Epidemiology of shoulder dislocations presenting to United States emergency departments: An updated ten-year study

BACKGROUND

Glenohumeral dislocation is a common injury that may predispose patients to chronic pain and instability. However, there is a paucity of current data available regarding the epidemiological trends of this injury.

AIM

To provide an updated, comparative assessment of the epidemiology of shoulder dislocations presenting to emergency departments in the United States. We also sought to analyze patient demographic risk factors and consumer products associated with dislocation events.

METHODS

Data were obtained from the national electronic injury surveillance system database for glenohumeral dislocations between 2012 and 2021. Incidence, age, sex, and injury characteristics were analyzed using weighted population statistics as well as incidence rates and 95% confidence intervals (CI).

RESULTS

In total, an estimated 773039 shoulder dislocations (CI: 640598-905481) presented to emergency rooms across the United States during the study period. The annual incidence rate was 23.96 per 100000 persons and the average patient age at the time of injury was 37.1 years. Significantly more male patients sustained dislocations than female patients (537189, 69.5%, vs 235834, 30.5%, P < 0.001). With regard to associated consumer products, sports and recreation equipment were involved in the highest proportion of incidents (44.31%), followed by home structures and construction materials (21.22%), and home furnishings, fixtures, and accessories (21.21%). Regarding product sub-groups, stairs, ramps, landings, floors was cited in the greatest number of cases (131745).

CONCLUSION

The national annual incidence rate of glenohumeral dislocations throughout the study period was approximately 23.92 per 100000 persons. Male adolescents sustained the highest proportion of dislocations, with a peak incidence in age group 15-20 years, predominantly secondary to participation in sporting and recreational activities. Conversely, women experienced a relatively consistent incidence of dislocation throughout their lifespan. After age 63, the incidence rate of dislocations in females was found to surpass that observed in males.

THU0312 AUTOLOGOUS NON-MYELOABLATIVE HEMATOPOIETIC STEM CELL TRANSPLANTATION FOR REFRACTORY TAKAYASU ARTERITIS: A RETROSPECTIVE MULTICENTRE CASE-SERIES FROM THE AUTOIMMUNE DISEASES WORKING PARTY (ADWP) OF THE EUROPEAN SOCIETY FOR BLOOD AND MARROW TRANSPLANTATION (EBMT)

Background:

Takayasu arteritis (TAK) is a chronic granulomatous large-vessel vasculitis, characterized by arterial thickening and fibrosis leading to stenosis and vascular occlusions. More than 10-20% of patients are refractory to conventional immunosuppressive therapy. Autologous hematopoietic stem cell transplantation (AHSCT) has emerged as a promising treatment option in severely affected and refractory patients with various autoimmune diseases and vasculitis, particularly ANCA-positive vasculitis and Behçet’s disease.

Objectives:

This study,approved by the ADWP, aims to evaluate the use and outcome of AHSCT in adult TAK patients.

Methods:

This is a retrospective survey of patients reported to the EBMT registry between 1998 and 2019, who received AHSCT primarily for TAK. Clinical and laboratory data, including data on diagnosis, previous lines of therapy, transplant regimen, treatment-related mortality, as well as data regarding course of disease and treatment were recorded.

Results:

Data from six adult patients treated with AHSCT between 2003 and 2019 for refractory Takayasu have been identified. Median (ranges) follow-up was 9.9 (1-14) years. Five patients were female (83%), median age was 25 (9-39) years at diagnosis and 28 (22-41) years at HSCT. All patients were pretreated with a median of 6 (4-8) lines of therapy, including systemic steroids (6 patients), methotrexate (5 patients), cyclophosphamide, mycophenolate mofetil or infliximab (4 patients), tocilizumab or etanercept (2 patients), and other biologic or conventional-synthetic DMARDs. Conditioning included cyclophosphamide and rabbit anti-thymocyte globulin in all patients. At six months post-transplantation, remission was obtained in all cases, which persisted at 12 months in 5 cases. Four patients reactivated TAK at a median time of 27 (7-52) months after AHSCT, and 3 resumed disease-modifying therapy. At last follow-up, all patients were alive, 2 patients were in remission (off-therapy), 2 patients improved compared to baseline, and 2 patients were in complete and partial remission, respectively, under immunosuppressive treatment.

