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Purpose Although childhood traumatic experiences are recognized as important determinants for adolescent psychiatric health in general, our objective was to explore the specific influence of childhood bereavement on the stress resilience development trajectory. Methods In this national register-based cohort study, we identified 407,639 men born in Sweden between 1973 and 1983, who underwent compulsory military enlistment examinations in late adolescence, including measures of psychological stress resilience. We defined exposure as loss of a first-degree family member in childhood, and estimated relative risk ratios (RRRs) for reduced (moderate or low), compared with high, stress resilience with 95% confidence intervals (CIs) using multinomial logistic regression. Results Loss of a parent or sibling in childhood conferred a 49% increased risk of subsequent low stress resilience (RRR, 1.49, 95% CI, 1.41–1.57) and an 8% increased risk of moderate stress resilience (RRR, 1.08, 95% CI, 1.03–1.13) in late adolescence. There was also a graded increase in risk with increasing age at loss; teenagers were at higher risk for low resilience (RRR, 1.64, 95% CI, 1.52–1.77) than children aged 7–12 (RRR, 1.47, 95% CI, 1.34–1.61) and ≤ 6 years (RRR, 1.16 95% CI, 1.02–1.32). The excess risk was observed for all causes of death, including suicide and unexpected deaths as well as deaths due to other illnesses. The associations remained after exclusion of parents with a history of hospitalization for psychiatric diagnoses. Conclusions The long-term consequences of childhood bereavement may include lower stress resilience in late adolescence. [ABSTRACT FROM AUTHOR]

Age-related hearing loss is experienced by one-third of individuals aged 65 years and older and can be socially debilitating. Historically, there has been poor correlation between age-related threshold changes, loss of speech understanding, and loss of cochlear hair cells. We examined changes in ribbon synapse number at four different ages in Fisher Brown Norway rats, an extensively studied rat model of aging. In contrast to previous work in mice/Wistar rats, we found minimal ribbon synapse loss before 20 months, with significant differences in 24- and 28-month-old rats at 4 kHz. Significant outer HC loss was observed at 24 and 28 months in low- to mid-frequency regions. Age-related reductions in auditory brainstem response wave I amplitude and increases in threshold were strongly correlated with ribbon synapse loss. Wave V/I ratios increased across age for click, 2, 4, and 24 kHz. Together, we find that ribbon synapses in the Fisher Brown Norway rat cochlea show resistance to aging until ∼60% of their life span, suggesting species/strain differences may underpin decreased peripheral input into the aging central processor. [ABSTRACT FROM AUTHOR]

This study aimed to investigate social and psychological factors in childhood and adulthood associated with self-reported hypertension in adulthood. Using data from the National Child Development Study, a nationally representative sample of 17,415 babies born in Great Britain in 1958 and followed up at 11, 33, and 50 years of age. Self-reported diagnosed hypertension by 50 years was the outcome measure. In total, 5753 participants with complete data on parental social class at birth, childhood cognitive ability test scores at 11 years, educational qualifications at 33 years, personality traits, occupational levels, and self-reported hypertension (all measured at age 50 years) were included in the study. Using logistic regression analyses, results showed that sex (OR = 0.60: 0.49–0.73, p < .001), educational qualifications (OR = 0.59: 0.37–0.92, p < .05), and traits emotional stability (OR = 0.84: 0.77–0.91, p < .001) and conscientiousness (OR = 0.89: 0.82–0.98, p < .05) were all significantly associated with the occurrence of self-reported hypertension in adulthood. Both psychological factors and socio-demographic factors were significantly associated with self-reported hypertension in adulthood. [ABSTRACT FROM AUTHOR]

