Dual disorder: does expert clinical experience support the rationale for cariprazine use?

Comorbid substance use disorder (SUD) in patients with schizophrenia (dual disorder, DD) is a frequent occurrence in the psychiatric clinical practice and is positively associated with poorer outcomes. Despite a very high co-prevalence, clinical guidelines for SUD and severe mental illnesses tend to give limited consideration to co-existing disorders regarding diagnosis and management. This article is the result of a meeting held in February 2023 to discuss common challenges and best clinical practice initiatives for patients with schizophrenia and DD in different treatment settings. The authors identified issues in the clinical approach to DD in schizophrenia spectrum disorders and suggested the most suitable management based on their experience as a group of experts, identifying possible improvement areas. In conclusion, the panel recommends that individuals with DD should be cared for in a single center. Pharmacologic treatment in individuals with DD needing both control of symptoms related to schizophrenia spectrum disorders and substance withdrawal should ideally be based on using a non-sedative antipsychotic with anti-craving activity.

Outcomes of a Brief Motivational Intervention for Heavy Alcohol Use in Racial or Ethnic Minority Compared to White Emerging Adults

PURPOSE

This study used secondary data from a randomized controlled trial of a Brief Motivational Intervention (BMI) to examine whether Non-White participants had different treatment results compared to White participants.

METHODS

The outcome variables of this study were divided into primary outcomes (heavy drinking and consequences associated with alcohol use) and secondary outcomes (cognitive variables such as motivation to change alcohol use, and behavioral variables, including protective behavioral strategies). Linear regression analyses were conducted with the PROCESS macro for SPSS, to test if race or ethnicity moderated the relationship between BMI and each treatment outcome. Data was collected at two time points, six weeks and three months after treatment.

RESULTS

This study showed that race or ethnicity did not moderate treatment results for the four outcome variables. Additional within-group effect sizes were calculated for all racial and ethnic categories, showing that Hispanic/Latine and Black participants had larger effect sizes in all the outcome variables.

DISCUSSION

The discussion examines the potential strength of Motivational Interviewing due to its client-centered spirit, which naturally allows for incorporating values and identity-based factors, such as culture, into the session.

CONCLUSION

The results suggest similar BMI outcomes among White and Non-White emerging adults who engage in heavy drinking, potentially due to its client-centered approach. This is a preliminary study, and the results are therefore tentative.

Community-Engaged Research (CEnR) to Address Gaps in Chronic Kidney Disease Education among Underserved Latines-The CARE Study

Ensuring equitable chronic kidney disease (CKD) education for Latine patients with low health literacy and low English proficiency stands as a critical challenge, and the "Caridad Awareness and Education" (CARE) initiative represents our ongoing effort to address this imperative issue. In collaboration with twenty-three patients living with CKD, diabetes and/or hypertension and twelve trained Community Health Workers (CHWs) from diverse Latine subgroups, we conducted a research initiative funded by the National Kidney Foundation. Our primary objective was to co-design and test culturally tailored patient education materials (PEMs) for underserved Latine adults at risk for or diagnosed with CKD. We effectively integrated Community-Engaged Research (CEnR) principles with a Human-Centered Design (HCD) approach to create a range of CKD-PEM prototypes in Spanish. Patient preferences for printed educational materials were clear. They favored printed materials that incorporated visual content with concise text over digital, email, texts, or online resources and personalized phone outreach and the involvement of CHWs. Additionally, patients identified their unwavering commitment to their families as a forceful motivator for caring for their kidney health. Currently, a culturally and linguistically tailored CKD flipchart for one-on-one education, led by CHWs, is undergoing a pilot testing phase involving a sample of one hundred Latine patients at risk for or diagnosed with CKD. This innovative approach signifies a commitment to amplifying the insights and expertise of the Latine community afflicted by kidney health disparities, effectively embracing a CEnR to forge meaningful and impactful CKD-PEMs.

Expression of Class II Human Leukocyte Antigens on Human Endothelial Cells Shows High Interindividual and Intersubclass Heterogeneity

SIGNIFICANCE STATEMENT

Donor-specific antibodies against class II HLA are a major cause of chronic kidney graft rejection. Nonetheless, some patients presenting with these antibodies remain in stable histological and clinical condition. This study describes the use of endothelial colony-forming cell lines to test the hypothesis of the heterogeneous expression of HLA molecules on endothelial cells in humans. Flow cytometry and immunofluorescence staining revealed substantial interindividual and interlocus variability, with HLA-DQ the most variable. Our data suggest that the expression of HLA class II is predicted by locus. The measurement of endothelial expression of HLA class II in the graft could present a novel paradigm in the evaluation of the alloimmune risk in transplantation and certain diseases.

BACKGROUND

HLA antigens are important targets of alloantibodies and allospecific T cells involved in graft rejection. Compared with research into understanding alloantibody development, little is known about the variability in expression of their ligands on endothelial cells. We hypothesized individual variability in the expression of HLA molecules.

METHODS

We generated endothelial colony forming cell lines from human peripheral blood mononuclear cells ( n =39). Flow cytometry and immunofluorescence staining were used to analyze the cells, and we assessed the relationship between HLA-DQ expression and genotype. Two cohorts of kidney transplant recipients were analyzed to correlate HLA-DQ mismatches with the extent of intragraft microvascular injury.

RESULTS

Large variability was observed in the expression of HLA class II antigens, not only between individuals but also between subclasses. In particular, HLA-DQ antigens had a low and heterogeneous expression, ranging from 0% to 85% positive cells. On a within-patient basis, this expression was consistent between endothelial cell colonies and antigen-presenting cells. HLA-DQ5 and -DQ6 were associated with higher levels of expression, whereas HLA-DQ7, -DQ8, and -DQ9 with lower. HLA-DQ5 mismatches among kidney transplant recipients were associated with significant increase in graft microvascular.

CONCLUSION

These data challenge the current paradigm that HLA antigens, in particular HLA class II, are a single genetic and post-translational entity. Understanding and assessing the variability in the expression of HLA antigens could have clinical monitoring and treatment applications in transplantation, autoimmune diseases, and oncology.

Trends and Projections in Surgical Stabilization of Glenohumeral Instability in the United States from 2009 to 2030: Rise of the Latarjet and Fall of the Open Bankart

INTRODUCTION

Advances in surgical techniques have improved the ability to address recurrent glenohumeral instability via arthroscopic capsulolabral repair and bone restoring procedures such as Latarjet. Given the paucity of studies analyzing temporal trends in surgical management of glenohumeral instability, the purpose of this study was to assess trends in treatment of anterior, posterior, and multidirectional instability over a 10-year period and model projections to 2030.

METHODS

Using IBM Watson Marketscan national database, all patients that underwent glenohumeral instability procedures from 2009 to 2018 were identified. Procedures were identified using common procedural terminology (CPT) codes for open Bankart Repair, Latarjet, anterior bone block, posterior bone block, multidirectional capsular shift, and arthroscopic Bankart procedures. Sample weights provided by the database were utilized to calculate national estimates. The United States (U.S.) Census Bureau annual population data were utilized for calculating incidence. Future projections to 2030 were modeled using Poisson and linear regression.

