Syndesmotic screws, unscrew them, or leave them? A systematic review and meta-analysis of randomized controlled trials

Background

Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however recent literature has brought into question the necessity of routine removal, citing no change in functional outcomes and the inherent risks of a second surgery. Our study aimed to compare outcomes of patients undergoing routine syndesmotic screw removal versus those undergoing an on-demand approach to removal.

Methods

A systematic search of studies comparing routine syndesmotic screw removal to on-demand screw removal following an acute ankle fracture, or an isolated syndesmotic injury was conducted across seven databases. Only Prospective randomized controlled trials were eligible for inclusion. Data reported on by at least 2 studies was pooled for analysis.

Results

Three studies were identified that met inclusion and exclusion criteria. No significant difference in Olerud-Molander Ankle Score (MD -2.36, 95% CI -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (MD 2.20, 95% CI -0.50 to 4.89, p = 0.11) was found between the routine removal group and on-demand removal group at 1-year postoperatively. Routine removal was associated with a significantly higher rate of complications than on-demand removal (RR 3.02, 95% CI 1.64 to 5.54, p = 0.0004). None of the included studies found significant differences in pain scores or range of motion by 1-year postoperatively.

Conclusion

Given the increased risk of complications with routine syndesmotic screw removal and the comparable outcomes when screws are retained, an as-needed approach to syndesmotic screw removal should be considered.

Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis

Background

This systematic review and meta-analysis investigated the treatment for Achilles tendon rupture (ATR) associated with the lowest risk of rerupture in older patients.

Methods

Five databases were searched through September 2022 for studies published in the past 10 years analyzing operative and nonoperative ATR treatment. Studies were categorized as "nonelderly" if they reported only on patients aged 18-60 years. Studies that included at least 1 patient older than age 70 were categorized as "elderly inclusive." Of 212 studies identified, 28 were eligible for inclusion. Of 2965 patients, 1165 were treated operatively: 429 (37%) from elderly-inclusive studies and 736 (63%) from nonelderly studies. Of the 1800 nonoperative patients 553 (31%) were from nonelderly studies and 1247 (69%) were from elderly-inclusive studies.

Results

For nonoperative treatment, the rate of rerupture was higher in nonelderly studies (83/1000 cases, 95% CI = 58, 113) than in elderly-inclusive studies (38/1000 cases, 95% CI = 22, 58; P<.001). For operative treatment no difference was found in the rate of rerupture between nonelderly studies (7/1000 cases, 95% CI = 0, 21) and elderly-inclusive studies (12/1000 cases, 95% CI = 0, 35; P<.78). Overall, operative treatment was associated with a rerupture rate of 1.5% (95% CI: 1.0%, 2.8%) (P<.001), which was lower than the 5% rate reported by other studies for nonoperative management (P<.001).

Conclusion

Older patients may benefit more than younger patients from nonoperative treatment of ATR. More studies are needed to determine the age at which rerupture rates decrease among nonoperatively treated patients.

Level of Evidence

3.

Correlation between research productivity during and after orthopaedic surgery training

Background

Research experience is mandatory for all Orthopaedic Surgery residency programs. Although the allocation of required protected time and resources varies from program to program, the underlying importance of research remains consistent with mutual benefit to both residents and the program and faculty. Authorship and publications have become the standard metric used to evaluate academic success. This study aimed to determine if there is a correlation between the research productivity of Orthopaedic Surgery trainees and their subsequent research productivity as attending Orthopaedic Surgeons.

Methods

Using the University of Mississippi Orthopaedic Residency Program Research Productivity Rank List, 30 different Orthopaedic Surgery Residency Programs were analyzed for the names of every graduating surgeon in their 2013 class. PubMed Central was used to screen all 156 physicians and collect all publications produced by them between 2008 and August 2022. Results were separated into two categories: Publications during training and Publications post-training.

Results

As defined above, 156 Surgeons were analyzed for publications during training and post-training. The mean number of publications was 7.02 ± 17.819 post-training vs. 2.47 ± 4.313 during training, P < 0.001. The range of publication post-training was 0-124 vs. 0-30 during training. Pearson correlation between the two groups resulted in a value of 0.654, P < 0.001.

Conclusion

Higher research productivity while training correlates to higher productivity post-training, but overall Orthopaedic surgeons produce more research after training than during. With the growing importance of research, more mentorship, time, and resources must be dedicated to research to instill and foster greater participation while in training.

