized metabolism (specialized metabolites) makes them rich sources of therapeutic medicine, nutrients, and other useful materials. With the rapid accumulation of reactome data that can be accessible on biological and chemical databases, along with recent advances in machine learning, this review sets out to outline how supervised machine learning can be used to design new compounds and pathways by exploiting the wealth of said data. We will first examine the various sources from which reactome data can be obtained, followed by explaining the different machine learning encoding methods for reactome data. We then discuss current supervised machine learning developments that can be employed in various aspects to help redesign plant specialized metabolism., Competing Interests: The authors declare no conflict of interest., (© 2023 The Author(s).)

Cannabinoid compounds are being increasingly used as an analgesic adjuvant in the orthopedic population, but little data exist to either support or oppose this practice pattern. A review of all contemporary (2000-2020) studies on the use of cannabinoids in orthopedics is presented. Physicians and patients are optimistic that cannabinoids can decrease pain scores and perhaps opioid use; however, their application in orthopedics is not well characterized. In addition to the social stigma regarding the use of cannabis, there is limited high-quality evidence of the efficacy of cannabinoids in treating orthopedic-related pain. As cannabis becomes more accessible, well-designed trials are needed to better understand cannabinoids and guide orthopedic practice. [ Orthopedics . 2022;45(6):e295-e302.].

To palliate suffering, understanding the circumstances leading to suffering and its amelioration could be helpful. Our study aimed to explore contributing and relieving factors of suffering in palliative care. Adult palliative care stage III or IV cancer in-patients were recruited from University of Malaya Medical Centre. Participants recorded their overall suffering score from 0 to 10 three times daily, followed by descriptions of their contributing and relieving factors. Factors of suffering were thematically analysed with NVIVO. Descriptive data were analysed with SPSS. 108 patients participated. The most common contributing factor of suffering was health factor (96.3%), followed by healthcare factor (78.7%), psychological factor (63.0%) and community factor (20.4%). The most common relieving factor was health factor (88.9%), followed by psychological factor (78.7%), community factor (75.9%) and healthcare factor (70.4%). Self-reported assessment of suffering offers a rapid approach to detect bothering issues that require immediate attention and further in-depth exploration.

There are now more than 300 000 RNA sequencing samples available, stemming from thousands of experiments capturing gene expression in organs, tissues, developmental stages, and experimental treatments for hundreds of plant species. The expression data have great value, as they can be re-analyzed by others to ask and answer questions that go beyond the aims of the study that generated the data. Because gene expression provides essential clues to where and when a gene is active, the data provide powerful tools for predicting gene function, and comparative analyses allow us to study plant evolution from a new perspective. This review describes how we can gain new knowledge from gene expression profiles, expression specificities, co-expression networks, differential gene expression, and experiment correlation. We also introduce and demonstrate databases that provide user-friendly access to these tools., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

During the last few decades, the study of microbial ecology has been enabled by molecular and genomic data. DNA sequencing has revealed the surprising extent of microbial diversity and how microbial processes run global ecosystems. However, significant gaps in our understanding of the microbial world remain, and one example is that microbial eukaryotes, or protists, are still largely neglected. To address this gap, we used gene expression data from 17 protist species to create protist.guru: an online database equipped with tools for identifying co-expressed genes, gene families, and co-expression clusters enriched for specific biological functions. Here, we show how our database can be used to reveal genes involved in essential pathways, such as the synthesis of secondary carotenoids in Haematococcus lacustris. We expect protist.guru to serve as a valuable resource for protistologists, as well as a catalyst for discoveries and new insights into the biological processes of microbial eukaryotes. AVAILABILITY: The database and co-expression networks are freely available from http://protist.guru/. The expression matrices and sample annotations are found in the supplementary data., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