Purpose To determine whether a 5-mm and/or 10-mm arthroscopic lateral acromioplasty (ALA) would weaken the structural and mechanical integrity of the lateral deltoid. Methods The acromion and lateral deltoid origin were harvested from 15 pairs (n = 30) of fresh-frozen human cadaveric shoulder specimens. One side of each specimen pair (left or right) was randomly assigned to either a 5-mm (n = 7) or 10-mm (n = 8) ALA group, and the contralateral sides (n = 15) were used as matched controls. Acromion thickness and width were measured pre- and postoperatively. After ALA, specimens were inspected for damage to the lateral deltoid origin. Each specimen was secured within a dynamic testing machine, and the deltoid muscle was pulled to failure. Statistical analysis was performed to determine whether ALA reduced the lateral deltoid's failure load. Results There was no significant difference in failure load between the 5-mm ALA group (661 ± 207 N) and its matched control group (744 ± 212 N; mean difference = 83 N; 95% confidence interval [CI], −91 to 258; P = .285) nor between the 10-mm ALA group (544 ± 210 N) and its matched control group (598 ± 157 N; mean difference = 54 N; 95% CI, −141 to 250; P = .532). There was no correlation found between the amount of bone resected (measured by percent thickness and width of the acromion after ALA) and the failure load of the deltoid. Visual evaluation of the acromion after ALA revealed the lateral deltoid origin had no damage in any case. Conclusions ALA did not weaken the structural or mechanical integrity of the lateral deltoid origin. Neither a 5-mm nor a 10-mm ALA significantly reduced the deltoid's failure load. The lateral deltoid origin was not macroscopically damaged in any case. Clinical Relevance ALA can be performed without the potential risk of macroscopically damaging the lateral deltoid origin or reducing its failure load. [ABSTRACT FROM AUTHOR]

Purpose: To compare glenoid retroversion and functional outcomes between patients with traumatic onset of posterior shoulder instability (PSI) and patients with atraumatic onset of PSI.Methods: Patients with PSI who underwent arthroscopic posterior capsulolabral anchor repair, were active in sports, and had undergone surgery a minimum of 2 years earlier were included. Traumatic onset was defined as PSI that occurred after a trauma with the shoulder in adduction, flexion, and internal rotation in patients with no history of instability. Subjective evaluations were obtained with the American Shoulder and Elbow Surgeons (ASES); Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation (SANE); and Short Form 12 Physical Component Summary scores preoperatively and after a minimum 2-year follow-up postoperatively. Additional questions assessed return to sport and shoulder stability. Glenoid version was measured with a 2-dimensional glenoid vault method on magnetic resonance imaging.Results: A total of 41 shoulders in 38 patients were eligible for inclusion (3 female and 35 male patients; mean age, 27.6 years; age range, 13 to 66 years). Three patients refused participation, and 2 patients required subsequent surgery for failure. Postoperative outcomes were available for 32 of the remaining 36 shoulders (89%) with a mean follow-up of 4.1 years (range, 2.0 to 7.8 years; 20 atraumatic and 12 traumatic). The ASES score improved significantly in both groups (P < .03), whereas the SANE; Quick Disabilities of the Arm, Shoulder and Hand; and Short Form 12 Physical Component Summary scores only significantly improved for patients with traumatic PSI (P < .02). Baseline score-adjusted comparison between groups showed that the postoperative median ASES scores (atraumatic, 95.8; traumatic, 99.9) and SANE scores (atraumatic, 86.5; traumatic, 98.0) were significantly more improved in patients with traumatic PSI (P = .01 and P = .012, respectively). Atraumatic PSI was associated with significantly higher glenoid retroversion (-21.8° ± 4.2° vs -17.7° ± 5.5°, P = .032). There was no significant difference regarding return to sport (P = .375) or postoperative re-dislocations (P = .99) between the groups.Conclusions: Atraumatic onset of PSI was associated with higher degrees of glenoid retroversion and less favorable functional outcomes of arthroscopic posterior capsulolabral anchor repair than traumatic PSI.Level Of Evidence: Level III, retrospective case-control study. [ABSTRACT FROM AUTHOR]

Background Although epidemiology studies have reported the relationship, including a dose-response relationship, between dietary magnesium intake and risk of cardiovascular disease (CVD), the risk for CVD mortality is inconclusive and the evidence for a dose-response relationship has not been summarized. Objective We conducted a systematic review and meta-analysis of prospective studies to summarize the evidence regarding the association of dietary magnesium intake with risk of CVD mortality and describe their dose-response relationship. Design We identified relevant studies by searching major scientific literature databases and grey literature resources from their inception to August 2015, and reviewed references lists of retrieved articles. We included population-based studies that reported mortality risks, i.e. relative risks (RRs), odds ratios (ORs) or hazard ratios (HRs) of CVD mortality or cause-specific CVD death. Linear dose-response relationships were assessed using random-effects meta-regression. Potential nonlinear associations were evaluated using restricted cubic splines. Results Out of 3002 articles, 9 articles from 8 independent studies met the eligibility criteria. These studies comprised 449,748 individuals and 10,313 CVD deaths. Compared with the lowest dietary magnesium consumption group in the population, the risk of CVD mortality was reduced by 16% in women and 8% in men. No significant linear dose-response relationship was found between increment in dietary magnesium intake and CVD mortality across all the studies. After adjusting for age and BMI, the risk of CVD mortality was reduced by 24–25% per 100 mg/d increment in dietary magnesium intake in women of all the participants and in all the US participants. Conclusion Although the combined data confirm the role of dietary magnesium intake in reducing CVD mortality, the dose-response relationship was only found among women and in US population. [ABSTRACT FROM AUTHOR]