RESULTS

There were an estimated 446,072 glenohumeral instability cases from 2009-2018. Per capita (per 100,000) incidence remained constant, from 14.8 in 2009 to 14.5 in 2018. Arthroscopic Bankart comprised the highest number of procedures throughout the study period, accounting for 89% of all procedures in 2009 and 93% in 2018. Open Bankart procedures decreased by 65% from 2009 to 2018, while there was a 250% increase in Latarjet procedures over the same period. Patient demographics did not change over the study period, and males aged 18-25 comprised the largest demographic group undergoing anterior instability procedures. Multidirectional instability procedures exhibited the least pronounced gender differences. Future modeling from 2018-2030 projected continued steady rise in arthroscopic Bankart (40,000-49,000 case/yr), rapid growth in Latarjet (1370-4300 cases/yr), and continued decline in open Bankart (1000-250 cases/yr) procedures.

CONCLUSIONS

Arthroscopic Bankart continues to be the most common glenohumeral instability procedure in the U.S. From 2009 to 2018, incidence of open Bankart procedures declined while Latarjet procedures markedly increased. Future projections to 2030 mirrored these findings. These data may provide an enhanced understanding of the evolution of surgical treatment of glenohumeral instability within the U.S. laying the foundation for continued prospective studies into the appropriate indications and advancements in surgical techniques.

Optimising plasma clozapine levels to improve treatment response: an individual patient data meta-analysis and receiver operating characteristic curve analysis

BACKGROUND

Although clozapine is the most efficacious medication for treatment-refractory schizophrenia, not all patients will have an adequate response. Optimising clozapine dose using therapeutic drug monitoring could therefore maximise response.

AIMS

Using individual patient data, we undertook a receiver operating characteristic (ROC) curve analysis to determine an optimal therapeutic range for clozapine levels to guide clinical practice.

METHOD

We conducted a systematic review of PubMed, PsycINFO and Embase for studies that provided individual participant level data on clozapine levels and response. These data were analysed using ROC curves to determine the prediction performance of plasma clozapine levels for treatment response.

RESULTS

We included data on 294 individual participants from nine studies. ROC analysis yielded an area under the curve of 0.612. The clozapine level at the point of optimal diagnostic benefit was 372 ng/mL; at this level, the response sensitivity was 57.3%, and specificity 65.7%. The interquartile range for treatment response was 223-558 ng/mL. There was no improvement in ROC performance with mixed models including patient gender, age or length of trial. Clozapine dose and clozapine concentration to dose ratio did not provide significantly meaningful prediction of response to clozapine.

CONCLUSIONS

Clozapine dose should be optimised based on clozapine therapeutic levels. We found that a range between 250 and 550 ng/mL could be recommended, while noting that a level of >350 ng/mL is the most optimal for response. Although some patients may not respond without clozapine levels >550 ng/mL, the benefits should be weighed against the increased risk of adverse drug reactions.

Intramedullary Metacarpal Fracture Fixation: A Biomechanical Study of Screw Diameter and Comparison With Intramedullary Wire Stabilization

PURPOSE

Interest in intramedullary metacarpal fracture fixation (IMFF) with screws is increasing. However, the optimal screw diameter for fracture fixation is not yet established. In theory, larger screws should be more stable, but there is concern about long-term sequelae of larger metacarpal head defects and extensor mechanism injury created during insertion as well as implant cost. Therefore, the purpose of this study was to compare different diameter screws for IMFF to a popular and more cost-effective alternative of intramedullary wiring.

METHODS

Thirty-two cadaveric metacarpals were used in a transverse metacarpal shaft fracture model. Treatment groups consisted of IMFF with 3.0 × 60 mm, 3.5 x 60 mm, and 4.5 x 60 mm screws as well as 4 1.1-mm intramedullary wires. Cyclic cantilever bending was performed with the metacarpals mounted at 45° to simulate physiologic loading. Cyclical loading at 10, 20, and 30 N was performed to determine fracture displacement, stiffness, and ultimate force.

RESULTS

At 10, 20, and 30 N of cyclical loading, all screw diameters tested provided similar stability as measured by fracture displacement and were superior to the wire group. However, ultimate force under load to failure testing was similar between the 3.5- and 4.5-mm screws and superior to 3.0-mm screws and wires.

CONCLUSIONS

For IMFF, 3.0, 3.5, and 4.5-mm diameter screws provide adequate stability for early active motion and are superior to wires. When comparing the different screw diameters, 3.5- and 4.5-mm diameter screws offer similar construct stability and strength superior to the 3.0-mm diameter screw. Therefore, to minimize metacarpal head morbidity, smaller screw diameters may be preferable.

CLINICAL RELEVANCE

This study suggests that IMFF with screws is biomechanically superior to wires in cantilever bending strength in the transverse fracture model. However, smaller screws may be sufficient to permit early active motion while minimizing metacarpal head morbidity.

A Pilot Study of Polysubstance Use Sequences across the Lifespan among Assiniboine and Sioux People Who Use Injection Drugs

Compared with other racial/ethnic groups in the United States, American Indians/Alaska Natives have the highest rates of acute Hepatitis C Virus (HCV) infection, the highest HCV-related mortality, and one of the fastest climbing rates of drug overdose deaths involving stimulants. In this pilot study, a life history calendar was administered to Indigenous people who use injection drugs (IPWIDs) to understand sequences of polysubstance use across the lifespan. 40 IPWIDs completed a questionnaire and life history calendar. Social sequence analysis was used to examine patterns in sequential phenomena among substances reported over years of the lifespan. Most participants (55%) began injecting substances before the age of 21, 62.5% shared syringes with others, and 45% had ever been diagnosed with HCV. An appreciably large increase in the use of stimulants occurred between the year prior to and following injection initiation (33% to 82%). A three-cluster solution distinguished younger IPWIDs transitioning into polysubstance use involving stimulants and/or narcotic analgesics from adults using narcotic analgesics with stimulants over longer periods of time, and adults most focused on stimulant use over time. Findings from this pilot study contribute to an understanding of how methamphetamine injection plays a role in the HCV epidemic among IPWIDs.

Characterization of Lifetime Agrichemical Exposure Sequences Relative to International Migration in Foreign Born Latinx Agricultural Workers Living in South Florida

There is a limited understanding of how toxic exposures to agrichemicals vary relative to international migration over the life course. A life history calendar (LHC) was piloted to explore sequences of agrichemical exposure relative to international migration. LHCs were administered to 41 foreign born individuals from Mexico and Central America who had agricultural work experience during their lifetime and who were living in South Florida. Social sequence analysis was used to explore occupation-by-agrichemical events relative to migration. A three-cluster solution was used to classify low, moderate, and high lifetime exposure sequences. The odds of any perceived effects of agrichemicals on the body increased with time prior to migration in the moderate and high exposure sequence clusters and continued to increase 20% with each year following migration in the moderate exposure cluster. Workers with high lifetime agrichemical exposures prior to migrating internationally showed lower likelihoods of a perceived effect on the body following migration despite continued exposure. Further research on instrument validity is warranted.

Winter sport musculoskeletal injuries: epidemiology and factors predicting hospital admission

INTRODUCTION

Participation in winter sports such as skiing, snowboarding and snowmobiling is associated with risk of musculoskeletal injury. The purpose of our study was to describe and quantify emergency department encounters associated with these sports.