Conclusion:

This small retrospective series demonstrates that AHSCT has the potential to provide significant clinical responses in TAK patients who had been unresponsive to previous immunosuppressive therapy, with an acceptable safety profile.

Acknowledgments:

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Disclosure of Interests:

CHARLOTTE LAURENT: None declared, ZORA MARJANOVIC: None declared, Jörg Henes Grant/research support from: Novartis, Roche-Chugai, Consultant of: Novartis, Roche, Celgene, Pfizer, Abbvie, Sanofi, Boehringer-Ingelheim,, DOMNIQUE FARGE: None declared, MANUELA BADOGLIO: None declared, John SNOWDEN: None declared, olivier fain: None declared, Tobias Alexander: None declared, Maria Carolina Oliveira: None declared, Arsene Mekinian: None declared

Patterns of cerebral amyloid angiopathy define histopathological phenotypes in Alzheimer's disease

AIMS

Pathological heterogeneity of Aβ deposition in senile plaques (SP) and cerebral amyloid angiopathy (CAA) in Alzheimer's disease (AD) has been long noted. The aim of this study was to classify cases of AD according to their pattern of Aβ deposition, and to seek factors which might predict, or predispose towards, this heterogeneity.

METHODS

The form, distribution and severity of Aβ deposition (as SP and/or CAA) was assessed semiquantitatively in immunostained sections of frontal, temporal and occipital cortex from 134 pathologically confirmed cases of AD.

RESULTS

Four patterns of Aβ deposition were defined. Type 1 describes cases predominantly with SP, with or without CAA within leptomeningeal vessels alone. Type 2 describes cases where, along with many SP, CAA is present in both leptomeningeal and deeper penetrating arteries. Type 3 describes cases where capillary CAA is present along with SP and arterial CAA. Type 4 describes a predominantly vascular phenotype, where Aβ deposition is much more prevalent in and around blood vessels, than as SP. As would be anticipated from the group definitions, there were significant differences in the distribution and degree of CAA across the phenotype groups, although Aβ deposition as SP did not vary. There were no significant differences between phenotype groups with regard to age of onset, age at death, disease duration and brain weight, or disease presentation. Women were over-represented in the type 1 phenotype and men in type 2. Genetically, type 3 (capillary subtype) cases were strongly associated with possession of the APOE ε4 allele.

CONCLUSIONS

This study offers an alternative method of pathologically classifying cases of AD. Further studies may derive additional genetic, environmental or clinical factors which associate with, or may be responsible for, these varying pathological presentations of AD.

Need for psychological follow-up among young adult survivors of childhood cancer

Follow-up is recommended for survivors of childhood cancer. Decisions about care tend to be made in terms of physical health, but psychological late effects including post-traumatic stress disorder (PTSD) and symptoms (PTSS) are prevalent. We report prevalence of PTSD/PTSS in a UK cohort, self-care and implications for organisation of follow-up. Eligible survivors (n= 218) under regular follow-up were invited to complete measures of PTSD, late effects and self-efficacy. Information about late effects was also taken from medical notes. A total of 118 survivors responded (54.1%) and 108 (49.5%) completed questionnaires. Prevalence of clinical PTSD (13.9%) was comparable with US findings. Female subjects and those who reported more late effects reported more PTSD. In regression analyses, number of survivor-reported late effects (but not number-recorded in medical notes) and PTSS predicted self-efficacy. Significant numbers of survivors report PTSS but this is unrelated to diagnosis or treatment. Female subjects and those who reported more physical late effects also reported more PTSS. Decisions to discharge survivors from routine care must consider psychological well-being as well as physical late effects. We recommend routine psychological screening for all survivors of childhood cancer and suggest this can be acceptable to survivors and feasible in clinic.