Background: Childhood exposures in mothers, signaled by number of older and younger siblings, have lifelong consequences for aspects of immune function. We hypothesized that these may influence young adult-onset Hodgkin's lymphoma (HL) risk in offspring.Materials and Methods: Swedish registers identified 2028 cases of young adult onset HL (diagnosed between ages 15-39 years) up to 2012 among those born since 1958; and 18,374 matched controls. Conditional logistic regression was used to assess HL risk associated with number of older and younger siblings of mothers.Results: Having a mother with more than two older siblings is associated with lower HL risk, and the association is statistically significant for mothers with three or more siblings, compared with none. The adjusted odds ratios (and 95% confidence intervals) are 1.04 (0.93-1.16); 0.95 (0.81-1.10); and 0.81 (0.66-0.98) for one, two, and three or more older siblings, respectively. There is no association between number of mothers' younger siblings and HL risk.Conclusions: Exposures during the childhood of mothers may influence young onset adult HL risk in offspring, perhaps through vertical transmission of infectious agents, or through other long-term influences on maternal immune function. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to evaluate and quantify the demographic characteristics of patients undergoing open and arthroscopic distal clavicle excision (DCE) in the United States while also describing changes in practice patterns over time. Methods Patients who underwent DCE from 2004 to 2009 were identified by Current Procedural Terminology (CPT) codes in a national database of orthopaedic insurance records. The year of procedure, age, sex, geographic region, and concomitant rotator cuff repair or subacromial decompression (SAD) were recorded for each patient. Results were reported as the incidence of procedures identified per 10,000 patients searched in the database. Results Between 2004 and 2009, 73,231 DCEs were performed; 74% were arthroscopic and 26% were open. The incidence of arthroscopic DCE increased from 37.8 in 2004 to 58.5 in 2009 (P < .001), whereas the incidence of open DCE decreased from 21.1 in 2004 to 14.1 in 2009 (P < .001). Sixty-one percent of DCEs were performed in men (P < .001). Women were more likely to undergo an arthroscopic procedure (P < .001). Arthroscopic DCE was most common in patients aged 50 to 59 years (P < .001). Open DCE was most common in patients aged 60 to 69 years (P < .001). Open rotator cuff repair and SAD were concomitantly performed in 38% and 23% of open DCEs, respectively. Arthroscopic rotator cuff repair and SAD were concomitantly performed in 33% and 95% arthroscopic DCEs, respectively. Conclusions This analysis of DCE using a private insurance database shows that arthroscopic DCEs progressively increased, whereas open DCEs concomitantly decreased between 2004 and 2009. The majority of DCEs were performed in men between the ages of 50 and 59 years. Both arthroscopic and open DCEs are frequently performed in conjunction with rotator cuff repair or SAD. Level of Evidence Level IV, cross-sectional study. [ABSTRACT FROM AUTHOR]