METHODS

The National Electronic Injury Surveillance System (NEISS) was queried for skiing-, snowboarding- and snowmobiling-related injuries from 2009 to 2018. Patient demographics and disposition data were collected from emergency department encounters. Descriptive statistics were utilized to describe the trends in injuries from each sport and factors associated with the sports-specific injuries.

RESULTS

From 2009 to 2018, there were an estimated 156,353 injuries related to snowboarding, skiing, or snowmobiling. Estimated injury incidence per 100,000 people decreased over time for skiing (3.24-1.23), snowboarding (3.98-1.22,) and snowmobiling (0.71-0.22,). The most common injury location by sport was shoulder for skiing (29.6%), wrist for snowboarding (32.5%) and shoulder for snowmobiling (21.9%), with fractures being the most common diagnosis. Only 4.5% required admission to the hospital. Fracture or dislocation was associated with highest likelihood of hospital admission (OR 42.34; 95% CI 22.59-79.37). Snowmobiling injuries (OR 1.63; 95% CI 1.20-2.22) and white race (OR 1.42; 95% CI 1.17-1.72) were also both associated with increased risk of hospital admission.

CONCLUSIONS

Upper extremity injuries, particularly those involving fractures, were more common than lower extremity injuries for all three sports, with the shoulder being the most common location of injury for skiing and snowmobiling. This study can serve as the foundation for future research in sports safety and health policy to continue the declining trend of musculoskeletal injuries in the future.

LEVEL OF EVIDENCE

III.

Dissecting the progression of cardiac dysfunction in tumor-bearing mice

Funding Acknowledgements

Type of funding sources: None.

Background

Cancer patients undergoing heart-related complications result in high incidences of mortality. Nevertheless, it is still not fully understood whether localized tumors affect heart function prior to the onset of cachexia, hence, making the heart more vulnerable for functional abnormalities in later stages of the disease. In addition to analyse heart function, we focus on the expression BCL-2–associated athanogene 3 (BAG3), a co-chaperone protein and Hsp70, which are highly expressed in tumor but decrease in cardiomyocytes (CM) in heart failure (HF).

Methods

Colon-26 adenocarcinoma cells (C26; n=22) with/without shIL-6 (C26 shIL-6; n=22) were injected subcutaneously into the right flank of 10-11 weeks old BALB/c male mice. Control mice were injected with vehicle (PBS; n=8). Cardiac function was assessed by echocardiography and invasive hemodynamic measurements 10 (early) and 20 (late) days after the injection, respectively. In addition, the expression of BAG3 and Hsp70 were determined by Western blot as well as the extend of cardiac fibrosis was determined by Masson-Goldner's trichrome staining.

Results

The tumor size was comparable between the two injected groups. However, only C26 group showed a significant loss of subcutaneous fat and skeletal muscle (p<0.05, respectively), suggesting cachexia. Heart weight normalized to tibia length was not changed in the injected groups as compared to controls (day 20). However, left ventricular ejection fraction (LVEF) showed a tendency to decline in the early phase (p~0.08) in both injected group and it reached significance at late stage (p<0.05). Invasive hemodynamic assessment also confirmed the contractile dysfunction, resulting in a decrease in LV systolic pressure and increase of LV end-diastolic pressure (p<0.05, respectively). Importantly, these functional changes in the heart in tumor-bearing mice were associated with a marked reduction in both BAG3 and Hsp70 in the myocardium. Furthermore,  there was no sign of cardiac fibrosis in the injected groups.

Discussion

Our study shows for the first time that tumor rather than cancer cachexia plays a significant maladaptive role in the progression of cardiac dysfunction in a mouse model of C26 injection-induced cachexia. The progression of cardiac contractile dysfunction was associated with a decline in BAG3 and Hsp70 in tumor-bearing mice, suggesting changes of BAG3/Hsp 70 signalling may be a critical component as well as target.

Territorial behaviour and conflict management in a semi-social cichlid fish, Neolamprologus caudopunctatus

Conflict solving strategies can prevent fights from escalating and reduce the costs of aggressive encounters. Having the capacity to efficiently assess an opponent’s fighting abilities before fully committing to a fight is a useful social skill. Here, we conducted two experiments to investigate how a colony living, cichlid species, Neolamprologus caudopunctatus, changes its aggressive behaviour when faced with familiar vs unfamiliar opponents. First, we staged size matched, same-sex, dyadic resource contests and found that fights were always of low-intensity with neither familiarity nor sex influencing how quickly the conflict ended. Second, we explored the dual defence of mated territorial pairs together defending their territory boundaries against other pairs, either familiar or unfamiliar ones, and discovered that fights between two pairs were more vigorous, and that unfamiliar neighbouring pairs were attacked significantly more often than familiar pairs. We also observed that dark bars sometimes appeared on the sides of contestant’s bodies, and that these bars were far more common in winners than in losers, suggesting that these might be visual signals of dominance. However, conflicts where contestants displayed bars were of longer duration than those without. Taken together, our results further advance our understanding of territoriality and conflict resolution strategies and set the stage for future studies focusing on how animals manage to co-exist in closely aggregated breeding territories and to form colonies.

Identification of mitofusin 1 and complement component 1q subcomponent-binding protein as mitochondrial targets in systemic lupus erythematosus

OBJECTIVE

Mitochondria are organelles that possess several bacterial features such as a double-stranded genome with hypomethylated CpG islets, formylated proteins, and cardiolipin-containing membranes. In systemic lupus erythematosus (SLE), mitochondria and their inner components are released into the extracellular space, potentially eliciting a pro-inflammatory response by the immune system. While cardiolipin and mitochondrial DNA and RNA are confirmed targets of autoantibodies, other antigenic mitochondrial proteins in SLE remain to be identified. Herein, we aim to characterize the protein repertoire recognized by anti-mitochondrial antibodies (AMA) in SLE patients.

METHODS

Using shotgun proteomic profiling, we identified 1345 proteins, 431 of which were associated with the mitochondrial proteome. Immunoreactivities to several of these candidates were assessed by direct ELISA in serum samples from a local cohort (healthy: n=30, SLE: n=87) and associated with demographic and disease characteristics.

RESULTS

We determined that IgGs to the C1q-binding protein (C1qBP) are significantly elevated in SLE patients included in our cohort (p=0.049) and are associated with positivity for lupus anticoagulant (p=0.049). IgG against the mitochondrial protein mitofusin 1 (Mfn1) displayed promising performances in the prediction of SLE diagnoses (aOR: 2.99, 95%CI: 1.39-6.43, p=0.0044) in our cohort. Moreover, anti-Mfn1 were associated with positivity to anti-phospholipids (p=0.011) and anti-dsDNA (p=0.0005).

CONCLUSION

This study presents the mitochondrial repertoire targeted in SLE, indicating that autoantibodies can recognize secreted and/or surface proteins of mitochondrial origin. Profiling of the AMA repertoire in large prospective cohorts may improve our knowledge on mitochondrial biomarkers and their usefulness for patient stratification.

Abstract P507: Comprehensive Characterization Of Poly(a)-clickseq Data Sets Reveal Novel Polyadenylation Signals In Human Right Ventricle Failure

Background: Many human genes hold more than 1 poly(A) site, and polyadenylation gives rise to transcripts with different 3′ untranslated regions (3’UTR) lengths, and this process known as alternative polyadenylation (APA). It plays a significant role in many cellular processes and dysregulation of APA leads to many human diseases. However, the functional consequences of APA events in the right ventricle (RV) failure in humans remain unexplored.