Autologous haematopoietic stem cell transplantation for secondary progressive multiple sclerosis: an exploratory cost-effectiveness analysis

Treatment options for secondary progressive multiple sclerosis (SPMS) are limited. Mitoxantrone is routinely used to stabilize disease progression; however, evolving evidence suggests clinical benefit from intensive treatment with autologous haematopoietic stem cell transplantation (HSCT). Given differences in cost and outcomes, preliminary cost-effectiveness studies are warranted if this approach is to be developed for more widespread application in SPMS. We developed a decision-analytic Markov model to explore the potential cost-effectiveness of autologous HSCT versus mitoxantrone in SPMS, using patient-level data from registry sources. The model evaluates the lifetime costs and health outcomes associated with disability progression and relapse. Sensitivity analyses were undertaken to examine the uncertainty surrounding cost-effectiveness outcomes. In the absence of randomised controlled trial (RCT) evidence, conditions for comparative analysis were not ideal. Under optimistic assumptions, HSCT is estimated to cost below pound3000 per quality adjusted life year gained. However, when a strict 6-month sustained progression rule is adopted, HSCT may be less effective and more expensive than mitoxantrone. The model results were sensitive to reducing procedural costs and HSCT-related mortality. We conclude that HSCT could potentially achieve an acceptable level of cost-effectiveness. However, caution should be exercised as large, high-quality RCTs comparing HSCT versus mitoxantrone are necessary to validate these findings.

The rationale behind autologous autoimmune hematopoietic stem cell transplant conditioning regimens: concerns over the use of total-body irradiation in systemic sclerosis

Hematopoietic stem cell transplantation (HSCT) is becoming an increasingly recognized indication for treatment of autoimmune diseases and severe immune-mediated disorders. However, multicenter registry data have demonstrated higher than anticipated early toxicity, approximately 10% for autoimmune diseases in general, and 20-27% for diffuse systemic sclerosis (scleroderma). If uncorrected, this high treatment-related mortality will hinder development of stem cell therapy for immune-mediated diseases. In order to develop safer regimens, we address some pitfalls and concepts involved in design and selection of conditioning regimens for autoimmune diseases in general, and because it is associated with the highest regimen-related toxicity, scleroderma in specific.

Profile of cognitive progression in early Huntington's disease

OBJECTIVE

To examine the pattern of cognitive decline in early Huntington's disease (HD).

METHODS

The authors studied 61 patients with mild to moderate HD who had at least three annual neuropsychological assessments using the Core Assessment Program for Intracerebral Transplantation in Huntington's Disease short battery. A subset of 34 patients had additional neuropsychological tests, and another subset of 21 patients was assessed annually on the Cambridge Neuropsychological Test Automated Battery. Neuropsychological measures that changed significantly over time were submitted to a multiple analysis of covariance to explore associations with demographic and neurologic indices.

RESULTS

Patients showed a progressive impairment in attention, executive function, and immediate memory, with timed tests of psychomotor skill being particularly sensitive to decline. In contrast, general cognition, semantic memory, and delayed recall memory were relatively unaffected.

CONCLUSION

The profile of cognitive performance shows selective and progressive dysfunction of attention and executive function in patients with mild to moderate HD, consistent with frontostriatal pathology at this stage of disease.

Development of a phase III trial of hematopoietic stem cell transplantation for systemic lupus erythematosus

At Northwestern University, a phase I/II trial of hematopoietic stem cell transplant (HSCT) for systemic lupus erythematosus (SLE) has shown promising results. A phase III HSCT trial is being developed to confirm efficacy of HSCT vs continuing the currently accepted standard of care, intravenous pulse cyclophosphamide.

Hematopoietic stem cell transplantation for severe rheumatoid arthritis

The substantial morbidity and mortality associated with rheumatoid arthritis (RA), while not widely appreciated, provide adequate justification for consideration of high-dose immunoablative therapy followed by hematopoietic stem cell transplantation. While some patients with RA follow a benign course, selected subsets of patients have been identified with 5-year survival rates of 40-70%. A number of factors that can be easily determined serve as useful prognostic indicators for poor outcome. These include the presence of many involved joints (total joint count), the degree of functional disability as measured by the health assessment questionnaire and the presence of rheumatoid factor. This article summarises the present status of hematopoietic stem cell transplantation for rheumatoid arthritis and proposes future directions for research.

High dose therapy and autologous hemopoietic stem cell transplantation in rheumatoid arthritis--the feasibility of phase III trials

If a niche is to be established for autografting in the treatment of severe rheumatoid arthritis (RA), investigators should have the common goal of providing higher levels of evidence. Autografting in RA can be envisaged only for severe RA that has resisted all safer available treatments, and given the relatively large numbers necessary for statistical power in randomized studies, investigators will need to work together. This article summarizes the current literature and discusses practical issues relating to future trials.