Treg in inborn errors of immunity: gaps, knowns and future perspectives

Regulatory T cells (Treg) are essential for immune balance, preventing overreactive responses and autoimmunity. Although traditionally characterized as CD4+CD25+CD127lowFoxP3hi, recent research has revealed diverse Treg subsets such as Tr1, Tr1-like, and CD8 Treg. Treg dysfunction leads to severe autoimmune diseases and immune-mediated inflammatory disorders. Inborn errors of immunity (IEI) are a group of disorders that affect correct functioning of the immune system. IEI include Tregopathies caused by genetic mutations affecting Treg development or function. In addition, Treg dysfunction is also observed in other IEIs, whose underlying mechanisms are largely unknown, thus requiring further research. This review provides a comprehensive overview and discussion of Treg in IEI focused on: A) advances and controversies in the evaluation of Treg extended subphenotypes and function; B) current knowledge and gaps in Treg disturbances in Tregopathies and other IEI including Treg subpopulation changes, genotype-phenotype correlation, Treg changes with disease activity, and available therapies, and C) the potential of Treg cell-based therapies for IEI with immune dysregulation. The aim is to improve both the diagnostic and the therapeutic approaches to IEI when there is involvement of Treg. We performed a non-systematic targeted literature review with a knowledgeable selection of current, high-quality original and review articles on Treg and IEI available since 2003 (with 58% of the articles within the last 6 years) in the PubMed database.

Changes in Treg and Breg cells in a healthy pediatric population

The interpretation of clinical diagnostic results in suspected inborn errors of immunity, including Tregopathies, is hampered by the lack of age-stratified reference values for regulatory T cells (Treg) in the pediatric population and a consensus on which Treg immunophenotype to use. Regulatory B cells (Breg) are an important component of the regulatory system that have been poorly studied in the pediatric population. We analyzed (1) the correlation between the three immunophenotypic definitions of Treg (CD4+CD25hiCD127low, CD4+CD25hiCD127lowFoxP3+, CD4+CD25hiFoxP3+), and with CD4+CD25hi and (2) the changes in Treg and Breg frequencies and their maturation status with age. We performed peripheral blood immunophenotyping of Treg and Breg (CD19+CD24hiCD38hi) by flow cytometry in 55 healthy pediatric controls. We observed that Treg numbers varied depending on the definition used, and the frequency ranged between 3.3-9.7% for CD4+CD25hiCD127low, 0.07-1.6% for CD4+CD25hiCD127lowFoxP3+, and 0.24-2.83% for CD4+CD25hiFoxP3+. The correlation between the three definitions of Treg was positive for most age ranges, especially between the two intracellular panels and with CD4+CD25hi vs CD4+CD25hiCD127low. Treg and Breg frequencies tended to decline after 7 and 3 years onwards, respectively. Treg's maturation status increased with age, with a decline of naïve Treg and an increase in memory/effector Treg from age 7 onwards. Memory Breg increased progressively from age 3 onwards. In conclusion, the number of Treg frequencies spans a wide range depending on the immunophenotypic definition used despite a good level of correlation exists between them. The decline in numbers and maturation process with age occurs earlier in Breg than in Treg.

The Use of Blocking Wires in Fibular Intramedullary Nailing of an Ankle Fracture with Hardware Failure: A Case Report

A 24-year-old male, with a body mass index (BMI) of 31.7 and a previous open reduction and internal fixation (ORIF) of the left ankle seven years ago, presented to the emergency department with a peri-implant, comminuted fibula fracture with broken hardware and syndesmotic injury. The nature of the revision surgery made proper guidewire placement during fibular nailing difficult. Blocking wires assisted in ensuring proper guidewire placement. The patient was successfully managed with revision ORIF, fibular nailing, and syndesmotic fixation. Blocking wires are a helpful tool for achieving proper fracture alignment and stability during intramedullary nailing procedures and may be considered in fibular nailing situations.

Trochanteric Bolt Failure in a Modular Femoral Revision System

With the incidence of primary total hip arthroplasty continuing to rise in the United States, the innovation behind improving current total hip arthroplasty systems inevitably grows with it-each new design potentially ushering in new flaws. We report a case of screw failure with the Arcos Modular Femoral Revision System-Trochanteric Bolt and Claw Technique in a 74-year-old male patient. The patient presented to the investigator's clinic for their 20-month follow-up evaluation of their complex right hip revision. Radiographs revealed failure of the screw attaching the claw plate to the stem resulting in dislodgement and relocation of the screw within the intra-articular cavity. The patient elected for nonsurgical management and will continue to be monitored. Consent by the patient involved in this case report was obtained.

Expected impact of immunomodulatory agents during pregnancy: A newborn's perspective

The neonatal immune ontogeny begins during pregnancy to ensure that the neonate is well-suited for perinatal life. It prioritizes Th2/M2 and regulatory responses over Th/M1 activity to avoid excessive inflammatory responses and to ensure immune tolerance and homeostasis. Newborns also present increased Th17/Th22 responses providing effective anti-fungal immunity and mucosal protection. Intrauterine exposure to immune modulatory drugs with the placental transfer may influence the natural course of the fetal immune development. The vertical transfer of both biological therapy and small molecules begins during the first trimester through neonatal Fc receptor or placental diffusion, respectively, reaching its maximum transfer potential during the third trimester of pregnancy. Most of the biological therapy have a prolonged half-life in newborn's blood, being detectable in infants up to 12 months after birth (usually 6-9 months). The use of immunomodulators during pregnancy is gaining global interest. Current evidence mainly reports birth-related outcomes without exhaustive analysis of the on-target side effect on the perinatal immune system ontogeny, the infection risk, or the immune dysregulation. The present review will focus on: (1) the main characteristics of the perinatal immune system to understand its specific features and vulnerabilities to immune modulation; (2) the mechanisms of placental transfer of immunomodulators; and (3) the immune changes reported to date in newborns exposed to immunomodulators with emphasis on the current concerns and gaps in knowledge.