Objectives To investigate the risk of future diabetes mellitus type 1 (T1D) in children who suffered from infection at time of gluten introduction. Study design Population-based prospective study. Parents filled out a diary at home. We hereby obtained data on date of gluten introduction, breastfeeding duration, and infections in 9414 children born in the southeast of Sweden from October 1, 1997, through October 1, 1999 (the All Babies in Southeast Sweden cohort). The Cox proportional hazards model was used to investigate the risk of future T1D until February 1, 2012, among children with infection at time of gluten introduction. Results Forty-six children (0.5%) developed T1D and were compared with 9368 reference children from the general population. Some 10 of 46 children with later T1D had an infection at time of gluten introduction (22%) compared with 2520 reference children (27%, P = .43). Later T1D was not associated with age at end of breastfeeding, age at any infection, or age at gluten introduction. Breastfeeding at time of gluten introduction was not protective against future T1D (hazard ratio 1.2; 95% CI, 0.5-2.7). In our final model, when we adjusted for age at gluten introduction, age at infection, and breastfeeding duration, infection at time of gluten introduction did not influence the risk of future T1D (hazard ratio 0.8; 95% CI, 0.3-1.6). Conclusion Infection at time of gluten introduction is not a major risk factor for future T1D in nonselected children. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate current trends in arthroscopic and open shoulder stabilization in the United States. Methods: Patients who underwent arthroscopic shoulder stabilization (Current Procedural Terminology code 29806) or open stabilization (Current Procedural Terminology codes 23455 [open Bankart repair], 23460 [anterior bone block], and 23462 [coracoid transfer]) were identified using a national database of insurance billing records during the years 2004 through 2009. Demographic data were recorded for each patient. Results: From 2004 through 2009, there were 23,096 cases of shoulder stabilization, of which 84% (19,337) were arthroscopic and 16% (3,759) were open procedures. There were 17,241 male patients (75%) and 5,855 female patients (25%). The incidence of arthroscopic shoulder stabilization nearly doubled during the period studied, increasing from 11.8 cases for every 10,000 patients in 2004 to 22.9 cases for every 10,000 patients in 2009. The percentage of arthroscopic stabilizations increased from 71% of stabilization procedures in 2004 to 89% in 2009, whereas the percentage of open stabilizations decreased from 29% in 2004 to 11% in 2009 (P < .0001). Among open procedures, a significant decline in the incidence of open Bankart repair was observed, from 4.5 cases for every 10,000 patients in 2004 to 2.2 cases for every 10,000 patients in 2009 (P < .0001), whereas the performance of open coracoid transfer increased from 0.17 cases per 10,000 patients in 2004 to 0.40 cases per 10,000 patients in 2009 (P < .0001). For both arthroscopic and open stabilization, the group aged 10 to 19 years had the highest rate of surgery (29%), followed by the group aged 20 to 29 years (25%). Conclusions: The current data indicate that arthroscopic stabilization is performed in nearly 90% of shoulder stabilization surgeries and nearly doubled in incidence from 2004 to 2009 in the United States. Additional research is needed to further investigate the long-term clinical outcomes of this practice pattern. Level of Evidence: Level IV, retrospective database review. [Copyright &y& Elsevier]