Objective: To understand whether a global APA event is presented in the progression of RV failure by using the novel algorithm PolyA miner in the RV of healthy donors and patients with RV failure.

Methods and Results: RV tissue samples were obtained from failing human hearts at the time of cardiac transplantation at the Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital. The RV tissues were immediately frozen in liquid nitrogen and stored at –80°C until use. Normal tissue samples were obtained from donor hearts that were not used for transplantation and were collected and stored in the same manner. We characterized the APA profiles of RV failing patients and compared them to healthy RV specimens by using Poly(A)-ClickSeq (PAC-seq) RNA sequencing and the PolyA-miner algorithm. We determined shortening versus lengthening of 3′UTRs based on the PolyA index, a metric unit that determines the length of 3′UTR. Based on these scores, we identified 435 transcripts with a significant shift in cleavage site usage. Further, we discovered 3'UTR shortening and lengthening of many genes in failing RV compared to healthy RV specimens. By examining polyadenylation events in these hearts, we identified disease-specific APA signatures in many genes. In addition, differential APA events in RV failure regulate many pathways important for the progression of the RV failure.

Conclusions: Our study highlights the important roles for APA in human RV failure, including reforming multiple pathways and regulating specific gene expression, representing the complex interplay between APA and other biological processes in the RV failure.

The sodium iodide symporter (NIS): novel applications for radionuclide imaging and treatment

Cloning of the sodium iodide symporter (NIS) 25 years ago has opened an exciting chapter in molecular thyroidology with the characterization of NIS as one of the most powerful theranostic genes and the development of a promising gene therapy strategy based on image-guided selective NIS gene transfer in non-thyroidal tumors followed by application of 131I or alternative radionuclides, such as 188Re and 211At. Over the past two decades, significant progress has been made in the development of the NIS gene therapy concept, from local NIS gene delivery towards promising new applications in disseminated disease, in particular through the use of oncolytic viruses, non-viral polyplexes, and genetically engineered MSCs as highly effective, highly selective and flexible gene delivery vehicles. In addition to allowing the robust therapeutic application of radioiodine in non-thyroid cancer settings, these studies have also been able to take advantage of NIS as a sensitive reporter gene that allows temporal and spatial monitoring of vector biodistribution, replication, and elimination - critically important issues for preclinical development and clinical translation.

Complications of Superior Capsule Reconstruction for the Treatment of Functionally Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

The purpose of this systematic review is to characterize the complications associated with superior capsule reconstruction (SCR) for the treatment of functionally irreparable rotator cuff tears (FIRCTs).

METHODS

This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers completed a search of PubMed, Embase, and Medline databases. Studies were deemed eligible for inclusion if they reported postoperative outcomes of arthroscopic SCR for FIRCTs and considered at least 1 postoperative complication. Statistical heterogeneity was quantified via the I² statistic. Due to marked heterogeneity, pooled proportions were not reported. All complications and patient-reported outcomes were described qualitatively.

RESULTS

Fourteen studies met the inclusion/exclusion criteria. The overall complication rate post-SCR ranged from 5.0% to 70.0% (I² = 84.9%). Image-verified graft retear ranged from 8% to 70%, I² = 79.4%), with higher rates reported when SCR was performed using allograft (19%-70%, I² 76.6%) compared to autograft (8%-29%, I² = 66.1%). Reoperation (0%-36%, I² = 73.4%), revision surgeries (0%-21%, I² = 81.2%), medical complications (0%-5%, I² = 0.0%), and infections (0%-5%, I² = 0.0%) were also calculated.

CONCLUSIONS

SCR carries a distinct complication profile when used for the treatment of FIRCTs. The overall rate of complications ranged from 5.0% to 70.0%. The most common complication is graft retear with higher ranges in allografts (19%-70%) compared to autografts (8%-29%). The majority of studies reported at least 1 reoperation (range, 0%-36%), most commonly for revision to reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV or better investigations.

[Radiological and functional results in high-energy tibial plate fractures]

INTRODUCTION

The tibial plateau fractures due to high-energy mechanisms are serious injuries that occur on a load bearing joint. These are difficult to approach because, also affect the bone structure of the leg, they usually have associated soft tissue injuries.

OBJECTIVE

To evaluate the radiological and functional results of high-energy tibial plateau fractures with a minimum follow-up of one year.

MATERIAL AND METHODS

Retrospective, observational and multicenter study. Analysis of radiological and functional outcomes in the treatment of high-energy tibial plateau fractures, treated by open reduction and internal fixation (ORIF) between 2014 and 2019.

RESULTS

54 fractures treated by ORIF. Follow-up one year. 98.1% consolidation in 13 weeks on average. 83.4% without alterations of the axis in the coronal plane. 74% without postoperative joint widening. Functional scores: Lysholm 82.1 average points and Oxford Knee Score (OKS) 39.5 average points.

CONCLUSION

The joint range of motion was reduced after a high-energy tibial plateau fracture, but with good functional results. The less off axis and less post-operative radiographic widening, the better results are obtained.

A review investigating the relationship between cannabis use and adolescent cognitive functioning

Given varying state-level laws regarding cannabis use, the objective of the review was to summarize contemporary literature on the relationship between adolescent cognitive function and academic performance with cannabis use. Frequency and quantity of cannabis use were associated with decreased functional connectivity of the brain. Earlier age at cannabis initiation and more frequent use was associated with poorer executive control and academic performance. Social determinants such as minimal parental monitoring, peer use and low social cohesion were associated with more frequent adolescent use. Race/ethnicity and residence were other factors influencing cannabis use. To prevent cannabis use disorders among adolescents, interventions should aim to prevent early initiation that can lead to chronic use in youth who may be more at risk.

Impact of smoking behavior on clozapine blood levels - a systematic review and meta-analysis

OBJECTIVE

Tobacco smoking significantly impacts clozapine blood levels and has substantial implications on individual efficacy and safety outcomes. By investigating differences in clozapine blood levels in smoking and non-smoking patients on clozapine, we aim to provide guidance for clinicians how to adjust clozapine levels for patients on clozapine who change their smoking habits.

METHODS

We conducted a meta-analysis on clozapine blood levels, norclozapine levels, norclozapine/clozapine ratios, and concentration to dose (C/D) ratios in smokers and non-smokers on clozapine. Data were meta-analyzed using a random-effects model with sensitivity analyses on dose, ethnic origin, and study quality.

RESULTS

Data from 23 studies were included in this meta-analysis with 21 investigating differences between clozapine blood levels of smokers and non-smokers. In total, data from 7125 samples were included for the primary outcome (clozapine blood levels in ng/ml) in this meta-analysis. A meta-analysis of all between-subject studies (N = 16) found that clozapine blood levels were significantly lower in smokers compared with non-smokers (Standard Mean Difference (SMD) -0.39, 95% confidence interval (CI) -0.55 to -0.22, P < 0.001, I²  = 80%). With regard to the secondary outcome, C/D ratios (N = 16 studies) were significantly lower in the smoker group (n = 645) compared with the non-smoker group (n = 813; SMD -0.70, 95%CI -0.84 to -0.56, P < 0.00001, I²  = 17%).