While bacteria can be beneficial to our health, their deadly pathogenic potential has been an ever-present concern exacerbated by the emergence of drug-resistant strains. As such, there is a pressing urgency for an enhanced understanding of their gene function and regulation, which could mediate the development of novel antimicrobials. Transcriptomic analyses have been established as insightful and indispensable to the functional characterization of genes and identification of new biological pathways, but in the context of bacterial studies, they remain limited to species-specific datasets. To address this, we integrated the genomic and transcriptomic data of the 17 most notorious and researched bacterial pathogens, creating bacteria.guru, an interactive database that can identify, visualize, and compare gene expression profiles, coexpression networks, functionally enriched clusters, and gene families across species. Through illustrating antibiotic resistance mechanisms in P. aeruginosa, we demonstrate that bacteria.guru could potentially aid in discovering multi-faceted antibiotic targets and, overall, facilitate future bacterial research. AVAILABILITY: The database and coexpression networks are freely available from https://bacteria.guru/. Sample annotations can be found in the supplemental data., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. We thank Nanyang Technological University for the Start Up Grant funding this research., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Aim: To compare children with type 1 diabetes (T1D) living in the Northwest England, United Kingdom (UK) or Singapore, and to correlate age at diagnosis with birthweight and anthropometry at T1D diagnosis., Methods: We included 166 T1D children of white ethnicity in England (UK-White) and 185 T1D children of East-Asian ethnicity origin in Singapore (SG-Asian) who were born between 2002 and 2020., Results: The cohorts from UK-White and SG-Asian children differed significantly in FH of T1D (p < 0.001), FH of T2D (p < 0.001) and pubertal status at diagnosis (p = 0.01). Median interquartile range (IQR) for age at diagnosis was similar in the two groups. UK-White children had significantly higher birthweight SDS, height SDS, weight SDS and BMI SDS (all p < 0.001). Among the subgroup of 174 children who were prepubertal and diagnosed after age 5 years, the UK-White children were 11 months older than the SG-Asian children (p = 0.02) indicating that SG-Asian children at the time of T1D diagnosis were more likely to be in puberty compared with UK-White children (30% vs. 18%)., Conclusion: These two cohorts have substantially different genetic and environmental backgrounds, yet age at the diagnosis of T1D was similar except for the prepubertal children who were diagnosed after 5 years old. Timing of puberty and other factors may influence how early T1D presents during childhood., (©2022 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures., Methods: We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism., Results: Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01)., Conclusions: Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH., Level of Evidence: III, systematic review of retrospective cohort studies., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: CT and three-dimensional (3D) CT reconstructions have been shown to improve the understanding of acetabular fractures. With the increased availability of 3D pelvic CT reconstructions, our goal for this study was to develop an algorithm to aid residents in the classification of acetabular fractures. We hypothesized that the use of a stepwise algorithm will markedly enhance the trainees' ability to correctly identify acetabular fracture patterns., Methods: This was a multicenter study that included 33 residents. Residents reviewed 15 sets of 3D reconstructions of the 10 acetabular fracture patterns. Residents completed the first round, and the results were collected electronically. Three weeks later, they were asked to classify the fractures a second time with the use of the algorithm. The number of correct responses from the two sessions was analyzed to determine if the algorithm improved residents' ability to correctly classify fracture patterns., Results: Thirty-three residents classified 15 fractures which yielded 495 unique responses. Residents correctly classified 52.5% (260/495) of fractures without the algorithm, which significantly increased to 77.5% (384/495) (P = 0.001) with the algorithm. When stratified by year in residency, all residents were able to correctly classify markedly more fractures with the algorithm., Discussion: Overall, we believe this method is a reproducible diagnostic tool that will assist residents in classifying acetabular fractures. We were able to demonstrate that with the use of this algorithm, residents' ability to correctly classify acetabular fractures is markedly enhanced, regardless of year in training. This algorithm will be a useful adjunct to assist and advance trainees' education and understanding of a complex topic., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

The stigma attached to intellectual disabilities (ID) can have profoundly adverse effects on the lives of people who suffer from these conditions. Stigma is also a major barrier to accessing specialist services and consequently many people with ID continue to suffer in silence. A confidential inquiry into the premature deaths of people with ID in England and Wales revealed the median age at death of individuals with this condition was 13 years (for males) to 20 years (for females) younger than the median age at death of the general population. It has been posited that stigma is a factor that contributes to the mortality gap between those with ID and those who don't have this condition. The COVID-19 pandemic has created new challenges for people with ID and has further fortified the barriers to specialist services. To reduce stigma, improve the quality of healthcare that is provided to people with this condition and to break down the barriers to specialist services, we must pioneer innovative interventions that leverage the power of technology and 'virtual' contact with people who live with these conditions.

Objective: Suffering is a common experience in palliative care. In our study, we aimed to determine the effect of 5-min mindfulness of love on suffering and the spiritual quality of life of palliative care patients., Methods: We conducted a parallel-group, blinded, randomized controlled study at the University of Malaya Medical Centre (UMMC), Malaysia from February 2019 to April 2019. Sixty adult palliative care patients with an overall suffering score of 4/10 or above based on the Suffering Pictogram were recruited and randomly assigned to either the 5-min mindfulness of love group (N = 30) or the 5-min supportive listening group (N = 30)., Results: There were statistically significant improvements in the overall suffering score (mean difference = -2.9, CI = -3.7 to -2.1, t = -7.268, p = 0.000) and the total FACIT-Sp-12 score (mean difference = 2.9, CI = 1.5 to 4.3, t = 4.124, p = 0.000) in the intervention group compared to the control group., Conclusion: The results provided evidence that 5-min mindfulness of love could affect the actual state of suffering and the spiritual quality of life of palliative care patients., (© 2021 John Wiley & Sons Ltd.)