Abstract: Background context: Lumbar foraminal stenosis is a common clinical problem and a significant cause of lower extremity radiculopathy. Minimal in vivo data exists quantifying changes in foraminal area (FA) as the spine moves from flexion to extension in the lumbar spine or on the relationship between FA and lumbar segmental angular motion, translational motion (TM), or disc bulge migration. Purpose: To use kinetic magnetic resonance imaging (kMRI) to evaluate changes in dimensions of lumbar neural foramina during weight bearing in neutral, flexion, and extension positions. To evaluate the relationship between foraminal stenosis and lumbar segmental angular motion, TM, and disc bulge migration. Study design: A retrospective radiographic study. Patient sample: Forty-five patients with a mean age of 44 years undergoing kMRI for symptoms of low back pain or radiculopathy. Outcome measures: Magnetic resonance imaging measurements of FA, angular motion, TM, and disc bulge migration. Methods: Kinetic magnetic resonance imaging of the lumbar spine was reviewed in 45 patients with low back pain or radiculopathy, and parasagittal images were evaluated for changes in neural foraminal dimensions in various degrees of motion with weight bearing. The changes in foraminal dimension were correlated to the amount of segmental angular motion, TM, and disc bulge migration at each level. Neural foramina were also assessed qualitatively by Wildermuth criteria. Only those foramina that were clearly visualized with well-defined anatomic boundaries in all three positions were taken into consideration. Patients with previous surgery, tumor, and scoliosis were excluded from the study. Results: There was a significant decrease in the FA from flexion to neutral (p<.05) at all levels except L5–S1 and from neutral to extension at all levels (p<.05). The average percent decrease in FA was 30.0% with the greatest decrease from flexion to extension occurring at L2–L3 (167–107 mm2) and the smallest change occurring at L5–S1 (135–106 mm2) (p<.05). The magnitude of change in FA increased as angular motion at a segment increased. The mean change in FA was 32.3 mm2 when angular motion was less than 5° and was 75.16 mm2 when angular motion exceeded 15°. The extent of disc bulging posteriorly in the neural foramen was also correlated with the reduction in the FA from flexion to extension, but TM had no effect. Conclusions: Foraminal area decreased significantly in extension compared with flexion and neutral on MRI. Lumbar disc bulge migration and angular motion at each level contributed independently to the decrease in FA in extension, whereas TM had no effect on FA. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to evaluate the trends and report on the demographics of patients undergoing hip arthroscopy in the United States. Methods: Patients who underwent hip arthroscopy from 2004 to 2009 were identified by searching Current Procedural Terminology codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopaedic insurance records. The year of procedure, age, gender, and region of the United States were recorded for each patient. Results were reported for each variable as the incidence of procedures identified per 10,000 patients searched in the database. Results: In total, 3,447 cases of hip arthroscopy were identified between 2004 and 2009. The incidence of procedures increased significantly over the study period, from 1.20 cases per 10,000 patients in 2004 to 5.58 in 2009 (P < .001). Hip arthroscopy was performed most commonly in patients aged 20 to 39 years (P < .05), with an incidence of 4.45 cases in each age group. In contrast to other common arthroscopic procedures searched, no gender differences were observed, with a male-to-female ratio of 0.89 (P = .18). The greatest incidence of hip arthroscopy was observed in the Western region with an incidence of 5.24 cases identified compared with 2.94, 2.70, and 2.56 in the Northeast, Midwest, and South, respectively (P < .001). Conclusions: A 365% increase in the rate of hip arthroscopy was observed in the examined cohort of patients between 2004 and 2009. The majority of cases were performed in patients aged 20 to 39 years, with no difference in gender. The Western region of the United States was found to have a higher incidence of hip arthroscopy compared with the Midwest, South, and Northeast. Level of Evidence: Level IV, cross-sectional study. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to identify current trends in open and arthroscopic surgical treatment of rotator cuff tears across sex, age, and region in the United States. Methods: Using the PearlDiver Patient Record Database (PearlDiver, Fort Wayne, IN), a publicly available national database of insurance records, patients who underwent rotator cuff repair from 2004 through 2009 were identified. The number of open (CPT codes 23410, 23412, 23420) and arthroscopic (CPT code 29827) rotator cuff repairs were quantified in isolation and in combination with acromioplasty (CPT codes 23415, 29826). The type of procedure, date, sex, and region of the country was identified for each patient. Trend tests (χ2 and Cochran-Armitage) were used to determine statistical significance. Results: There were 151,866 rotator cuff repair procedures identified in the database from 2004 through 2009, which represented an incidence of 13.6 for every 1,000 patients assigned an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or Current Procedural Terminology (CPT) code. Male patients accounted for 60% of the repairs and female patients for 40%. There were 98,174 arthroscopic cuff repairs (65%) and 53,692 open repairs (35%). The annual percentage of arthroscopic cases increased from 48.8% in 2004 to 74.3% in 2009, whereas the percentage of open cases decreased from 51.2% in 2004 to 25.7% in 2009 (P < .0001). Acromioplasty was also performed in 47.3% of cases, and the rate showed only a slight increase (from 46.6% to 47.8%) between 2004 and 2009 (P < .01). All regions of the United States showed similar surgical trends and trends for sex and age distributions. Conclusions: Our analysis shows that the majority of rotator cuff repairs in the United States are now performed arthroscopically (>74%) and there has been a recent steady decline in performance of open rotator cuff repair. Concomitant acromioplasty is performed approximately half the time, and this trend is increasing slightly. These findings were consistent across age, sex, and region in the United States. Level of Evidence: IV, cross-sectional study. [Copyright &y& Elsevier]

The article discusses the failed rotator cuff repair and common mechanisms of failure, patient evaluation and the treatment algorithm in the setting of failed rotator cuff surgery. The rotator cuff surgery fails mainly because of biologic factors, technical errors and traumatic failure. When managing a patient with symptomatic re-tear, revision rotator cuff repair can be successful but patient selection is critical and managing patient expectations is vital.