Triterpenoid CDDO-EA inhibits lipopolysaccharide-induced inflammatory responses in skeletal muscle cells through suppression of NF-κB

Chronic inflammation is a major contributor to the development of obesity-induced insulin resistance, which then can lead to the development of type 2 diabetes (T2D). Skeletal muscle plays a pivotal role in insulin-stimulated whole-body glucose disposal. Therefore, dysregulation of glucose metabolism by inflammation in skeletal muscle can adversely affect skeletal muscle insulin sensitivity and contribute to the pathogenesis of T2D. The mechanism underlying insulin resistance is not well known; however, macrophages are important initiators in the development of the chronic inflammatory state leading to insulin resistance. Skeletal muscle consists of resident macrophages which can be activated by lipopolysaccharide (LPS). These activated macrophages affect myocytes via a paracrine action of pro-inflammatory mediators resulting in secretion of myokines that contribute to inflammation and ultimately skeletal muscle insulin resistance. Therefore, knowing that synthetic triterpenoid 2-cyano-3,12-dioxooleana-1,9(11)-dien-28-oic acids (CDDOs) can attenuate macrophage pro-inflammatory responses in chronic disorders, such as cancer and obesity, and that macrophage pro-inflammatory responses can modulate skeletal muscle inflammation, we first examined whether CDDO-ethyl amide (CDDO-EA) inhibited chemokine and cytokine production in macrophages since this had not been reported for CDDO-EA. CDDO-EA blocked LPS-induced tumor necrosis factor-alpha (TNF-α), monocyte chemotactic protein-1 (MCP-1), interleukine-1beta (IL-1β), and interleukine-6 (IL-6) production in RAW 264.7 mouse and THP-1 human macrophages. Although many studies show that CDDOs have anti-inflammatory properties in several tissues and cells, little is known about the anti-inflammatory effects of CDDOs on skeletal muscle. We hypothesized that CDDO-EA protects skeletal muscle from LPS-induced inflammation by blocking nuclear factor kappa B (NF-κB) signaling. Our studies demonstrate that CDDO-EA prevented LPS-induced TNF-α and MCP-1 gene expression by inhibiting the NF-κB signaling pathway in L6-GLUT4myc rat myotubes. Our findings suggest that CDDO-EA suppresses LPS-induced inflammation in macrophages and myocytes and that CDDO-EA is a promising compound as a therapeutic agent for protecting skeletal muscle from inflammation.

Using Clustered Regularly Interspaced Short Palindromic Repeats gene editing to induce permanent expression of fetal hemoglobin in β-thalassemia and sickle cell disease: A comparative meta-analysis

β-hemoglobinopathies like sickle cell disease (SCD) and β-thalassemia are characterized by differing mutations in the hemoglobin subunit beta gene (HBB). These disorders vary in phenotypic presentation and severity, with more severe manifestations leading to transfusion dependence along with associated complications such as infection and iron overload. β-hemoglobinopathies symptoms rapidly worsen after birth as the levels of fetal hemoglobin (HbF) begin to decline. To reverse this decline, current treatment plans typically involve the use of pharmacological agents such as hydroxyurea to raise expression levels of HbF. However, these treatments only result in transient effects and must be consistently administered. Gene editing technologies such as CRISPR/Cas9 (Clustered Regularly Interspaced Short Palindromic Repeats- CRISPR associated protein) offer the opportunity to create novel treatments which can raise HbF expression with potential permanent effects. Two gene targets, B-cell lymphoma/leukemia 11A gene (BCL11A) and the promoter regions of gamma globin genes (HBG1/2), have been identified to significantly increase HbF protein expression. In order to differentiate the effectiveness of BCL11A and HBG1/2 editing, a meta-analysis was performed by first identifying 119 studies for inclusion based on the search terms terms “β-Thalassemia,” “beta-thal” “sickle cell disease,” “SCD,” and “CRISPR.” Following application of exclusion and inclusion criteria, we performed analysis on 8 peer-reviewed published studies from 2018 to 2021 were included in the study. Forest plots were generated using R (version 4.1.2). Primary comparative analysis shows HBG1/2 had a significantly (p &lt; 0.01)greater impact on induction of HbF expression compared to BCL11A. This analysis leads us to conclude that HBG1/2 merits further investigation as a possible gene editing target for treatment of SCD and β-thalassemia.