Background: Periprosthetic distal femur fractures (PPDFFs) present a challenge in terms of optimizing fixation in patients with poor bone quality and limited bone stock. The main treatment options include laterally based plating and intramedullary nailing. We hypothesized that treatment of PPDFFs with intramedullary nails would result in improved union rate, fewer complications, and an equivalent rate of malalignment compared to plating., Materials and Methods: Cases of PPDFFs were identified through a query of our institutional trauma database between 2011-2018. Adult patients (>18 years) were included if they sustained a fracture of the distal femur around a total knee arthroplasty (TKA) that was not initially treated at another institution. The anatomic lateral distal femoral angle (aLDFA) and the anatomic posterior distal femoral angle (aPDFA) were measured on the follow-up radiographs., Results: Ninety-seven PPDFFs in 97 patients, with a mean age of 76 years and 74% female were identified. Plating was used in 74 patients (76%) and 23 patients (24%) were treated with intramedullary nailing. Extension deformity in the sagittal plane was more common following intramedullary nailing compared to plating (10/23 nailing versus 10/74 plating) (p=0.002). There were 12 reoperations (12/75, 16%), and the method of fixation was not associated with rate of reoperation (p=0.9)., Conclusion: Intramedullary nailing was associated with an increased risk of malalignment, most commonly an extension deformity, in this series. However, malalignment was not associated with worse outcomes., Competing Interests: Declaration of Comprting Interest None., (Copyright © 2021. Published by Elsevier Ltd.)

Introduction: Cannabinoids are an increasingly popular therapy among orthopaedic patients for musculoskeletal conditions. A paucity of evidence to support their use in orthopaedics exists, likely because of the incongruence of federal and state legalization and the stigma surrounding cannabis. The purpose of this study is to elucidate sentiments and knowledge base of the orthopaedic trauma community with regard to cannabinoid-containing compounds., Methods: A 21-question online survey was distributed to the members of the Orthopaedic Trauma Association with a response window of 3 months., Results: We evaluated 251 responses. Most (88%) of the respondents did not believe that they were knowledgeable about the mechanism of action of cannabis/cannabidiol (CBD) but did feel that cannabis or CBD products play a role in managing postoperative pain (73%). Most respondents did not believe that they would be stigmatized if they suggested CBD (83%) or cannabis (67%) to patients. Despite this, fewer respondents have suggested CBD (38%) or cannabis (29%) to their patients., Conclusions: Sentiment toward cannabinoids among orthopaedic traumatologists is remarkably favorable; however, in-depth understanding is admittedly poor and routine use is uncommon. More clinical research for cannabinoids is needed to help orthopaedic traumatologists provide guidance for patients seeking advice for this recently popular therapeutic., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Childhood diabetes is a rising concern as the overall annual increase in diabetes among children/adolescents is estimated to be around 3% over the past decade. Diabetes management places children/adolescents and their parents at greater risks of psychological distress. This study aims to measure the levels of diabetes-related emotional distress in children/adolescents with diabetes and their caregiving parents and to identify associations between sociodemographic characteristics and clinical variables in Singapore. A cross-sectional study was conducted using validated questionnaires. Ninety-two parent-child/adolescent dyads completed self-reported questionnaires. Elevated levels of diabetes-related distress were found in both children/adolescents with diabetes and their parents. Female children/adolescents with diabetes, low-income households, and less-educated parents of children/adolescents with diabetes were more susceptible to diabetes-related distress. It is important for healthcare professionals to educate less-educated parents in the management of their children's/adolescents' diabetes. Greater financial assistance should be provided to low-income households that may not have access to advanced diabetes treatments.

Background and Aims: Studies of hereditary transthyretin amyloidosis (ATTRv amyloidosis) in South-East Asia are underrepresented in the literature. We report the unique phenotypic and genetic characteristics of this disorder in a multiracial South-East Asian cohort., Methods: Patients with genetically proven ATTRv amyloidosis were identified over a 13-year period (2007-2020) at the National Neuroscience Institute, Singapore. Clinical, laboratory, genotypic and electrophysiological features were retrospectively reviewed., Results: 29 patients comprising Chinese, Malay, Burmese, Vietnamese and Indonesians with ATTRv amyloidosis were identified. Somatic neuropathy was the most common initial presentation, followed by carpal tunnel syndrome, autonomic dysfunction and cardiac dysfunction. ATTR-A97S (p.Ala117Ser) was the most common variant found in 14 patients, constituting 66.7%of ethnic Chinese patients and 48.3%of the entire cohort. Five patients had early-onset disease (age < 50 years) with the following variants: ATTR-V30M (p.Val50Met), ATTR-G47A (p.Gly67Ala), ATTR-S50I (p.Ser70Ile) and ATTR-A97S (p.Ala117Ser); one patient with ATTR-A97S (p.Ala117Ser) had isolated unilateral carpal tunnel syndrome with amyloid deposits identified on histological examination of the transverse carpal ligament. All early-onset patients had a positive parental history; two patients, with ATTR-S50I (p.Ser70Ile) and ATTR-Ala97Ser (p.Ala117Ser) respectively, demonstrated anticipation with mother-to-daughter inheritance. Amongst the 24 patients with late-onset disease (age≥50 years), two patients had novel variants, ATTR-G66D (p.Glu86Asp) and ATTR-A81V (p.Ala101Val) that were confirmed to be pathogenic based on the histological identification of transthyretin amyloid. Other identified variants included ATTR-V30M (p.Val50Met), ATTR-R34T (p.Arg54Thr), ATTR-S50I (p.Ser70Ile), ATTR-H88R (p.His108Arg) and ATTR-A97S (p.Ala117Ser)., Conclusion: Our study further expands the genotypic and phenotypic knowledge regarding ATTRv amyloidosis.

