Understanding risks and complications in the management of ankle fractures

Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.     

Quantifying a Rare Disease in Administrative Data: The Example of Calciphylaxis

BACKGROUND

Calciphylaxis, a rare disease seen in chronic dialysis patients, is associated with significant morbidity and mortality. As is the case with other rare diseases, the precise epidemiology of calciphylaxis remains unknown. Absence of a unique International Classification of Diseases (ICD) code impedes its identification in large administrative databases such as the United States Renal Data System (USRDS) and hinders patient-oriented research. This study was designed to develop an algorithm to accurately identify cases of calciphylaxis and to examine its incidence and mortality.

DESIGN, PARTICIPANTS, AND MAIN MEASURES

Along with many other diagnoses, calciphylaxis is included in ICD-9 code 275.49, Other Disorders of Calcium Metabolism. Since calciphylaxis is the only disorder listed under this code that requires a skin biopsy for diagnosis, we theorized that simultaneous application of code 275.49 and skin biopsy procedure codes would accurately identify calciphylaxis cases. This novel algorithm was developed using the Partners Research Patient Data Registry (RPDR) (n?=?11,451 chronic hemodialysis patients over study period January 2002 to December 2011) using natural language processing and review of medical and pathology records (the gold-standard strategy). We then applied this algorithm to the USRDS to investigate calciphylaxis incidence and mortality.

KEY RESULTS

Comparison of our novel research strategy against the gold standard yielded: sensitivity 89.2 %, specificity 99.9 %, positive likelihood ratio 3,382.3, negative likelihood ratio 0.11, and area under the curve 0.96. Application of the algorithm to the USRDS identified 649 incident calciphylaxis cases over the study period. Although calciphylaxis is rare, its incidence has been increasing, with a major inflection point during 2006–2007, which corresponded with specific addition of calciphylaxis under code 275.49 in October 2006. Calciphylaxis incidence continued to rise even after limiting the study period to 2007 onwards (from 3.7 to 5.7 per 10,000 chronic hemodialysis patients; r?=?0.91, p?=?0.02). Mortality rates among calciphylaxis patients were noted to be 2.5–3 times higher than average mortality rates for chronic hemodialysis patients.

CONCLUSIONS

By developing and successfully applying a novel algorithm, we observed a significant increase in calciphylaxis incidence. Because calciphylaxis is associated with extremely high mortality, our study provides valuable information for future patient-oriented calciphylaxis research, and also serves as a template for investigating other rare diseases.

     

INAUGURAL ARTICLE by a Recently Elected Academy Member:Natural history-driven,plant-mediated RNAi-based study reveals CYP6B46’s role in a nicotine-mediated antipredator herbivore defense