Penguin: A Tool for Predicting Pseudouridine Sites in Direct RNA Nanopore Sequencing Data

Pseudouridine is one of the most abundant RNA modifications, occurring when uridines are catalyzed by Pseudouridine synthase proteins. It plays an important role in many biological processes and has been reported to have application in drug development. Recently, the single-molecule sequencing techniques such as the direct RNA sequencing platform offered by Oxford Nanopore technologies have enabled direct detection of RNA modifications on the molecule being sequenced. In this study, we introduce a tool called Penguin that integrates several machine learning (ML) models to identify RNA Pseudouridine sites on Nanopore direct RNA sequencing reads. Pseudouridine sites were identified on single molecule sequencing data collected from direct RNA sequencing resulting in 723K reads in Hek293 and 500K reads in Hela cell lines. Penguin extracts a set of features from the raw signal measured by the Oxford Nanopore and the corresponding basecalled k-mer. Those features are used to train the predictors included in Penguin, which in turn, can predict whether the signal is modified by the presence of Pseudouridine sites in the testing phase. We have included various predictors in Penguin, including Support vector machines (SVM), Random Forest (RF), and Neural network (NN). The results on the two benchmark data sets for Hek293 and Hela cell lines show outstanding performance of Penguin either in random split testing or in independent validation testing. In random split testing, Penguin has been able to identify Pseudouridine sites with a high accuracy of 93.38% by applying SVM to Hek293 benchmark dataset. In independent validation testing, Penguin achieves an accuracy of 92.61% by training SVM with Hek293 benchmark dataset and testing it for identifying Pseudouridine sites on Hela benchmark dataset. Thus, Penguin outperforms the existing Pseudouridine predictors in the literature by 16 % higher accuracy than those predictors using independent validation testing. Employing penguin to predict Pseudouridine revealed a significant enrichment of "regulation of mRNA 3'-end processing" in Hek293 cell line and positive regulation of transcription from RNA polymerase II promoter involved in cellular response to chemical stimulus in Hela cell line. Penguin software and models are available on GitHub at https://github.com/Janga-Lab/Penguin and can be readily employed for predicting Ψ sites from Nanopore direct RNA-sequencing datasets.

Symptomatology of attention deficit, hyperactivity and defiant behavior as predictors of academic achievement

BACKGROUND

It is essential to understand the factors that affect the academic achievement of schoolchildren, both in general and in terms of the major subsectors of each grade. Although symptoms of Attention Deficit Hyperactivity Disorder (ADHD) and Negative Defiant Disorder (NDD-which are commonly recognized as externalizing problems in childhood and adolescence-have been associated with lower academic achievement in the international literature, few studies have addressed this problem in Latin America. This study aimed to analyze the possible predictive relationship of attention problems, hyperactivity, and defiant behavior on academic achievement.

METHODS

We recruited a sample of 4580 schoolchildren (50.9% female, 1754 belonging to primary school, and 2826 to secondary school, ranging from 9 to 18 years old). This cross-sectional study used the scales pertaining to attention problems, hyperactivity, and challenging behavior from the Child and Adolescent Evaluation System.

RESULTS

The analysis showed that attention problems significantly affected all academic achievement areas, while hyperactivity and challenging behavior affected only some of them. The regression models explained 24% of the variability in overall academic achievement in primary school and 17% in secondary school. Other predictors included sex, age, socioeconomic level, and school attendance.

CONCLUSIONS

It is important to consider this symptomatology in the design of educational interventions.

Relationship between eating disorders and internalized problems in chilean adolescents

BACKGROUND

Eating disorders (ED) are associated with internalized problems (INTP), such as depression and anxiety. Evidence shows that ED and INTP are associated with comorbidities. The relationship between these variables has not been the focus of studies on young people from Northern Chile. Children and adolescents are considered as an at-risk group, since they have been found to experience greater vulnerability to psychological problems than other age groups within the population and given the scarcity of studies in Chile, it is necessary to study the relationship between these variables.

METHODS

This study analyzed the relationship between ED and INTP in Chilean high school students aged 12 to 18 years using Pearson's correlation. This is a non-experimental and transactional correlational study. We included 2277 students belonging to the public, government-subsidized, and private educational establishments in Northern Chile. The Child and Adolescent Evaluation System [Sistema de Evaluación de Niños y Adolescentes (SENA)] was used to detect a range of INTP, as well as ED. The Brief Self-Control Scale was used in this study.

RESULTS

A strong and direct correlation of the eating disorder variable with depression and anxiety was found. Additionally, significant differences were observed with sex, highlighting females with a higher presence of INTP and ED.

CONCLUSIONS

There is a need to establish strategies in the school setting for detecting frequent symptomatology in adolescents with INTP and ED to achieve a timely and accessible intervention. Since the symptomatology of ED is more prevalent in adolescents, this research evaluated relationships between ED and INTP in young people from Northern Chile. This research is relevant because the evidence on this topic in Chile is scarce and the relationships found could be the first research on the subject and serve to design an intervention plan at the school level in the medium and long terms. It is a non-experimental and transactional correlational study because all variables were measured at a single moment, and it sought to establish relationships between variables without assuming causality. The sample of secondary school students consisted of 2277 students, belonging to the public, subsidized, and private schools. Strong relationships were observed between INTP and ED, the strongest correlations being with the variables depression and anxiety. In addition, female participants presented greater problems in ED and INTP.