Background: The purpose of this study was to determine the importance of factors considered by orthopaedic trauma fellowship applicants when evaluating programs. We hypothesized that applicants will prioritize consistent factors when applying to programs. In addition, we assessed how the applicants use the Internet to research potential fellowships. Our goal is to provide fellowships with information to optimize both their fellowship and online contents., Methods: At the 2018 and 2019 Orthopaedic Trauma Association meetings, a paper survey was given to each attendee of multiple fellowships' informational sessions. The survey consisted of 25 factors that applicants may consider when evaluating fellowships ranked on a 1-to-5 Likert scale. Additional questions were asked to determine how applicants use the Internet and social media when researching fellowships., Results: We received 111 surveys (roughly a 56% response rate). Ninety-eight applicants (88%) indicated that they use fellowship websites to research fellowships. The utilization of fellowship websites was markedly greater than the use of other online resources. The highest rated factors surveyed were surgical experience (mean 4.95; SD 0.26), pelvic and acetabular experience (4.80; 0.52), lower extremity fracture experience (4.75; 0.58), and current faculty at the fellowship (4.55; 0.78). The lowest rated factors were the ability to moonlight (2.04; 1.08), salary (1.88; 1.12), and spine trauma experience (1.45; 0.87). Surgical experience and pelvic/acetabular experience were rated markedly higher than every other factor surveyed., Discussion: To our knowledge, this is the first study to demonstrate that most orthopaedic trauma fellowship applicants use fellowship websites when researching programs. Programs may use this study to optimize their fellowship experience to reflect what the applicants value. In addition, programs may use this study as a guide when updating their websites. Fellowships with informative websites that meaningfully highlight their fellowship experience may have a competitive edge in attracting applicants to their programs.

Introduction: Obesity is an epidemic facing the United States affecting nearly 40% of the population (93.3 million adults). The objective of this study was to compare early perioperative complications in patients with a normal BMI to patients who are pre-obese, obese, and morbidly obese., Materials and Methods: The study was conducted at a Level-I trauma center. Patients were separated into 4 groups based on their BMI. Group 1 had a BMI < 25 (normal), Group 2 had a BMI between 25-29.9 (pre-obesity), Group 3 had a BMI between 30-39.9 (obese), and Group 4 had a BMI ≥40 (morbidly obese). Outcome variables included total operative time (OT), estimated blood loss (EBL), length of stay (LOS), and early medical and surgical complications. A comparison between groups was performed for each outcome variable and surgical complication., Results: We identified 333 patients and the number of patients in Groups 1-4 were 86, 96, 121, and 30, respectively. The average BMI for Groups 1-4 was 22.3, 27.3, 35.9, and 44.9, respectively (p < 0.001). OT, EBL, and LOS did not differ between groups or between the surgical approach utilized. There were no significant relationships when comparing complication rates between groups. Patients in Group 4 experienced significantly more PE compared to patients in Group 2 (p=0.01). Additionally, patients in Group 4 experienced a significantly more PE than patients in Groups 1 and 2 combined (p<.01). The relative risk of having a PE if BMI is ≥40, compared to a BMI <30 is 18.40 (95% CI = 1.98 - 171.13). The PEs were not fatal in all cases., Conclusions: In the treatment of the obese and morbidly obese with acetabular fractures, we find that these cohorts are not at a greater risk of wound complications or infection. The higher rate of pulmonary embolism seen in the morbidly obese should be considered when evaluating these patients for appropriate thromboembolic prophylaxis., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Palliative care providers find meaning in their work, even though stress, burnout, and compassion fatigue can be a concern. In this study, we aimed to explore the experiences of well-being of palliative care providers in Malaysia. Data collected using semistructured interviews were thematically analyzed. Eighteen palliative care providers participated: 9 doctors and 9 nurses. Five subthemes were generated: (1) values and strengths, (2) coping and work-life balance, (3) social support and spirituality, (4) passion and satisfaction, and (5) learning, growth, and transformation. These subthemes were further categorized into 2 themes: resilience and reward. The results may inform the development of interventions in the promotion and sustenance of well-being of palliative care providers.