CONCLUSION

Smoking behavior and any change in smoking behavior is associated with a substantial effect on clozapine blood levels. Reductions of clozapine dose of 30% are recommended when a patient on clozapine stops smoking. Reductions should be informed by clozapine steady-state trough levels and a close clinical risk-benefit evaluation.

A comprehensive review of the normal, abnormal, and post-operative MRI appearance of the distal biceps brachii

The biceps brachii myotendinous unit is a common source of shoulder, arm, and elbow pain. Its complex anatomy can present a challenge when interpreting MR images. We discuss the clinical and imaging presentations of injury related to the proximal biceps brachii separately in another manuscript. The purpose of this manuscript is to review the distal biceps anatomy along with pathology and post-operative appearance as seen on MRI.

A comprehensive review of the normal, abnormal, and post-operative MRI appearance of the proximal biceps brachii

The biceps brachii myotendinous unit, particularly the long head of the biceps tendon and its labral attachment, is a common cause of shoulder and arm pain. Its complex anatomy and normal variations can present a challenge when interpreting MR images. The purpose of this manuscript is to review the proximal biceps anatomy, variants, pathology, and post-operative appearance as seen on MRI. Recent data regarding the accuracy of clinical examination and MRI will be summarized.

Lower Mortality Associated With Adjuvant Corticosteroid Therapy in Non-HIV-Infected Patients With Pneumocystis jirovecii Pneumonia: A Single-Institution Retrospective US Cohort Study

Background

Pneumocystis jirovecii pneumonia (PJP) remains a cause of mortality in HIV-negative patients. The clinical benefit of adjuvant corticosteroids in these patients is uncertain. This study aimed to determine if corticosteroids would reduce mortality in a cohort of HIV-negative PJP patients.

Methods

We examined a retrospective case series of patients diagnosed with PJP at the University of Colorado Hospital between 1995 and 2019. Data were collected in 71 PJP-infected patients. Twenty-eight patients were HIV-negative, and 43 were infected with HIV. We performed bivariate and forward, stepwise multivariable logistic regressions to identify mortality predictors.

Results

Common underlying conditions in HIV-negative patients were hematologic malignancies (28.6%), autoimmune disorders (25.9%), and solid organ transplantation (10.7%). HIV-negative patients had higher rates and durations of mechanical ventilation and intensive care unit stay. Survival was significantly increased in HIV-negative patients receiving adjuvant corticosteroids, with 100% mortality in patients not receiving corticosteroids vs 60% mortality in patients receiving corticosteroids (P = .034). In an adjusted multivariable model, no adjuvant corticosteroid use was associated with higher mortality (odds ratio, 13.5; 95% CI, 1.1–158.5; P = .039) regardless of HIV status.

Conclusions

We found substantial mortality among HIV-negative patients with PJP, and adjuvant corticosteroid use was associated with decreased mortality. Response to corticosteroids is best established in HIV-infected patients, but emerging reports suggest a similar beneficial response in PJP patients without HIV infection. Further prospective studies may establish a more definitive role of the addition of corticosteroids among HIV-negative patients with PJP.

The impact of COVID-19 on African American communities in the United States

Importance:

The novel Coronavirus Disease 2019 (COVID-19), declared a pandemic in March 2020, may present with disproportionately higher rates in underrepresented racial/ethnic minority populations in the United States, including African American communities who have traditionally been over-represented in negative health outcomes.

Study Objective:

To understand the impact of the density of African American communities (defined as the percentage of African Americans in a county) on COVID-19 prevalence and death rate within the three most populous counties in each U.S. state and territory (n=152). Design: An ecological study using linear regression was employed for the study.

Setting:

The top three most populous counties of each U.S. state and territory were included in analyses for a final sample size of n=152 counties.

Participants:

Confirmed COVID-19 cases and deaths that were accumulated between January 22, 2020 and April 12, 2020 in each of the three most populous counties in each U.S. state and territory were included.

Main outcome measures:

Linear regression was used to determine the association between African American density and COVID-19 prevalence (defined as the percentage of cases for the county population), and death rate (defined as number of deaths per 100,000 population). The models were adjusted for median age and poverty.

Results:

There was a direct association between African American density and COVID-19 prevalence; COVID-19 prevalence increased 5% for every 1% increase in county AA density (p<.01). There was also an association between county AA density and COVID-19 deaths, such; the death rate increased 2 per 100,000 for every percentage increase in county AA density (p=.02).

Conclusion:

These study findings indicate that communities with a high African American density have been disproportionately burdened with COVID-19. Further study is needed to indicate if this burden is related to environmental factors or individual factors such as types of employment or comorbidities that members of these community have.

A comparison of saline and gadolinium shoulder MR arthrography to arthroscopy

PURPOSE

Compare the diagnostic performance of saline and gadolinium shoulder magnetic resonance arthrograms (MRA) in the detection of labral and rotator cuff injury compared to arthroscopy.

MATERIALS AND METHODS

Consecutive patients who underwent a gadolinium or saline MRA followed by arthroscopy were retrospectively reviewed. The reports were reviewed for injuries. A chi square or Fisher's exact test was performed to compare the MRA and surgery. Kappa values were calculated to correlate diagnosis of tear between MRA and arthroscopy.

RESULTS

There were a total of 58 patients included, including 34 gadolinium arthrograms and 24 saline arthrograms. The accuracy of saline MRA was similar compared to gadolinium MRA in the diagnosis of tears of the supraspinatus (accuracy 0.88 vs 0.74, respectively) and infraspinatus (accuracy 0.88 vs 0.65, respectively) tendons and tears of the anterior/anterior inferior, posterior, and superior labrum, (accuracy 0.79 vs 0.76, 0.71 vs 0.62, and 0.58 vs 0.56), and saline vs gadolinium, respectively. Although there was a trend toward overall better saline MRA performance, a statistically significant difference in the accuracy to detect tears was only noted for the infraspinatus tendon. Interobserver agreement for rotator cuff tears was higher for saline than gadolinium MRA.

CONCLUSION

Saline MRA was accurate, with no significant differences compared gadolinium arthrograms in the diagnosis of labral and rotator cuff pathology. Given expense, and the potential additional information provided by fluid sensitive sequences over T1 fat-suppressed sequences, consideration should be given to using saline for shoulder MRAs.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture

PURPOSE

The aims of our study were to evaluate the rates and predictors of reinterventions and direct costs of 3 common treatments of Dupuytren contractures-needle aponeurotomy, collagenase injection, and surgical fasciectomy.

METHODS

A retrospective review identified 848 interventions for Dupuytren contracture in 350 patients treated by a single surgeon from 2005 to 2016. The treatments included needle aponeurotomy (NA) (n = 444), collagenase injection (n = 272), and open fasciectomy (n = 132). We collected information on demographics, contracture details, and comorbidities. Outcomes included reintervention rates, time to reintervention, and direct cost of treatments. Standardized costs were calculated by applying 2017 Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges.

RESULTS

Demographics were similar among the 3 treatment groups. The fifth finger was the most commonly affected digit including 43% of the NA, 60% of the collagenase, and 45% of the fasciectomy groups. The 2-year rates of reintervention following NA, collagenase, and fasciectomy were 24%, 41%, and 4%, respectively, and the 5-year rates were 61%, 55%, and 4%, respectively. Younger age and severity of preintervention proximal interphalangeal (PIP) joint contracture were predictive of reintervention in the NA and collagenase groups. The standardized direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and $5,291, respectively. Including all reinterventions, the cumulative costs per digit following NA, collagenase, and surgery at 5 years were $1,540, $5,952, and $5,507, respectively.