Functional and MRI outcomes of Superior Capsule Reconstruction with Acellular Dermal Matrix

Objectives:

Superior capsular reconstruction (SCR) is an emerging treatment option for irreparable massive rotator cuff tears (MRCT). The initial description utilized fascia lata autograft, but acellular dermal matrix (ADM) has become the graft of choice in the United States. Several reports have demonstrated excellent short-term functional improvement and patient satisfaction, but there is limited data correlating imaging studies of graft integrity to functional outcome. The purpose of this study was to determine if functional outcome after SCR is dependent on dermal allograft integrity on post-operative MRI.

Methods:

Inclusion criteria were patients who underwent an SCR by one of 5 fellowship-trained surgeons at a single institution for the indication of pain attributable to irreparable MRCT that failed non-operative treatment. Exclusion criteria included arthritis, prior infection, revision SCR, and less than 6 months follow-up. Pre- operative data including age, gender, prior surgery, Hamada grade, and Goutallier stage were recorded. Intra-operative data including surgical findings and concomitant procedures were recorded. Pre- and post-operative acromiohumeral distance (AHD), American Shoulder and Elbow Surgeons (ASES), Oxford, visual analogue scale (VAS) and post-operative SANE score were recorded. In 90% of cases, a 3 mm ADM was used and in 10% of cases, a 6 mm ADM was used (doubled over 3 mm graft). All grafts were fixed by a double-row, trans-osseous equivalent technique on the tuberosity and with a mean of 3 anchors on the glenoid. Patients were routinely offered to undergo an MRI postoperatively regardless of symptoms.

Results:

53 patients met our inclusion criteria. Mean age was 60.1+7.9 years (range 34 to 77). 68% were male; 34% had at least one prior procedure; 58% had a concomitant procedure; 57% were Hamada 1, 38% Hamada 2, and 5% Hamada 3. Pre-op Goutallier stage was 3.7% grade 0, 17% grade 1, 40% grade 2; 26% grade 3; 13% grade 4. The mean clinical follow-up was 15+7.8 months (range 6-42 months). 81% of patients underwent an MRI post-operatively. The mean time for MRI was 14+7 months (range 6 -40). MRI revealed that 38% had a completely intact graft, 33% had a tear from the glenoid, 12% had a mid-substance tear, 14% tear from the tuberosity, and 2% had complete graft absence. There was a significant improvement in ASES (37.7 to 79.5, P<0.0001), Oxford (26.3 to 44, P<0.0001), and VAS (7 vs 2.3, P<0.0001). There was no difference between pre-op and post-op AHD (7.3 mm vs 6.9mm, P=0.57). There was no association between pre-operative AHD (P=0.9), Goutallier stage (P=0.43), Hamada grade (P=0.49) with post-operative ASES scores. There was a significant correlation between graft integrity with final outcome. There was no difference in post-operative ASES score when the graft was completely intact or torn from the glenoid (P=0.39), but graft tear from the tuberosity resulted in a significantly lower ASES score (P=0.013).

Conclusions:

In patients who undergo SCR for MRCT, there is significant improvement in ASES, Oxford, and VAS. This improvement is seen in patients who have an intact graft, as well as those where the graft is torn from the glenoid, but not those torn from the tuberosity. This supports the concept of the graft functioning as a ”biologic tuberoplasy” preventing bone-to-bone contact between the tuberosity and acromion. Preoperative AHD, Goutallier, Hamada, gender, or age did not have an association with post-operative ASES scores.

Physician Rating Websites: an Analysis of Physician Evaluation and Physician Perception

BACKGROUND

The goal of this study was to evaluate current physician ratings websites (PRWs) to determine which factors correlated to higher physician scores and evaluate physician perspective of PRWs.

METHODS

This study evaluated two popular websites, Healthgrades.com and Vitals.com, to gather information on practicing physician members of the American Shoulder and Elbow Society database. A survey was conducted of the American Shoulder and Elbow Society (ASES) membership to gather data on the perception held by individual physicians regarding PRWs.

RESULTS

We found that patients were more likely to give physicians positive reviews and the average overall score was 8.35 (3.75-10). Patient wait time (P=0.052) trended toward significance as a major factor in determining the overall scores, while ratings in both physician bedside manner (P=0.001) and physician/staff courtesy (P=0.002) were significant in reflecting the overall score given to the physician. According to our survey, a majority of the respondents were indifferent to highly unfavorable to PRWs (88%) and the validity of their ratings (78%).