Autologous stem cell transplantation for rheumatoid arthritis--interim report of 6 patients

We assessed the safety and efficacy of autologous stem cell transplantation (ASCT) using T cell depleted grafts in the treatment of severe rheumatoid arthritis. Methods included mobilization 2 g/m2 cyclophosphamide (Cy) and granulocyte-colony stimulating factor; graft manipulation of positive CD34+ and negative T cell selection; and conditioning by 200 mg/kg Cy. All 6 patients improved according to American College of Rheumatology response criteria (one patient ACR70, 2 ACR50, 3 ACR20), but relapsed at 1.5-9 months when they began cyclosporine A (CSA). Five improved (one patient ACR remission, 2 ACR70, one ACR50, one improved but did not satisfy ACR response criteria). No serious complications occurred during ASCT or up to 30 months' followup. There was prolonged reduction in CD4+ T cells. ASCT is safe and has short term efficacy. T cell purging does not prevent relapse. Five patients responded to CSA when their disease had previously been refractory, suggesting an immunomodulatory effect. No serious infectious complications occurred despite prolonged reduction in CD3+CD4+ lymphocytes.

Considerations in the selection of an appropriate conditioning regimen for the treatment of rheumatoid arthritis by autologous peripheral blood stem cell transplantation

Autologous hematopoietic stem cell transplantation (HSCT) is becoming more widely accepted as an investigational therapeutic modality for selected patients with severe autoimmune diseases such as rheumatoid arthritis. However, many aspects of the procedure remain controversial--not the least of these is the choice of conditioning regimen. This article briefly reviews the potential advantages and disadvantages of the conditioning regimens commonly employed for the treatment of severe autoimmune diseases in order to facilitate the development of future clinical trials of HSCT for rheumatoid

Collection of hematopoietic stem cells from patients with autoimmune diseases

We reviewed data from 24 transplant centers in Asia, Australia, Europe, and North America to determine the outcomes of stem cell collection including methods used, cell yields, effects on disease activity, and complications in patients with autoimmune diseases. Twenty-one unprimed bone marrow harvests and 174 peripheral blood stem cell mobilizations were performed on 187 patients. Disease indications were multiple sclerosis (76 patients), rheumatoid arthritis (37 patients), scleroderma (26 patients), systemic lupus erythematosus (19 patients), juvenile chronic arthritis (13 patients), idiopathic autoimmune thrombocytopenia (8 patients), Behcet's disease (3 patients), undifferentiated vasculitis (3 patients), polychondritis (1 patient) and polymyositis (1 patient). Bone marrow harvests were used in the Peoples Republic of China and preferred worldwide for children. PBSC mobilization was the preferred technique for adult stem cell collection in America, Australia, and Europe. Methods of PBSC mobilization included G-CSF (5, 10, or 16 microg/kg/day) or cyclophosphamide (2 or 4 g/m2) with either G-CSF (5 or 10 microg/kg/day) or GM-CSF (5 microg/kg/day). Bone marrow harvests were without complications and did not affect disease activity. A combination of cyclophosphamide and G-CSF was more likely to ameliorate disease activity than G-CSF alone (P < 0.001). g-csf alone was more likely to cause disease exacerbation than the combination of cyclophosphamide and g-csf (P = 0.003). Three patients died as a result of cyclophosphamide-based stem cell collection (2.6% of patients mobilized with cyclophosphamide). When corrected for patient weight and apheresis volume, progenitor cell yields tended to vary by underlying disease, prior medication history and mobilization regimen. Trends in the approaches to, and results of, progenitor cell mobilization are suggested by this survey. While cytokine-based mobilization appears less toxic, it is more likely to result in disease reactivation. Optimization with regard to cell yields and safety are likely to be disease-specific and prospective disease-specific studies of mobilization procedures appear warranted.