CONCLUSIONS

Treatment with collagenase resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to NA at 5 years, and the highest cumulative costs. The NA was the least expensive and resulted in longer duration before reintervention compared with collagenase. More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after collagenase and NA. Fasciectomy has a high initial cost but the lowest reintervention rate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Different and diverse anaerobic microbiota were seen in women living with HIV with unsuppressed HIV viral load and in women with recurrent bacterial vaginosis: a cohort study

OBJECTIVE

To compare the vaginal microbiota of women living with HIV (WLWH) with the vaginal microbiota of women with recurrent bacterial vaginosis (BV) and healthy women without HIV to determine if there are differences in the vaginal microbiome, what factors influence these differences, and to characterise HIV clinical parameters including viral load and CD4 count in relation to the vaginal microbiome.

DESIGN

Observational cohort study.

SETTING

Canada.

POPULATION

Women aged 18-49 years who were premenopausal and not pregnant were recruited into three cohorts: healthy women, WLWH and women with recurrent BV.

METHODS

Demographic and clinical data were collected via interviews and medical chart reviews. Vaginal swabs were collected for Gram-stain assessment and microbiome profiling using the cpn60 barcode sequence.

MAIN OUTCOME MEASURES

To compare overall community composition differences, we used compositional data analysis methods, hierarchical clustering and Kruskal-Wallis tests where appropriate.

RESULTS

Clinical markers such as odour and abnormal discharge, but not irritation, were associated with higher microbial diversity. WLWH with unsuppressed HIV viral loads were more likely than other groups to have non-Gardnerella-dominated microbiomes. HIV was associated with higher vaginal microbial diversity and this was related to HIV viral load, with unsuppressed women demonstrating significantly higher relative abundance of Megasphaera genomosp. 1, Atopobium vaginae and Clostridiales sp. (all P < 0.05) compared with all other groups.

CONCLUSIONS

In WLWH, unsuppressed HIV viral loads were associated with a distinct dysbiotic profile consisting of very low levels of Lactobacillus and high levels of anaerobes.

TWEETABLE ABSTRACT

Vaginal microbiomes in WLWH with viral load >50 copies/ml have distinct dysbiotic profiles with high levels of anaerobes.

Quality of Spiritual Care at the End of Life: What the Family Expects for Their Loved One

Spiritual care at the End of Life (EOL) is a "keystone" investment at any Regional Tertiary Acute Care Hospital. Spiritual Care Departments need to demonstrate quality indicators in the provision of spiritual care at an EOL not only for their patients, but to satisfy family expectations of that care for their loved one. A fixed choice survey instrument using a structured interview via telephone was utilized for 202 criterion families who had lost a loved one. Three domains surfaced: (1) Families retained traditional chaplain role expectations of Priestly/Liturgical (78.6%) and Pastoral/Shepherd (67.5%); (2) Expectations of an expanded chaplain role after the EOL (50%); and, (3) Traditional spiritual care services regardless of one's religion or spirituality: Comfort and care, emotional support (96%); active listening (96.5%); the Chaplain as a reminder of God's presence (93.6%); prayer (96%); scripture reading (69.3%); and ritual/sacramental anointing of the sick (71.3%).

Gap analysis of service needs for adults with neurodevelopmental disorders

In Florida, the Agency for Persons with Disabilities provides waivers for adults with the following types of disabilities: intellectual disability, autism spectrum disorder, cerebral palsy, spina bifida, Down syndrome, and Prader-Willi syndrome. This review examined the peer-reviewed literature to indicate and assess the common needs for individuals with intellectual and developmental disabilities. Current models of service delivery, the efficacy of these services, and remaining gaps in the need fulfillment of individuals within the six diagnostic categorizations of interest were examined. Severity level within each diagnostic category was plotted on a matrix according to whether the needs of individuals were minimal, moderate, severe, or universal. The study found that sexual health education, socialization, and adult-focused medical care are universal needs among the six conditions. The study indicates that health-care professionals must work toward addressing the many unmet needs in comprehensive life span care services for adult individuals with neurodevelopmental disorders.

Long-term outcomes of silicone metacarpophalangeal arthroplasty: a longitudinal analysis of 325 cases

An analysis was conducted of 325 consecutive metacarpophalangeal arthroplasties prospectively collected using a single institution's total joints registry over a 14-year time period to characterize long-term radiographic and functional outcomes. Patients were followed for a mean of 7.2 years (2-18) or until revision. The 5-, 10- and 15-year survival free from revision were 98%, 95% and 95%, respectively. The 5-, 10- and 15-year survival rates free from radiographic implant fracture were 93%, 58% and 35%, respectively. The 5-, 10- and 15-year survival rates free from coronal plane deformity greater than 10° were 81%, 37% and 17%, respectively. Patients had significant improvements in their postoperative pain levels and metacarpophalangeal arc of motion. Neither implant fracture, nor coronal plane deformity >10° had a significant association with worse function. Overall, pain relief and functional improvement are reliable, though silicone implants do not protect from progression of coronal plane deformity and have a high fracture rate. Level of evidence: IV.

The diagnosis of hereditary angioedema with C1 inhibitor deficiency: a survey of Canadian physicians and laboratories

Background

Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is an autosomal dominant disease resulting in random and unpredictable attacks of swelling. The swelling in C1-INH-HAE is a result of impaired regulation of bradykinin production. The fact that the array of tests needed to diagnose HAE is not always available to the treating physicians is challenging for them and their patients.

Methods

The data for this article were extracted from two distinct surveys. The first survey was conducted among HAE treating physicians and aimed to determine the availability and utilization of the various assays performed to help the diagnosis of C1-INH-HAE. The second survey was conducted with the various laboratories across Canada that performs the assays used in the diagnosis of HAE. The aim of this survey was to determine the availability and profile of the various assays used in the diagnosis of C1-INH-HAE in Canada, thereby ultimately bringing a rational basis for the biological testing.

Results

C1-INH functional assay was widely available in Canada (93%), but was only offered by a small numbers of hospitals meaning that there could be longer delays in the analysis of these samples that may explain why the physicians expressed a lower level of confidence in this assay (59%). Antigenic C1-INH was available to the vast majority of the physicians treating C1-INH-HAE (93%) and was considered reliable by 96% of the respondents. Antigenic C4 was found available to all Canadian physicians and, although with limited specificity, was considered very reliable by all the participants. This study revealed that 81% of physicians were able to order the antigenic C1q and the confidence in this assay was moderate (70%). Concerning genetic testing, the survey revealed that most of the CHAEN members never had to or couldn't order this test.

Conclusion

This study highlights the need for improved education and knowledge exchange, about biological assays available to Canadian physicians and their performance in proper diagnosis of C1-INH-HAE to improve confidence and access to relevant tests.