CONCLUSION

As PRWs become increasingly popular amongst patients in this digital age, it is critical to understand that the scores are not reflective of a significant proportion of the physicians' patient population. Physicians can use this study to determine what affects a patient's experience and focus efforts on improving patients' perception of quality, overall satisfaction, and overall care. Consumers may use this study to increase their awareness of the potential for significant sampling error inherent in PRWs when making decisions about their care.

Cytokine Regulation of Metastasis and Tumorigenicity

The human body combats infection and promotes wound healing through the remarkable process of inflammation. Inflammation is characterized by the recruitment of stromal cell activity including recruitment of immune cells and induction of angiogenesis. These cellular processes are regulated by a class of soluble molecules called cytokines. Based on function, cell target, and structure, cytokines are subdivided into several classes including: interleukins, chemokines, and lymphokines. While cytokines regulate normal physiological processes, chronic deregulation of cytokine expression and activity contributes to cancer in many ways. Gene polymorphisms of all types of cytokines are associated with risk of disease development. Deregulation RNA and protein expression of interleukins, chemokines, and lymphokines have been detected in many solid tumors and hematopoetic malignancies, correlating with poor patient prognosis. The current body of literature suggests that in some tumor types, interleukins and chemokines work against the human body by signaling to cancer cells and remodeling the local microenvironment to support the growth, survival, and invasion of primary tumors and enhance metastatic colonization. Some lymphokines are downregulated to suppress tumor progression by enhancing cytotoxic T cell activity and inhibiting tumor cell survival. In this review, we will describe the structure/function of several cytokine families and review our current understanding on the roles and mechanisms of cytokines in tumor progression. In addition, we will also discuss strategies for exploiting the expression and activity of cytokines in therapeutic intervention.

Total shoulder arthroplasty using an inlay mini-glenoid component for glenoid deficiency: a 2-year follow-up of 9 shoulders in 7 patients

BACKGROUND

Glenoid bone loss and severe retroversion can pose difficulties when implanting a glenoid component for total shoulder arthroplasty for primary osteoarthritis. Mini-glenoid implants may be useful in the setting of severe glenoid wear in which a standard pegged glenoid component cannot be placed.

MATERIALS AND METHODS

This study is a retrospective review, performed over a 3-year period, of patients who received a total shoulder arthroplasty using an inset mini-glenoid in the setting of severe glenoid dysplasia and/or medial glenoid bone loss. We identified patients with a minimum of 2 years' follow-up and evaluated preoperative and postoperative range of motion, visual analog scale scores, Single Assessment Numeric Evaluation scores, complications, and patient satisfaction.

RESULTS

Seven patients (4 female and 3 male patients; 9 shoulders) with a mean age of 66 years were treated with the described procedure and had a mean follow-up of 34 months. There were 6 primary arthroplasties and 3 revision cases. Four shoulders were classified as Walch type A2 glenoids, 2 were classified as Walch type C, and 3 were unable to be classified. There was a statistically significant increase in range of motion (forward elevation, 48°; external rotation, 14°), decrease in pain scores (8 points to 1 point), and improvement in Single Assessment Numeric Evaluation scores (31.7% to 89.4%). The mean patient satisfaction score was 8.6 points on a 10-point scale.

CONCLUSION

At 2-year follow-up, total shoulder arthroplasty with a mini-glenoid component can offer adequate pain relief and functional results in the setting of glenoid bone loss or severe retroversion.

The societal and economic value of rotator cuff repair

BACKGROUND

Although rotator cuff disease is a common musculoskeletal problem in the United States, the impact of this condition on earnings, missed workdays, and disability payments is largely unknown. This study examines the value of surgical treatment for full-thickness rotator cuff tears from a societal perspective.

METHODS

A Markov decision model was constructed to estimate lifetime direct and indirect costs associated with surgical and continued nonoperative treatment for symptomatic full-thickness rotator cuff tears. All patients were assumed to have been unresponsive to one six-week trial of nonoperative treatment prior to entering the model. Model assumptions were obtained from the literature and data analysis. We obtained estimates of indirect costs using national survey data and patient-reported outcomes. Four indirect costs were modeled: probability of employment, household income, missed workdays, and disability payments. Direct cost estimates were based on average Medicare reimbursements with adjustments to an all-payer population. Effectiveness was expressed in quality-adjusted life years (QALYs).

RESULTS

The age-weighted mean total societal savings from rotator cuff repair compared with nonoperative treatment was $13,771 over a patient's lifetime. Savings ranged from $77,662 for patients who are thirty to thirty-nine years old to a net cost to society of $11,997 for those who are seventy to seventy-nine years old. In addition, surgical treatment results in an average improvement of 0.62 QALY. Societal savings were highly sensitive to age, with savings being positive at the age of sixty-one years and younger. The estimated lifetime societal savings of the approximately 250,000 rotator cuff repairs performed in the U.S. each year was $3.44 billion.