Longitudinal evaluation of cognitive disorder in Huntington's disease

The study investigated longitudinal change in cognitive function in 87 patients with Huntington's disease (HD), using a range of neuropsychological tests, which tap mental manipulative abilities, memory, and frontal executive skills. Over a 1-year period the largest changes were noted in letter fluency, object recall, and Stroop Test performance, whereas no changes were noted over more than 3 years on the modified Wisconsin Card Sorting Test. Contrary to expectation, greater change was evident over 1 year for tasks with low compared to high cognitive demands. The differential sensitivity of tasks was attributed in part to inherent characteristics of the tests themselves: their capacity to detect minor gradations of change and their vulnerability to practice effects. However, the greater change for relatively automatic, speed-based tasks with low cognitive demands was interpreted as reflecting the evolution of HD, with a greater magnitude of change occurring in basal ganglia than cortical function. One purpose of the study was to identify tasks sensitive to the progression of HD and hence most suitable for the evaluation of therapies. Despite reaching statistical significance by virtue of the large group size, numerical differences in test scores over 1 year were very small, suggesting that the use of such tests to evaluate change in individuals or small groups of subjects would be problematic. The data highlight the slow progression of HD, the limitations of standard cognitive tests in detecting change over short periods, and the need for therapeutic studies that encompass a relatively prolonged time frame.

Fatal cold anti-i autoimmune haemolytic anaemia complicating hairy cell leukaemia

Hairy cell leukaemia (HCL) is a rare lymphoproliferative disorder associated with pancytopenia, splenomegaly and the presence of typical hairy B lymphocytes in the bone marrow and/or peripheral blood. The most significant complication relates to opportunistic infections that arise as a consequence of neutropenia and monocytopenia. HCL is occasionally associated with systemic autoimmune disorders including polyarteritis nodosa and rheumatoid disease. Secondary autoimmune haemolytic anaemia (AIHA) appears to be rare. We report on two cases of HCL complicated by fatal cold anti-i AIHA. Fulminant haemolysis causing death is rare in cold AIHA and only a few individual cases have been reported, none having anti-i specificity.

Apolipoprotein E epsilon4 allele has no effect on age at onset or duration of disease in cases of frontotemporal dementia with pick- or microvacuolar-type histology

Frontotemporal dementia (FTD) is the second most common cause of presenile dementia. Here we have investigated the frequency of the epsilon4 allele of the Apolipoprotein (APOE) gene in FTD and in other non-Alzheimer forms of dementia related to FTD such as Motor Neurone disease dementia, semantic dementia, progressive aphasia, progressive supranuclear palsy, and corticobasal degeneration. In none of these diagnostic groups did we find a significant increase in the APOE epsilon4 allelic frequency, compared to population values. Neither did we observe any affects of the epsilon4 allele upon age at onset or duration of disease. We conclude therefore that polymorphic variations in the APOE gene do not modulate either the occurrence or progression of these non-Alzheimer forms of dementia.

Molecular classification of the dementias

Most patients with frontotemporal dementia do not have taupathology as shown by immunohistochemistry. The use of the term tauopathy to classify frontotemporal dementia is inappropriate.

Frequency of tau mutations in three series of non-Alzheimer's degenerative dementia

Splice-site and missense mutations have been identified in tau associated with frontotemporal dementia with parkinsonism linked to chromosome 17. In this study we assessed the genetic contribution of tau mutations to three patient series with non-Alzheimer's (non-AD) degenerative dementia. The groups included (1) a community-based dementia series from Minnesota, MN; (2) a referral series with clinicopathological tauopathy; and (3) a pathologically confirmed familial frontotemporal dementia series from Manchester, UK. Comparing the three clinical series: in the stringently diagnosed Manchester frontotemporal dementia series, tau mutations were present in 13.6% of cases (three splice-site mutations); in the clinicopathological referral series that used more general inclusion criteria, 3 cases with P301L mutations were observed, which represents a lower mutation frequency of 3.6% (9.4% in familial cases); in contrast, tau mutations were not detected in the Minnesota community-based dementia series, suggesting the occurrence of these mutations in dementia generally is rare (<0.2%). These data identify the prevalence of mutations in three different clinical settings and indicate that this figure is sensitive to the diagnostic criteria used in each patient series.

Crayfish: a newly recognized vehicle for vibrio infections

We conducted a 1-year case-control study of sporadic vibrio infections to identify risk factors related to consumption of seafood products in two coastal areas of Louisiana and Texas. Twenty-six persons with sporadic vibrio infections and 77 matched controls were enrolled. Multivariate analysis revealed that crayfish (P < 0.025) and raw oysters (P < 0.009) were independently associated with illness. Species-specific analysis revealed an association between consumption of cooked crayfish and Vibrio parahemolyticus infection (OR 9.24, P < 0.05). No crayfish consumption was reported by persons with V. vulnificus infection. Although crayfish had been suspected as a vehicle for foodborne disease, this is the first time to our knowledge that consumption of cooked crayfish has been demonstrated to be associated with vibrio infection.