Introduction: The goal of this study was to identify the current practices and rationale of orthopaedic surgeons regarding venous thromboembolism (VTE) prophylaxis for pelvic and acetabular (P&A) fractures., Methods: A 25-item web-based questionnaire was made available to all Orthopaedic Trauma Association (OTA) members on the OTA website. Analysis of data was performed after the three-month study period., Results: One hundred three active OTA members completed the survey. Most respondents practiced at an academic level I trauma centers. The most important factor in selecting a VTE regimen was its effectiveness, whereas cost was the least important. Low-molecular-weight heparin (LMWH) remains the preferred agent for VTE prophylaxis after P&A trauma. Factors such as surgical intervention and weight-bearing had a variable effect on surgeons' opinions regarding the type and duration of VTE prophylaxis., Conclusion: Most surgeons treating P&A fractures use LMWH for VTE prophylaxis, but the decision on which agent to use and duration of treatment is multifactorial. Published VTE prophylaxis literature and guidelines provide some guidance, but there is no consensus. Overall, LMWH appears to be the VTE prophylaxis agent of choice for most orthopaedic trauma surgeons, irrespective of nonsurgical or surgical management of these fractures.

Objective: Periprosthetic fractures of the distal femur can be challenging injuries to treat; nonunion rates of up to 22% have been reported. The purpose of this study was to determine the rate of complications and nonunion in a multicenter series, and to identify patient or surgical factors that were associated with nonunion., Design: Retrospective comparative study SETTING: Three Level 1 trauma centers PATIENTS: Fifty-five patients with a periprosthetic distal femur fracture proximal to a total knee arthroplasty. Minimum follow up for inclusion was six months or until union or failure., Intervention: Surgical fixation using a precontoured lateral locking plate MAIN OUTCOME MEASUREMENT: Fracture union was the primary outcome. Patient demographic and injury variables (age, comorbidities, fracture classification and characteristics) and surgical technique factors (mode of plate fixation, plate material, working length, screw density, and proximal screw type) were identified and compared between patients who developed a nonunion and those who did not. Regression analysis was performed to identify independent risk factors for nonunion., Results: The overall rate of nonunion was 18% and the total complication rate was 24%. After additional surgery, 49 of 55 patients went on to heal (89%). There were no statistical differences in patient demographic or injury variables between the union and nonunion groups, and none of the variables studied were independent risk factors for nonunion in the regression analysis., Conclusions: In this series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates, 18% developed nonunion and the overall complication rate was 24%. No patient or surgical variables were identified as risk factors. Future research should seek to identify patients at high risk for complication and nonunion who could benefit from alternative fixation strategies or distal femoral replacement., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: To report the clinical result of a series of patients who underwent acetabular fracture fixation using a Kocher-Langenbeck approach without a specialty traction table., Design: Retrospective case series., Setting: Level 1 trauma center., Patients/participants: All patients who sustained posterior wall or posterior wall associated acetabular fractures that were treated operatively with a Kocher-Langenbeck approach over a 5-year period., Intervention: Surgical fixation of acetabular fractures using a flat, radiolucent table., Main Outcome Measurements: Outcomes included reduction quality and complications such as infection, heterotopic ossification, loss of reduction or fixation, medical complications, and neurologic injury., Results: We identified 172 patients. No articular malreductions of greater than 2 mm were noted on postoperative CT scans. There were 13 surgical complications observed (8.1%). There was 1 death in our cohort (0.6%), and 3 patients had nonfatal pulmonary emboli (1.9%). There were no nerve injuries observed. There were 6 acute infections (3.1%) requiring surgical intervention. Three patients had symptomatic heterotopic bone that required excision (1.9%). Four patients (2.5%) required eventual total hip arthroplasty., Conclusion: Overall, we report on the largest cohort in the literature undergoing a prone Kocher-Langenbeck without a specialty table for acetabular fracture fixation. We found that limited extremity prepping and draping for a prone Kocher-Langenbeck on a flat, radiolucent table did not result in an increased rate of postoperative neurological complications or malreductions of acetabular fractures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures., Design: Retrospective review., Setting: Two Level 1 and 1 Level 2 trauma centers., Patients: Two hundred eighty-seven patients met the criteria and were included in the study., Intervention: Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm., Main Outcome Measurements: Nonunion rates, mean time to union., Results: Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups., Conclusion: Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Approximately one in 2000 babies are born with craniosynostosis, and primary open repair is typically performed before 1 year of age. Historically, the procedure has been associated with nearly 100 percent transfusion rates. To decrease the rates of transfusion, the authors' center has developed a novel multimodal blood conservation protocol., Methods: The authors administered their standard of care to children aged 1 year or younger undergoing primary repair of craniosynostosis between 2008 and 2014. In 2014, the authors implemented the following protocol: (1) preoperative erythropoietin and ferrous sulfate, (2) local anesthetic with epinephrine infiltration of the incision, (3) PlasmaBlade incision and subgaleal dissection, (4) hypervolemic hemodilution, and (5) intravenous tranexamic acid. Procedures performed before the protocol implementation served as controls. The authors performed classic fronto-orbital advancement with anterior cranial vault remodeling for coronal and metopic craniosynostosis. For lambdoid and sagittal craniosynostosis, barrel stave osteotomies, cranial base outfracture, and interposition bone grafting were performed., Results: A total of 279 children with a mean age of 6 months who had craniosynostosis repairs were included. One hundred forty-five underwent repair before the authors' protocol, and 134 had repairs during the authors' blood conservation protocol. Both groups were similar in demographics. Overall blood loss and operative times were significantly reduced by 73 percent and 11 percent, respectively. Blood transfusion rate decreased 92 percent (p < 0.001)., Conclusions: These results show a strong association between the authors' blood conservation protocol and significantly reduced transfusion rates. The authors believe this is a significant step forward and can be safely applied in the great majority of children undergoing craniosynostosis repairs., Clinical Question/level of Evidence: Therapeutic, III.