CONCLUSIONS

Rotator cuff repair for full-thickness tears produces net societal cost savings for patients under the age of sixty-one years and greater QALYs for all patients. Rotator cuff repair is cost-effective for all populations. The results of this study should not be interpreted as suggesting that all rotator cuff tears require surgery. Rather, the results show that rotator cuff repair has an important role in minimizing the societal burden of rotator cuff disease.

Mixing implants of differing metallic composition in the treatment of upper-extremity fractures

Mixing implants with differing metallic compositions has been avoided for fear of galvanic corrosion and subsequent failure of the implants and of bone healing. The purpose of this study was to evaluate upper-extremity fractures treated with open reduction and internal fixation with metallic implants that differed in metallic composition placed on the same bone. The authors studied the effects of using both stainless steel and titanium implants on fracture healing, implant failure, and other complications associated with this method of fixation. Their hypothesis was that combining these metals on the same bone would not cause clinically significant nonunions or undo clinical effects from galvanic corrosion. A retrospective review was performed of 17 patients with upper-extremity fractures fixed with metal implants of differing metallic compositions. The primary endpoint was fracture union. Eight clavicles, 2 proximal humeri, 3 distal humeri, 3 olecranons, and 1 glenoid fracture with an average follow-up 10 months were reviewed. All fractures healed. One patient experienced screw backout, which did not affect healing. This study implies that mixing implants with differing metallic compositions on the same bone for the treatment of fractures does not adversely affect bone healing. No evidence existed of corrosion or an increase in complications with this method of treatment. Contrary to prior belief, small modular hand stainless steel plates can be used to assist in reduction of smaller fracture fragments in combination with anatomic titanium plates to obtain anatomic reduction of the fracture without adversely affecting healing.

Influence of distinct anatomic subregions of the supraspinatus on humeral rotation

The supraspinatus, having distinct anterior and posterior subregions, is most commonly considered an abductor of the humerus, but it has also been shown to induce humeral rotation. The objective of this study was to quantify the magnitude and direction of humeral rotation that results from loading the distinct anterior and posterior subregions of the supraspinatus. Fourteen cadaver specimens were tested under four loading conditions based on physiological cross section area of the supraspinatus: (1) anterior only; (2) posterior only; (3) physiologic (each subregion loaded simultaneously); and (4) nonphysiologic (the tendon loaded as a whole). Each specimen was tested at 0, 15, 30, 45, and 60 degrees of glenohumeral abduction in the scapular plane and from 60 degrees of internal to 45 degrees of external rotation in 15 degrees increments. The humeral rotation that occurred with loading from the initial starting rotation position was measured using a rotary variable inductance transducer. In the scapular plane, the anterior subregion of the supraspinatus acts as both an internal and external rotator depending on the initial position of the humerus. The posterior subregion either acted as an external rotator or did not induce rotation. This study demonstrated a distinct functional difference between the anatomic subregions of the supraspinatus. This understanding will help to improve testing methods and the development of repair strategies of the supraspinatus.

Clinical laboratory automated urinalysis: comparison among automated microscopy, flow cytometry, two test strips analyzers, and manual microscopic examination of the urine sediments

Urinalysis is one of the habitual clinical laboratory procedures, which implies that one of the largest sample volumes currently requires significant labor to examine microscopic sediments. Different analyzers currently used to perform this task have been compared with the manual microscopic sediment examination. The Atlas Clinitek 10 (Bayer Corporation, Diagnostics Division, Tarrytown, NY) and Urisys 2400 (Hitachi Science Systems Ltd., Ibaraki, Japan) test strips analyzers and two automated urinalysis systems, Sysmex UF-100 (Sysmex Corporation Kobe, Japan) and IRIS iQ200 (International Imaging Remote Systems, Chatsworth, CA), have been considered. We assessed the concordance between the results obtained from 652 freshly collected urine samples for erythrocytes (RBC), leukocytes (WBC), squamous epithelial cells (EC), nitrites/bacteria, and crystals using the methodologies mentioned. A principal components analysis was performed in order to examine the correlation between these parameters. Instrument accuracy was also assessed. The Spearman's statistic (p) showed an adequate agreement between methods for RBC (iQ200=0.473; UF-100=0.439; Atlas=0.525; Urisys=0.539), WBC (iQ200=0.695; UF-100=0.761; Atlas=0.684: Urisys=0.620), and bacteria/nitrites (iQ200=0.538; UF-100=0.647; Atlas=0.532; Urisys=0.561) counts. By applying the Wilcoxon and McNemar tests, a concordance degree was found between 82-99 and 52-95% for the values obtained from the two test strips analyzers considered and from the iQ200 and UF-100 systems, respectively. From these results, we can conclude that both test strips analyzers are similar and, on the other hand, that automated urinalysis is needed to improve precision and the response time; but sometimes manual microscopic revisions are required, mainly when flags, because of crystals, are detected.