Manduca sexta (Ms) larvae are known to efficiently excrete ingested nicotine when feeding on their nicotine-producing native hostplant, Nicotiana attenuata. Here we describe how ingested nicotine is co-opted for larval defense by a unique mechanism. Plant-mediated RNAi was used to silence a midgut-expressed, nicotine-induced cytochrome P450 6B46 (CYP6B46) in larvae consuming transgenic N. attenuata plants producing MsCYP6B46 dsRNA. These and transgenic nicotine-deficient plants were planted into native habitats to study the phenotypes of larvae feeding on these plants and the behavior of their predators. The attack-behavior of a native wolf spider (Camptocosa parallela), a major nocturnal predator, provided the key to understanding MsCYP6B46’s function: spiders clearly preferred CYP6B46-silenced larvae, just as they had preferred larvae fed nicotine-deficient plants. MsCYP6B46 redirects a small amount (0.65%) of ingested nicotine from the midgut into hemolymph, from which nicotine is exhaled through the spiracles as an antispider signal. CYP6B46-silenced larvae were more susceptible to spider-attack because they exhaled less nicotine because of lower hemolymph nicotine concentrations. CYP6B46-silenced larvae were impaired in distributing ingested nicotine from midgut to hemolymph, but not in the clearing of hemolymph nicotine or in the exhalation of nicotine from hemolymph. MsCYP6B46 could be a component of a previously hypothesized pump that converts nicotine to a short-lived, transportable, metabolite. Other predators, big-eyed bugs, and antlion larvae were insensitive to this defense. Thus, chemical defenses, too toxic to sequester, can be repurposed for defensive functions through respiration as a form of defensive halitosis, and predators can assist the functional elucidation of herbivore genes.Plants produce a pharmacopeia of potent chemical defenses that prevent the attack of unadapted herbivores and thwart the growth of adapted ones. Frequently, lepidopteran herbivores co-opt these diet-acquired toxins for their own defensive purposes. The eastern tent caterpillar (Malacosoma americanum) regurgitates hydrogen cyanide and benzaldehyde ingested from their cyanogenic hostplants when attacked by ants (1). The Atala butterfly (Eumaeus atala) acquires a toxic azoxyglycoside from its cycad hosts and becomes unpalatable to bird and ant predators (2). Similarly, rattlebox moths (Utetheisa ornatrix) co-opt pyrrolizidine alkaloids that their larvae sequester while feeding on rattlebox legume hostplants (Crotalaria spp.) to deter predatory spiders (3). Prey frequently advertise their toxic status with warning colorations, odors, and behaviors, and predators readily learn these aposematic signals to avoid consuming toxic prey (4). The molecular mechanisms of how herbivores co-opt plant defenses for their own defense remain largely unexplored.The pyridine alkaloid nicotine is a defense metabolite of several Nicotiana spp. Nicotine is extremely effective against herbivores because of its ability to poison the essential neuromuscular junction common to all animals that use muscles to move: the acetylcholine receptor (5, 6). Nicotiana spp. hostplants respond to the herbivore attack with large increases in nicotine accumulation (7). However, the tobacco hornworm (Manduca sexta, Ms), a specialist lepidopteran herbivore that feeds on nicotine-producing Nicotiana plants, tolerates doses of nicotine that are lethal for unadapted herbivores (8). More endoparasitoid wasps (Cotesia congregata) emerged as adults from parasitized M. sexta larvae fed on low nicotine varieties of cultivated tobacco than from larvae fed on nicotine-rich varieties (9). The generalist predatory argentine ant (Iridomyrmex humilis) also preferred M. sexta larvae reared on artificial diets (AD) without nicotine over those reared on high nicotine diets, and were deterred by topical nicotine treatments (10). These results suggest that M. sexta larvae might be able to use this diet-derived toxin for their own protection. How this happens remains a mystery, as the larvae’s resistance of ingested nicotine does not appear to include sequestration and storage of this toxin.The exact mechanisms responsible for M. sexta’s nicotine resistance remain unclear, but both efficient excretion and metabolism appear to be involved. Some researchers have focused on the polar metabolites of nicotine, such as cotinine and the N-oxides of both nicotine and cotinine, which are commonly found in the urine and blood of human smokers (8, 11, 12); cytochrome P450s (CYPs) are thought to mediate nicotine’s oxidation to these metabolites (8, 11, 13–15), but other researchers have been unable to find the oxides in M. sexta’s excretions and propose that nicotine is rapidly excreted without modification (16–18). Although this theory is widely accepted, most studies have not been able to recover all of the ingested nicotine in the frass and nicotine can be found in the hemolymph of larvae feeding on nicotine-containing diets. Hence, within these physiological limits of M. sexta’s excretory-based tolerance lie opportunities for the defensive use of nicotine. Whether nicotine-resistance and co-option are regulated by a common mechanism remains unknown.Here we examine how M. sexta larvae co-opt diet-ingested nicotine for their own defense. In a previous unbiased microarray study, we found that a midgut-expressed cytochrome P450 (CYP6B46) was strongly down-regulated in larvae that were fed genetically modified hostplants with suppressed nicotine production (19, 20). To evaluate if this CYP6B46 is involved in nicotine resistance and co-option, we used a reverse genetics approach, plant-mediated RNA interference (PMRi) (20, 21), to silence this gene in larvae feeding on nicotine-containing, native coyote tobacco (Nicotiana attenuata) hostplants transformed to harbor the silencing construct. Lepidopteran herbivores appear to lack the RNA-dependent RNA polymerase required to sustain gene silencing by RNAi; however, a continuous supply of double-stranded (ds)RNA administered via the hostplant (or diet) effectively silences genes in these herbivores (21, 22).N. attenuata plants were transformed with an expression vector containing a 300-bp fragment of CYP6B46 in an inverted repeat (ir) orientation. Continuous dsRNA ingestion efficiently silenced CYP6B46 in the midguts of larvae feeding on these plants in a highly target-sequence–specific manner, as the most similar CYP expressed in larval midguts, CYP6B45, was not cosilenced (20). These PMRi plants were planted into the native habitat of both hostplant and larvae, the Great Basin Desert, Utah, which teems with larval predators—such as bugs, mantids, ants, antlions, spiders, and lizards—but lacks the Argentine ants and C. congregata endoparasitoids previously reported to be nicotine-sensitive. One of these predators, a wolf spider [Camptocosa parallela (Lycosidae)], selectively attacked CYP6B46-silenced larvae just as it did larvae feeding on nicotine-free hostplants. The particular predatory behavior of these spiders revealed the function of MsCYP6B46 in externalizing ingested nicotine for defensive use. The combination of natural history studies and the plant- and herbivore-reverse genetic procedures can fruitfully dissect the molecular mechanisms governing the tritrophic interactions.     

Blue-emissive two-component supergelator with aggregation-induced enhanced emission

Two-component organogels offer several advantages over one-component gels, but their design is highly challenging. Hence, it is extremely important to design new approaches for the crafting of two-component organogels with interesting optical and mechanical properties. Herein, we report the design of a new class of two-component supergelators obtained from the assembly between acid functionalized tetraphenylethylene (TPE)-based dendrons and alkylated melamine. No gelation behaviour is observed for the individual components, but interestingly, remarkable gelation behaviour is observed for their hydrogen-bonded complex. The primary driving force responsible for the gelation is the strong π–π stacking interaction of TPE units. Because of the strong π-stacking of TPEs in the gel state, the C(sp²)–C(sp²) bond rotation of the TPE segment is completely arrested in the gel state, which results in intense fluorescence emission of the gels. Furthermore, excellent elastic response is observed for the gels as evident from their high storage modulus compared to loss modulus values. Our results clearly demonstrate that by the appropriate selection of the molecular components, this approach can be applied for the creation of functional nanomaterials with emergent properties absent in the individual blocks.

Design of a novel class of two-component, highly emissive, low molecular weight supergelator is reported.     

Hereditary Ataxias in Cuba: A Nationwide Epidemiological and Clinical Study in 1001 Patients

The Cerebellum - The prevalence estimations of hereditary ataxias are biased since most epidemiological studies are confined to isolated geographical regions and few nationwide studies are...