Introduction: Lambdoid craniosynostosis is an extremely rare anomaly in which there is premature fusion of one or both lambdoid sutures. The mainstay of treatment is surgical intervention, for which various procedures have been described, but there is a paucity of data on long-term outcomes. This study examines the long-term outcomes in the surgical management of this challenging condition, showing that accurate diagnosis and careful planning can lead to safe and consistent results., Materials and Methods: A retrospective chart review was performed looking at all cases of isolated lambdoid craniosynostosis treated with surgical intervention by the senior author from 1999 to 2016. Data collected included gender, age at diagnosis, age at surgery, length of follow up, method of diagnosis, side of affected suture, pre-operative and post-operative physical exam findings, surgical technique, complications, re-operation rate, and associated torticollis., Results: Twenty-five patients (N = 25) were included in the study. All patients underwent posterior calvarial remodeling with/without barrel stave osteotomies and full thickness calvarial bone grafts. Mean length of follow up after operative intervention was 43.8 months (+/- 23.2 months). All patients were judged to have significantly improved head contour which was near-normal at conversational distance during post-operative follow up by the senior author. Residual plagiocephaly was present in 24% of patients. There were no major complications in this series. Reoperation rate was 8%. Seventy-six percent of patients also presented with torticollis, of which 37% had refractory torticollis that required sternocleidomastoid (SCM) release by the senior author., Discussion: The authors present one of the largest series of operative cases of isolated lambdoid craniosynostosis to date. Our data show that with accurate diagnosis and careful planning, safe and consistent long-term results can be achieved with surgical intervention. A significant number of patients in our series also presented with concomitant torticollis. The authors recommend that all patients being evaluated for posterior plagiocephaly should also be evaluated for torticollis, because without recognition and intervention, patients may continue to have residual facial asymmetry and head shape abnormalities despite optimal surgical correction of the lambdoid synostosis.

Alcohol is one of most commonly abused substances in the United States, and it has contributed to a growing epidemic of medical ailments, including cirrhosis, neurologic and psychosocial disorders, impairment to fertility, and cancer. Moreover, acute and chronic alcohol use represent a significant risk factor for orthopaedic injury and postoperative complications. Yet, relatively little is known about the clinical implications of alcohol abuse in common orthopaedic procedures. Acute withdrawal from alcohol is potentially fatal, particularly in the orthopaedic inpatient whose abstinence is mandated by the hospital setting. The aim of this review is to address the screening, diagnostic, and therapeutic tools available to appropriately manage acute alcohol withdrawal in the orthopaedic inpatient. The influence of chronic alcohol consumption on bone metabolism, fracture healing, and surgical fixation will also be reviewed because this information may guide surgical decision making.

Traumatic through-knee or transfemoral amputations with concomitant ipsilateral femoral fractures are extremely rare injuries. The initial goal of management is patient resuscitation and stabilization. Subsequent interventions focus on limb salvage and the creation of a residual limb that can be fitted successfully for a functional lower extremity prosthesis. We present the case of a patient who sustained a traumatic through-knee amputation ipsilateral to an open comminuted femoral fracture. Soft tissue injury prohibited initial primary closure over the distal femoral condyles. A functional residual limb was achieved with acute femoral shortening, maintenance of the femoral condyles and fracture stabilization with a short retrograde intramedullary nail. This approach allowed maintenance of muscular attachments to the femur, soft tissue closure and resulted in a residual limb of acceptable length with a broad weight-bearing surface that was fitted with a prosthesis successfully.