Abstract: Introduction: Chronic pain and the pattern of opioid use after skeletal fractures has been a neglected topic in pain medicine. Pelvic and in particular acetabular fractures represent some of the most troublesome injuries for patients with a high incidence of chronic pain after fracture. We examined the long-term opioid analgesic use among patients with acetabular fractures and analysed if potential risk factors would predict a prolonged opioid therapy. Patients and methods: Data were extracted from medical databases such as the Swedish National Hospital Discharge Register and the National Pharmacy Register. The study period was 2005–2008. Kaplan–Meier analysis constructed the cumulative opioid consumption with 95% confidence intervals (CI). Cox multiple-regression model was used to study risk factors for a prolonged opioid prescription after admission for fracture. An age- and sex-matched control group was included for comparisons. Results: We identified 1017 patients with isolated acetabular fractures. The proportion of dispensing opioids for these patients was 39%, which was 7 times higher than in the age- and sex-matched non-fracture controls (n =5077). The median follow-up time was 14 (interquartile range [IQR] 5–24) months. Most patients with opioid use after fracture were male (60%) and the median age was 76 (IQR 61–85) years. The leading mechanism of injury was fall on the same level (52%). At 6 and 12 months after fracture, 41% (95% CI 36–47) and 33% (28–39) were still treated with opioids. The multiple Cox regression-analysis (adjusted for age, sex, type of treatment, and mechanism of injury) revealed that younger patients (age <70 compared with ≥70 years) were more likely to end using opioids (Hazard ratio 2.0 [95% CI 1.5–2.7]). The median daily morphine equivalent dose was 22 (IQR 14–42)mg within the first month after fracture. Discussion: During follow-up, the frequency of patients on moderate and high doses was falling off. There was no evidence of analgesic tolerance in the majority of the patients who were treated for at least 6 months. To set our findings into perspective, studies of patterns of chronic opioid use among patients with other types of fractures would be valuable. [Copyright &y& Elsevier]

Abstract: Introduction: Femoral shaft fractures are commonly thought to be primarily associated with high-energy trauma in young persons. Only limited attention has been given to low-energy violence as a cause of these fractures among the elderly. National epidemiological data on characteristics of patients with femoral shaft fractures are lacking, so the purpose of this study was to analyse the incidence, admissions, causes of fracture and operations for these fractures on a nationwide basis in Sweden during 1998–2004. Patients and methods: Data on all femoral shaft fractures were extracted from the Swedish National Hospital Discharge Registry. Sex- and age-specific fracture incidence, hospital admissions, mechanisms of injury and surgical procedures were analysed using descriptive analysis, linear-regression analysis and other methods as appropriate. Results: Over a period of 7 years, 6409 patients with femoral shaft fractures were identified, corresponding to an annual incidence of 10 per 100,000 person-years. Men had a younger median age (27 years, IQR 12–68) than women (79 years, IQR 62–86) (p <0.001). Females (54%) generated more admissions than males (46%). The incident rate ratio between men and women was 0.9 (p <0.001). Most hospital admissions were generated among females by the 80–89 years age-group and among males <10 years of age. 2% of the fractures were open fractures. The total number of hospital admissions was stable during 1998–2004. The two major mechanisms of injury were falls on the same level (50%) and transport accidents (17%). A significant number of fractures occurred among elderly patients after low-energy trauma. Osteosynthesis with femoral nail (54%) was the preferred operation, followed by osteosynthesis with plate and screws (16%), skeletal traction (14%) and external fixation (6%). Discussion: This nationwide study on femoral shaft fractures provides an update on incidence, admissions, external causes and surgical procedures. This information assists health-care providers in planning hospital beds, surgical interventions and risk preventions. Moreover, these data can be used for power calculations for further clinical studies. [Copyright &y& Elsevier]

Background & Aims: The importance of genetic factors for the development of primary sclerosing cholangitis (PSC) is incompletely understood. This study assessed the risk of PSC and inflammatory bowel disease (IBD) among first-degree relatives of patients with PSC, compared with the first-degree relatives of a cohort without PSC. Methods: Subjects from the national Swedish cohort of PSC patients (n = 678) were matched for date of birth, sex, and region to up to 10 subjects without a diagnosis of PSC (n = 6347). Linkage through general population registers identified first-degree relatives of subjects in both the PSC and comparison cohorts (n = 34,092). Diagnoses among first-degree relatives were identified by using the Inpatient Register. Results: The risk of cholangitis was statistically significantly increased in offspring, siblings, and parents of the PSC patient cohort, compared with relatives of the comparison cohort, with the hazard ratios and 95% confidence intervals, 11.5 (1.6–84.4), 11.1 (3.3–37.8), and 2.3 (0.9–6.1), respectively. The hazard ratios for ulcerative colitis (UC) among first-degree relatives of all PSC patients was 3.3 (2.3–4.9) and for Crohn''s disease 1.4 (0.8–2.5). The risk of UC for relatives of PSC patients without IBD was also increased, 7.4 (2.9–18.9). Conclusions: First-degree relatives of patients with PSC run an increased risk of PSC, indicating the importance of genetic factors in the etiology of PSC. First-degree relatives of PSC patients without IBD are also at an increased risk of UC, which might indicate shared genetic susceptibility factors for PSC and UC. [Copyright &y& Elsevier]