Using visual design experts in critique-based evaluation of 2D vector visualization methods

We describe an experiment in which art and illustration experts evaluated six 2D vector visualization methods. We found that these expert critiques mirrored previously recorded experimental results; these findings support that using artists, visual designers and illustrators to critique scientific visualizations can be faster and more productive than quantitative user studies. Our participants successfully evaluated how well the given methods would let users complete a given set of tasks. Our results show a statistically significant correlation with a previous objective study: designers' subjective predictions of user performance by these methods match users measured performance. The experts improved the evaluation by providing insights into the reasons for the effectiveness of each visualization method and suggesting specific improvements.

Scientific sketching for collaborative VR visualization design

We present four studies investigating tools and methodologies for artist-scientist-technologist collaboration in designing multivariate, virtual reality (VR) visualizations. Design study 1 identifies the promise of 3D drawing-style interfaces for VR design and also establishes limitations of these tools with respect to precision and support for animation. Design study 2 explores animating artist-created visualization designs with scientific 3D fluid flow data. While results captured an accurate sense of flow that was advantageous as compared to the results of study 1, the potential for visual exploration using the design tools tested was limited. Design study 3 reveals the importance of a new 3D interface that overcomes the precision limitation found in study 1 while remaining accessible to artist collaborators. Drawing upon previous results, design study 4 engages collaborative teams in a design process that begins with traditional paper sketching and moves to animated, interactive, VR prototypes "sketched" by designers in VR using interactive 3D tools. Conclusions from these four studies identify important characteristics of effective artist-accessible VR visualization design tools and lead to a proposed formalized methodology for successful collaborative design that we expect to be useful in guiding future collaborations. We call this proposed methodology Scientific Sketching.

Subjective quantification of perceptual interactions among some 2D scientific visualization methods

We present an evaluation of a parameterized set of 2D icon-based visualization methods where we quantified how perceptual interactions among visual elements affect effective data exploration. During the experiment, subjects quantified three different design factors for each method: the spatial resolution it could represent, the number of data values it could display at each point, and the degree to which it is visually linear. The class of visualization methods includes Poisson-disk distributed icons where icon size, icon spacing, and icon brightness can be set to a constant or coupled to data values from a 2D scalar field. By only coupling one of those visual components to data, we measured filtering interference for all three design factors. Filtering interference characterizes how different levels of the constant visual elements affect the evaluation of the data-coupled element. Our novel experimental methodology allowed us to generalize this perceptual information, gathered using ad-hoc artificial datasets, onto quantitative rules for visualizing real scientific datasets. This work also provides a framework for evaluating visualizations of multi-valued data that incorporate additional visual cues, such as icon orientation or color.

Calcium regulation of agonist binding to alpha7-type nicotinic acetylcholine receptors in adult and fetal rat hippocampus

Quantitative autoradiography was used to compare the binding properties of alpha7-type nicotinic acetylcholine receptors in fetal and adult rat hippocampus. Whereas there were high levels of 125I-alpha-bungarotoxin (125I-alpha-BTX) binding throughout fetal hippocampal field CA1, there was a significant decrease in binding site density in the adult. The affinity of 125I-alpha-BTX binding, as well as alpha-cobratoxin and nicotine potency to displace 125I-alpha-BTX, did not change with age. Addition of Ca2+ to the assay buffer did not alter 125I-alpha-BTX binding, or alpha-cobratoxin inhibition of 125I-alpha-BTX binding, although it significantly increased nicotine affinity at both ages. The effect of Ca2+ on agonist affinity was dose-dependent, with an EC50 value of 0.25-0.5 mM. Ca2+ also significantly increased the cooperativity of nicotine displacement curves in stratum oriens of the adult, but not in the fetus. These findings indicate that the properties of hippocampal 125I-alpha-BTX binding sites are largely similar across age. Ca2+ selectively enhances the affinity of agonist binding, with no change in antagonist binding. This ionic effect may result from potentiation of agonist binding to a desensitized state of the alpha7 nicotinic acetylcholine receptor and may represent an important neuroprotective mechanism.

The Study of Solid/Liquid Interfaces with X-ray Standing Waves

The principles and applications of the x-ray standing wave technique are described. Emphasis is placed on its utility for the study of structure, composition, and distribution of interfacial species especially at solid/liquid interfaces.

[Benign hemophagocytic syndrome. First confirmed case in Panama]

The authors present the clinical history of the first case of benign hemophagocytic syndrome diagnosed in Panama. The patient, a 4 year old girl, presented with fever, anemia, cervical lymphadenitis, hepatomegaly, lymphocytosis and histophagocytosis of red cells, lymphocytes, neutrophils and platelets. Spontaneous remission of the fever occurred sixty days after the onset of the disease. Although it was not possible to demonstrate serologically that the syndrome was due to acute toxoplasmosis, she was treated with sulfadiazine and pyrimethamine for fifteen days, on the 37th hospital day, and with clindamycin for ten days, consecutively. Remission occurred seventy days after the onset of fever. A second serological examination for toxoplasmosis (immunofluorescent antibodies) was positive in a titer of 1:2048 again, nine months after the first serology.