Objective: To determine if three-dimensional (3D) printed models can be used to improve acetabular fracture pattern recognition and be a valuable adjunct in orthopedic resident education., Design: Fifteen randomized testing stations with each containing plain radiographs (XRs), two-dimensional computed tomography (CT) scans, or 3D model of an acetabular fracture., Setting: Two orthopedic residency programs based at Level 1 trauma centers., Participants: Forty-one orthopedic residents, PGY 1-5., Results: Senior residents were superior to junior residents at correctly identifying the provided acetabular fracture pattern. Overall, use of CT scans or the 3D model improved fracture classification as compared to standard XRs, but there was no significant difference between use of the CT scans and 3D models. Subjective survey results indicated agreement among residents that 3D models were accurate representations of acetabular fractures and that models would be a desired educational modality., Conclusions: 3D models improved the accuracy of acetabular fracture identification compared to XR. In addition, trainees were able to use 3D models to obtain similar accuracy compared to CT scans despite not having previous exposure to the models. Interobserver agreement improved when comparing CT to 3D, but did not provide greater than a fair agreement indicating that fracture patterns were difficult to accurately classify even with the use of 3D models. Residents' subjective responses indicated a positive experience with the use of 3D models. We conclude that the incorporation of 3D models could be an important adjunct to orthopedic residency education for the evaluation complex fracture patterns, but is not significantly superior to identification with CT scans., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The photoplethysmography (PPG) signal, commonly used in the healthcare settings, is easily affected by movement artefact leading to errors in the extracted heart rate and SpO 2 estimates. This study aims to develop an online artefact detection system based on adaptive (dynamic) template matching, suitable for continuous PPG monitoring during daily living activities or in the intensive care units (ICUs)., Approach: Several master templates are initially generated by applying principal component analysis to data obtained from the PhysioNet MIMIC II database. The master template is then updated with each incoming clean PPG pulse. The correlation coefficient is used to classify the PPG pulse into either good or bad quality categories. The performance of our algorithm was evaluated using data obtained from two different sources: (i) our own data collected from 19 healthy subjects using the wearable Sotera Visi Mobile system (Sotera Wireless Inc.) as they performed various movement types; and (ii) ICU data provided by the PhysioNet MIMIC II database. The developed algorithm was evaluated against a manually annotated 'gold standard' (GS)., Main Results: Our algorithm achieved an overall accuracy of 91.5%  ±  2.9%, with a sensitivity of 94.1%  ±  2.7% and a specificity of 89.7%  ±  5.1%, when tested on our own data. When applying the algorithm to data from the PhysioNet MIMIC II database, it achieved an accuracy of 98.0%, with a sensitivity and specificity of 99.0% and 96.1%, respectively., Significance: The proposed method is simple and robust against individual variations in the PPG characteristics, thus making it suitable for a diverse range of datasets. Integration of the proposed artefact detection technique into remote monitoring devices could enhance reliability of the PPG-derived physiological parameters.

We report an Elizabethkingia anophelis case cluster associated with contaminated aerators and tap water in a children's intensive care unit in Singapore in 2017. We demonstrate a likely transmission route for E. anophelis to patients through acquisition of the bacteria on hands of healthcare workers via handwashing.

Aim: To measure skin thickness (ST) and skin + subcutaneous layer thickness (SCT) by ultrasound and estimate the risk of intramuscular injection (IM) with different needle lengths across injection sites according to age group., Method: Children recruited between 1 and 18 years with type 1 and 2 diabetes on insulin injections and divided into three age groups: 1-6 years, 7-12 years and 13-18 years. A portable ultrasound was used to measure ST and SCT at four injection sites on the abdomen, arm, thigh and buttock., Results: Total 153 children enrolled for the study. The mean (SD) measurement of ST & SCT at four sites on abdomen, arm, thigh & buttocks were as follows; 4.33 mm (±2.22), 5.55 mm (±2.26), 5.83 mm (±3.12), 6.48 mm (±3.47) in 1-6 years old; 7.11 mm (±3.68), 7.79 mm (±4.54), 7.17 mm (±3.62), 8.51 mm (±3.65) in 7-12 years old; 8.94 mm (±4.50), 8.42 mm (±5.00), 8.61 mm (±4.76), 9.76 mm (±4.38) in 13-18 years old. Young children, 1-6 years have the highest risk of IM injection with all needle lengths, i.e. 4, 5, 6, 8 & 12.7 mm, while older children 7-12 & 13-18 years have a lower risk with shorter needles (4, 5 and 6 mm) as compared to longer needles (8 and 12.7 mm)., Conclusions: Children with diabetes on insulin therapy should be advised on the appropriate needle length accordingly to their age and BMI.

Human toxocariasis which is caused mainly by the larvae of Toxocara canis and Toxocara cati, is a worldwide zoonotic disease that can be a potentially serious human infection. The enzyme-linked immunosorbent assay (ELISA) using T. canis excretory-secretory (TES) antigens harvested from T. canis larvae is currently the serological test for confirming toxocariasis. An alternative to producing large amounts of Toxocara TES and improved diagnosis for toxocariasis is through the development of highly specific recombinant antigens such as the T. canis second stage larva excretory-secretory 30 kDa protein (recTES-30). The aim of this study was to evaluate the sensitivity and specificity of a rapid diagnostic kit (RDT, named as iToxocara kit) in comparison to recTES-30 ELISA in Serendah Orang Asli village in Selangor, Malaysia. A total of 133 subjects were included in the study. The overall prevalence rates by ELISA and RDT were 29.3% and 33.1%, respectively, with more positive cases detected in males than females. However, no association was found between toxocariasis and gender or age. The percentage sensitivity, specificity, positive predictive value and negative predictive value of RDT were 85.7%, 90.1%, 80% and 93.2%, respectively. The prevalence for toxocariasis in this population using both ELISA and RDT was 27.1% (36/133) and the K-concordance test suggested good agreement of the two tests with a Cohen's kappa of 0.722, P<0.01. In addition, the followed-up Spearman rank correlation showed a moderately high correlation at R=0.704 and P<0.01. In conclusion, the RDT kit was faster and easier to use than an ELISA and is useful for the laboratory diagnosis of hospitalized cases of toxocariasis., (Copyright © 2015 The Authors. Published by Elsevier B.V. All rights reserved.)