Association of missense and 5'-splice-site mutations in tau with the inherited dementia FTDP-17

Thirteen families have been described with an autosomal dominantly inherited dementia named frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17), historically termed Pick's disease. Most FTDP-17 cases show neuronal and/or glial inclusions that stain positively with antibodies raised against the microtubule-associated protein Tau, although the Tau pathology varies considerably in both its quantity (or severity) and characteristics. Previous studies have mapped the FTDP-17 locus to a 2-centimorgan region on chromosome 17q21.11; the tau gene also lies within this region. We have now sequenced tau in FTDP-17 families and identified three missense mutations (G272V, P301L and R406W) and three mutations in the 5' splice site of exon 10. The splice-site mutations all destabilize a potential stem-loop structure which is probably involved in regulating the alternative splicing of exon10. This causes more frequent usage of the 5' splice site and an increased proportion of tau transcripts that include exon 10. The increase in exon 10+ messenger RNA will increase the proportion of Tau containing four microtubule-binding repeats, which is consistent with the neuropathology described in several families with FTDP-17.

Fronto-temporal dementia: nosology, neuropsychology, and neuropathology

Fronto-temporal dementia is the commonest clinical manifestation of fronto-temporal lobar atrophy. It is associated with three types of underlying histology: microvacuolation or spongiosus (frontal lobe degeneration type), gliosis with or without inclusion bodies and swollen neurones (Pick-type), and motor neurone disease type. The clinical disorder presents in the presenium, is highly familial and is characterized by profound personality change, social incompetence and stereotypic ritualistic behavior. Language becomes attenuated, culminating in total mutism. Visuo-spatial skills are strikingly preserved. The electroencephalogram is normal and structural and functional imaging reflect fronto-temporal lobar atrophy. In a minority of cases the amyotrophic form of motor neurone disease coexists with fronto-temporal dementia and has a rapid and brief duration of illness. Phenotypic characterization of patients at each level of description: clinical, anatomical, and histological, provides a foundation for the molecular genetic studies which ought to shed light on the etiology of this form of focal cerebral degeneration.

Semi-automatic quantification of regional cerebral perfusion in primary degenerative dementia using 99m technetium-hexamethylpropylene amine oxime and single photon emission tomography

A new semi-automatic method for quantifying regional cerebral uptake of 99m technetium-hexamethylpropylene amine oxime (99mTc-HMPAO) was used to assess single photon emission tomograms from 5 normal subjects, 14 patients with Alzheimer's disease, 14 patients with dementia of frontal lobe type and 4 patients with dementia with motor neurone disease. Uptake in both posterior cortical regions, although not in other regions, was significantly lower (P less than 0.05) in Alzheimer's disease than in normal controls. Conversely in both dementia of frontal lobe type and dementia with motor neurone disease, uptake was significantly reduced (P less than 0.05) compared with controls in all anterior cortical regions but not in posterior regions. Numerical findings in each disease mirrored the pattern of reduced tracer uptake previously reported by visual assessment. Nine patients were re-examined after an interval of at least 1 year. Comparison of follow-up scans with original images showed significant decreases in mid-anterior, left anterior and left posterior cortical uptake (P less than 0.01) in patients with Alzheimer's disease and in left middle, left posterior and right posterior cortical uptake (P less than 0.01) in patients with dementia of frontal lobe type. The method of quantification may be a useful adjunct to the visual assessment of single photon emission tomograms.

Treatment of obsessive-compulsive neurosis with history of childhood autism

A young man was followed-up over three years who had severe obsessive-compulsive rituals and ruminations, interpersonal deficits, complicating depression and a history of childhood autism. Intensive behavioural treatment was given in an operant framework, with exposure in vivo, modelling, response prevention and social skills training. Compulsive rituals improved markedly and lastingly, but ruminations and social defects persisted. When intercurrent depression occurred dothiepin facilitated behavioural treatment. Adjustment remained fragile. Minimum maintenance treatment in the community could not be adequately arranged, so that gains made in hospital were partly lost at follow-up, despite continuing improvement in rituals.