Comparing Pathways of Bradykinin Formation in Whole Blood From Healthy Volunteers and Patients With Hereditary Angioedema Due to C1 Inhibitor Deficiency

Multiple pathways have been proposed to generate bradykinin (BK)-related peptides from blood. We applied various forms of activation to fresh blood obtained from 10 healthy subjects or 10 patients with hereditary angioedema (HAE-1 or −2 only) to investigate kinin formation. An enzyme immunoassay for BK was applied to extracts of citrated blood incubated at 37°C under gentle agitation for 0–2 h in the presence of activators and/or inhibitory agents. Biologically active kinins in extracts were corroborated by c-Fos accumulation in HEK 293a cells that express either recombinant human B₂ or B₁ receptors (B₂R, B₁R). Biological evidence of HAE diagnostic and blood cell activation was also obtained. The angiotensin converting enzyme inhibitor enalaprilat, without any effect per se, increased immunoreactive BK (iBK) concentration under active stimulation of blood. Tissue kallikrein (KLK-1) and Kontact-APTT, a particulate material that activates the contact system, rapidly (5 min) and intensely (>100 ng/mL) induced similar iBK generation in the blood of control or HAE subjects. Tissue plasminogen activator (tPA) slowly (≥1 h) induced iBK generation in control blood, but more rapidly and intensely so in that of HAE patients. Effects of biotechnological inhibitors indicate that tPA recruits factor XIIa (FXIIa) and plasma kallikrein to generate iBK. KLK-1, independent of the contact system, is the only stimulus leading to an inconsistent B₁R stimulation. Stimulating neutrophils or platelets did not generate iBK. In the HAE patients observed during remission, iBK formation capability coupled to B₂R stimulation appears largely intact. However, a selective hypersensitivity to tPA in the blood of HAE patients suggests a role of plasmin-activated FXIIa in the development of attacks. Proposed pathways of kinin formation dependent on blood cell activation were not corroborated.

Somatosensory Evoked Responses Elicited by Haptic Sensations in Midair

The design of human-machine interfaces (HMIs) by virtual haptics is an emerging field of research. So far, the perception of virtual haptic feedback, e.g., generated by focused ultrasound in midair has not been objectively evaluated. This paper demonstrates the feasibility of eliciting somatosensory evoked potentials (SEPs) with ultrasonic stimuli in midair for the first time. The palm was stimulated by short ultrasonic focal points generated by an ultrasound board. The results are compared with a no stimulation condition as well as with the results of a vibro tactile stimulation. The SEPs are analyzed with the wavelet phase synchronization stability (WPSS) and the M-consecutive averaged WPSS. The results indicate a clear SEP waveform elicited by ultrasound. It can be significantly differentiated from a no stimulation condition by the M-consecutive averaged WPSS. These results could enable the possibility of developing an objective evaluation method for virtual haptic feedback in HMIs.

Abstract 435: Post-transcriptional Regulation of Tropomyosin Isoforms Altered in Human Heart Diseases

Background: Tropomyosin 1 (TPM1) is a coiled coil protein that forms polymers along with the actin filament, and it is required for myofibril organization, myocardial contraction, and cardiac development. TPM1 has cardiac muscle and non-muscle specific protein isoforms that dictate its function in cardiac muscle contraction or in cytoskeleton. TPM1 mutations in exon 2b, 5, 6b or 8 are associated with cardiovascular diseases including familial hypertrophic cardiomyopathy, dilated cardiomyopathy and left ventricular non-compaction. Thus, it is of great importance to investigate the mechanisms that control tropomyosin isoforms in order to identify novel therapeutic targets for cardiovascular diseases in which TPM1 is mutated.

Method: We used nanopore sequencing technology using MinION and poly(A)click seq (PAC-seq) to identify different TPM1 transcripts generated in rat heart derived H9c2 cells. RT-PCR and western blotting were conducted to measure mRNA and protein levels of TPM1 respectively.

Results: We identified 10 different isoforms of TPM1 using nanopore sequencing and determined several exons that are extensively spliced and favored in cardiac cells. We further identified an RNA binding protein that controls cardiac specific isoforms of TPM1 via alternative splicing and polyadenylation. Importantly, we found that this RNA binding protein regulates alternative splicing of exon 6b of TPM1, which is mutated in patients with cardiomyopathies.

Conclusions: We identified an RNA binding protein, which controls expression of cardiac specific TPM1 isoforms by alternative polyadenylation and alternative splicing.

Non-polymeric asymmetric binary glass-formers. II. Secondary relaxation studied by dielectric, 2H NMR, and 31P NMR spectroscopy

We investigate the secondary (β-) relaxations of an asymmetric binary glass former consisting of a spirobichroman derivative (SBC; T_g = 356 K) as the high-T_g component and the low-T_g component tripropyl phosphate (TPP; T_g = 134 K). The main relaxations are studied in Paper I [B. Pötzschner et al., J. Chem. Phys. 146, 164503 (2017)]. A high T_g contrast of ΔT_g = 222 K is put into effect in a non-polymeric system. Component-selective studies are carried out by combining results from dielectric spectroscopy (DS) for mass concentrations c_TPP ≥ 60% and those from different methods of ²H and ³¹P NMR spectroscopy. In the case of NMR, the full concentration range (10% ≤ c_TPP ≤ 100%) is covered. The neat components exhibit a β-relaxation (β₁ (SBC) and β₂ (TPP)). The latter is rediscovered by DS in the mixtures for all concentrations with unchanged time constants. NMR spectroscopy identifies the β-relaxations as being alike to those in neat glasses. A spatially highly restricted motion with angular displacement below ±10° encompassing all molecules is involved. In the low temperature range, where TPP shows the typical ³¹P NMR echo spectra of the β₂-process, very similar spectral features are observed for the (deuterated) SBC component by ²H NMR, in addition to its "own" β₁-process observed at high temperatures. Apparently, the small TPP molecules enslave the large SBC molecules to perform a common hindered reorientation. The temperature dependence of the spin-lattice relaxation time of both components is the same and reveals an angular displacement of the SBC molecules somewhat smaller than that of TPP, though the time constants τ_β2 are the same. Furthermore, T₁(T) of TPP in the temperature region of the β₂-process is absolutely the same as in the mixture TPP/polystyrene investigated previously. It appears that the manifestations of the β-process introduced by one component are essentially independent of the second component. Finally, at c_TPP ≤ 20% one finds indications that the β₂-process starts to disintegrate. More and more TPP molecules get immobilized upon decreasing c_TPP. We conclude that the β-process is a cooperative process.

Arthroscopic Latarjet Procedure Combined With Bankart Repair: A Technique Using 2 Cortical Buttons and Specific Glenoid and Coracoid Guides

The arthroscopic Latarjet procedure is challenging because it can be difficult to place 2 screws parallel to the glenoid surface and a medial portal (dangerous for the brachial plexus) is mandatory. In addition, precise positioning of the coracoid bone block flush with the joint line and in a subequatorial position as recommended is troublesome without the use of a guiding system because of the arthroscopic lens distortion. To improve the reproducibility of the arthroscopic Latarjet procedure and to minimize the risk of nerve complications, we developed a guiding system to optimize the positioning of the coracoid bone block and 2 cortical buttons to facilitate its fixation. Four portals are used: a posterior standard portal and 3 anterior portals, all lateral to the conjoint tendon. The anterior rim of the glenoid and the coracoid process are prepared. Two holes are drilled in the glenoid and in the coracoid process with 2 specific guides. The subscapularis is then split, and 2 cortical buttons are passed from posterior to anterior through the tunnels with a shuttle relay. The coracoid process undergoes osteotomy and is guided through the split in the subscapularis to the anteroinferior rim of the glenoid by pulling on the cortical buttons.