We present a novel approach to improve the estimation of systolic (SBP) and diastolic blood pressure (DBP) from oscillometric waveform data using variable characteristic ratios between SBP and DBP with mean arterial pressure (MAP). This was verified in 25 healthy subjects, aged 28 ± 5 years. The multiple linear regression (MLR) and support vector regression (SVR) models were used to examine the relationship between the SBP and the DBP ratio with ten features extracted from the oscillometric waveform envelope (OWE). An automatic algorithm based on relative changes in the cuff pressure and neighbouring oscillometric pulses was proposed to remove outlier points caused by movement artifacts. Substantial reduction in the mean and standard deviation of the blood pressure estimation errors were obtained upon artifact removal. Using the sequential forward floating selection (SFFS) approach, we were able to achieve a significant reduction in the mean and standard deviation of differences between the estimated SBP values and the reference scoring (MLR: mean ± SD = -0.3 ± 5.8 mmHg; SVR and -0.6 ± 5.4 mmHg) with only two features, i.e., Ratio2 and Area3, as compared to the conventional maximum amplitude algorithm (MAA) method (mean ± SD = -1.6 ± 8.6 mmHg). Comparing the performance of both MLR and SVR models, our results showed that the MLR model was able to achieve comparable performance to that of the SVR model despite its simplicity.

Widespread food poisoning due to microbial contamination has been a major concern for the food industry, consumers and governing authorities. This study is designed to determine the levels of fungal contamination in edible bird nests (EBNs) using culture and molecular techniques. Raw EBNs were collected from five house farms, and commercial EBNs were purchased from five Chinese traditional medicine shops (companies A-E) in Peninsular Malaysia. The fungal contents in the raw and commercial EBNs, and boiled and unboiled EBNs were determined. Culturable fungi were isolated and identified. In this study, the use of these methods revealed that all EBNs had fungal colony-forming units (CFUs) that exceeded the limit set by Standards and Industrial Research Institute of Malaysia (SIRIM) for yeast and moulds in EBNs. There was a significant difference (p < 0.05) in the number of types of fungi isolated from raw and commercial EBNs, but no significant difference in the reduction of the number of types of fungi after boiling the EBNs (p > 0.05). The types of fungi isolated from the unboiled raw EBNs were mainly soil, plant and environmental fungi, while the types of fungi isolated from the boiled raw EBNs, unboiled and boiled commercial EBNs were mainly environmental fungi. Aspergillus sp., Candida sp., Cladosporium sp., Neurospora sp. and Penicillum sp. were the most common fungi isolated from the unboiled and boiled raw and commercial EBNs. Some of these fungi are mycotoxin producers and cause opportunistic infections in humans. Further studies to determine the mycotoxin levels and methods to prevent or remove these contaminations from EBNs for safe consumption are necessary. The establishment and implementation of stringent regulations for the standards of EBNs should be regularly updated and monitored to improve the quality of the EBNs and consumer safety.

Edible bird nests (EBNs) are consumed worldwide for various health benefits. EBNs are nests built from the saliva of swiftlets of Aerodramus species. The global market for EBNs is on the rise, especially from Hong Kong and mainland China. In the past, EBNs were harvested mainly from natural caves; however in the recent years, there has been a rapid growth of swiftlet farming. Little is known about the actual composition of EBNs except for protein, carbohydrate, ash and lipid contents, amino acids, vitamins and macro/ micronutrients. Besides the biochemical components of EBNs, are there any other structures that are associated with EBNs? This paper reports on the structural analysis of raw unprocessed farm and processed commercial EBNs. The raw EBNs were purchased from swiftlet farms in five locations in Peninsula Malaysia: Kuala Sanglang (Perlis; 6° 16' 0"N, 100° 12' 0"E), Pantai Remis (Perak; 4º 27' 0" N, 100º 38' 0" E), Kluang (Johor; 02º 012 303N 103º 192 583E), Kajang (Selangor; 2º 59' 0"N, 101º 47' 0"E) and Kota Bharu (Kelantan; 6º 8' 0"N, 102º 15' 0"E). The commercial nests were purchased from five different Chinese traditional medicinal shops (Companies A-E). A portion of each EBN was randomly broken into small fragments, attached to carbon tape and coated with gold and palladium particles for examination and photography under a scanning electron microscope. Structural analysis revealed the presence of mites, fungi, bacteria and feather strands on both the raw and commercial nests. Mite eggshells and faecal pellets, and body parts of other arthropods were seen only in the raw nests. The commercial nests had a variety of unidentified structures and substances coated on the nests' surfaces that were not found on the raw nests. The presence of these contaminants may jeopardise the quality of EBNs and pose health risks to consumers. Further identification of the mites and their allergens, fungi and bacteria are on-going and will be reported separately.