Outcomes Following Acute Metacarpophalangeal Joint Arthroplasty Dislocation: An Analysis of 37 Cases

PURPOSE

There remains a paucity of information regarding the treatment outcomes of dislocation after metacarpophalangeal (MCP) joint arthroplasty. The purpose of this study was to assess the outcomes of surgical and nonsurgical treatment modalities of MCP arthroplasty dislocations.

METHODS

Of 816 MCP joint arthroplasties over a 14-year period, there were 37 (4%) acute MCP joint dislocations that required intervention by a health care professional. Implants involved included 28 nonconstrained implants including pyrocarbon (n = 17) and surface replacement arthroplasty (n = 11), and 9 silicone implants. The analysis included the treatment of dislocations after primary (n = 30) and revision (n = 7) MCP joint arthroplasty. Dislocation was defined as clinical and radiographic evidence of MCP joint prosthetic acute dislocation diagnosed and treated by a fellowship trained hand surgeon.

RESULTS

Etiologies underlying the dislocations included implant fracture (n = 6), component loosening (n = 2), and soft tissue deficiency (n = 29). Of the 37 dislocations, treatments included 14 nonsurgical (closed reduction, orthosis fabrication) all of which ultimately failed. Surgically, including some of the failed prior procedures, 18 soft tissue stabilization procedures and 21 revision arthroplasties were performed, with 6 that had failed soft tissue stabilization. The soft tissue stabilization procedures had a 28% success rate in achieving a stable MCP joint. Revision arthroplasty had a 71% success rate. Subgroup analysis showed an 86% success rate for silicone revisions and a 43% success rate with nonconstrained revisions, with 80% and 36% 5-year survival free of instability, for the 2 types of implants, respectively.

CONCLUSIONS

The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Decisive Diagnosis of Seronegative Polyarthritis by 3-phase Bone Scintigraphy

Inflammatory joint disease is mainly diagnosed on grounds of clinical investigation, laboratory testing (acute phase reactants), and radiography. Radionuclide imaging has recently been added to the armamentarium of clinician. This case report points out the role of three-phase bone scan and HIG (human immunoglobulin) scan in the discovery of the inflammatory nature of polyarthralgia in a young woman with equivocal clinical and laboratory results. In the aim of diagnosing arthritis early in its course scintigraphy proved to be superior to conventional radiography. It also allows more discriminating selection of subsequent X-ray examination to limit radiation exposure.

Revision of failed shoulder hemiarthroplasty to reverse total arthroplasty: analysis of 157 revision implants

BACKGROUND

There remains a paucity of studies examining the conversion of failed hemiarthroplasty (HA) to reverse total shoulder arthroplasty (RTSA). Therefore, the purpose of this study was to examine a large series of revision HA to RTSA.

METHODS

A population of 157 patients who underwent conversion of a failed HA to a revision RTSA from 2006 through 2014 were included. The mean follow-up was 49 months (range, 24-121 months). The indications for revision surgery included instability with rotator cuff insufficiency (n = 127) and glenoid wear (n = 30); instability and glenoid wear were associated in 38 cases. Eight patients with infection underwent 2-stage reimplantation.

RESULTS

Patients experienced significant improvements in their preoperative to postoperative pain and shoulder range of motion (P < .0001), with median American Shoulder and Elbow Surgeons and Simple Shoulder Test scores of 60 and 6 points, respectively. There were 11 (7%) repeated revision surgeries, secondary to glenoid component loosening (n = 3), instability (n = 3), humeral component disassembly (n = 2), humeral stem loosening (n = 1), and infection (n = 2). Implant survivorship was 95.5% at 2 years and 93.3% at 5 years. There were 4 reoperations including axillary nerve neurolysis (n = 2), heterotopic ossification removal (n = 1), and hardware removal for rupture of the metal cerclage for an acromial fracture (n = 1). At final follow-up, there were 5 "at-risk" glenoid components.

CONCLUSION

Patients experience satisfactory pain relief and recovery of reasonable shoulder function after revision RTSA from a failed HA. There was a relatively low revision rate, with glenoid loosening and instability being the most common causes.

Glenoid bone grafting in primary reverse total shoulder arthroplasty

BACKGROUND

Severe glenoid bone loss remains a challenge in patients requiring shoulder arthroplasty and may necessitate glenoid bone grafting. The purpose of this study was to determine results, complications, and rates of failure of glenoid bone grafting in primary reverse shoulder arthroplasty.

METHODS

Forty-one shoulders that underwent primary reverse arthroplasty between 2006 and 2013 with a minimum follow-up of 2 years (mean, 2.8 years; range, 2-6 years) were reviewed. Thirty-four (83%) received corticocancellous grafts and 7 (17%) structural grafts.

RESULTS

Active range of motion and pain levels were significantly improved (P < .001), with mean American Shoulder and Elbow Surgeons score of 77, Simple Shoulder Test score of 9, and patient satisfaction of 93% at the most recent follow-up. Preoperative severe glenoid erosion and increasing body mass index were significantly associated with worse American Shoulder and Elbow Surgeons scores (P = .04). On radiographic evaluation, 7 patients (18%) had grade 1 or grade 2 glenoid lucency. Glenoid bone graft incorporation was observed in 31 patients (78%). Twelve patients (30%) suffered from grade 1 or grade 2 scapular notching. All of the patients with structural grafts showed graft incorporation and no signs of glenoid lucency.

CONCLUSION

Although glenoid lucency, glenoid graft resorption, and scapular notching were present at short-term to midterm follow-up, none of the patients needed revision surgery. Primary reverse shoulder arthroplasty with glenoid reconstruction using bone graft relieved pain and restored shoulder function and stability.

Microfluidic self-assembly of folate-targeted monomolecular siRNA-lipid nanoparticles

Non-viral delivery of nucleic acids for therapies based on RNA interference requires a rational design and optimal self-assembly strategies. Nucleic acid particles need to be small, stable and functional in terms of selective cell uptake and controlled release of encapsulated nucleic acids. Here we report on small (∼38 nm) monomolecular nucleic acid/lipid particles (mNALPs) that contain single molecules of short double-stranded oligonucleotides covered by a tight, highly curved lipid bilayer. The particles consist of DOPE, DOTAP, DOPC and DSPE-PEG(2000) and are assembled with 21 bp double-stranded DNA or small interfering RNA by solvent exchange on a hydrodynamic-focusing microfluidic chip. In comparison to vortex mixing by hand this method increases the encapsulation efficiency by 20%, and yields particles with a narrower size distribution, negligible aggregate formation and high stability in blood plasma and serum. Modification of mNALPs with folate-conjugated PEG-lipids results in specific binding and uptake by epithelial carcinoma KB cells overexpressing folate receptors. Binding is significantly reduced by competitive inhibition using free folate and is not observed with non-targeted mNALPs, revealing high specificity. The functionalized mNALPs show gene silencing in the presence of chloroquine, an endosome-destabilizing agent. Together, the robust self-assembly of small-sized mNALPs with their high stability and receptor-specific cell uptake demonstrate that the tight, PEG-grafted lipid-bilayer encapsulation may offer a promising approach towards the delivery of short double-stranded oligonucleotides.