Purpose: The ideal surgical management of isolated and combined posterior cruciate ligament (PCL) injuries is controversial. One active debate concerns the advantages of an open tibial inlay technique versus an arthroscopic transtibial tunnel technique. Therefore, the goal of this study is to biomechanically compare arthroscopic and open double-bundle PCL tibial inlay procedure with and without posterolateral corner (PLC) deficiency. Methods: Ten matched pairs of cadaveric knees were randomly assigned to undergo PCL sectioning and reconstruction using either the open inlay or arthroscopic inlay approach. Clinical testing consisted of posterior drawer, TELOS stress testing, and dial testing at both 30° and 90°. The knee conditions tested were intact, after PCL sectioning, after PLC release, and following PCL reconstruction, with and without the PLC repair. Both 1-way repeated measures and 2-way mixed design analyses of variance were used to determine differences between the knee conditions, with significance set at P < .05. Results: After PCL and PLC reconstruction, 10 of 10 open specimens and 9 of 10 arthroscopic specimens were a grade 0 posterior drawer. The remaining arthroscopic specimen was grade I. The average radiographic posterior displacement for arthroscopic and open reconstructions (PCL+/PLC+) was 3.9 and 2.7 mm, respectively, with no significant difference. However, if the PLC was deficient (PCL+/PLC-), the translation for arthroscopic and open specimens increased to 8.5 and 6.5 mm, respectively, and was statistically different from the intact state but not from each other. At 30° of knee flexion, both the open and arthroscopic specimen averaged 8.4° of external rotation. At 90° of knee flexion, the external rotation measurements increased to 9.6° and 9.3° in the arthroscopic and open groups, respectively. Additionally, there was no significant difference in external rotation between intact and reconstructed knees with either group. Conclusions: The arthroscopic method of double-bundle inlay PCL reconstruction provides comparable stability to the open inlay using clinically relevant measurement tools both in the PLC intact or deficient state. Clinical Relevance: This novel arthroscopic double-bundle PCL inlay reconstruction provides comparable stability to the open approach with a potential for lower operative morbidity. [Copyright &y& Elsevier]

Background & Aims: The aim of this study was to examine the risk of pancreatitis in patients with celiac disease (CD) from a general population cohort. Methods: By using Swedish national registers, we identified 14,239 individuals with a diagnosis of CD (1964–2003) and 69,381 reference individuals matched for age, sex, calendar year, and county of residence at the time of diagnosis. Cox regression estimated the hazard ratios (HRs) for a subsequent diagnosis of pancreatitis. We restricted analyses to individuals with more than 1 year of follow-up and no diagnosis of pancreatitis before or within 1 year after study entry. Conditional logistic regression estimated the association of pancreatitis with subsequent CD. Results: CD was associated with an increased risk of subsequent pancreatitis of any type (HR, 3.3; 95% confidence interval [CI], 2.6–4.4; P < .001; on the basis of 95 positive events in individuals with CD vs 163 positive events in reference individuals) and chronic pancreatitis (HR, 19.8; 95% CI, 9.2–42.8; P < .001; on the basis of 37 and 13 positive events, respectively). Adjustment for socioeconomic index, diabetes mellitus, alcohol-related disorders, or gallstone disease had no notable effect on the risk estimates. The risk increase for pancreatitis was only found among individuals with CD diagnosed in adulthood. Pancreatitis of any type (odds ratio, 3.2; 95% CI, 2.5–4.3; P < .001) and chronic pancreatitis (odds ratio, 7.3; 95% CI, 4.0–13.5; P < .001) were associated with subsequent CD. Conclusions: This study suggests that individuals with CD are at increased risk of pancreatitis. [Copyright &y& Elsevier]

The article discusses the components for providing medical care for athletes regardless of team structures and level of competition they will participate in. Good personnel and an organized plan of care are said to be the pillars of effective care. Structures and standards are presented for medical care setting for high school, college, university clinical rehabilitation setting and professional sports, including Olympic venue athlete medical care.

Abstract: We have previously shown that both chloroquine and paracetamol (acetaminophen) have antipyretic activity during treatment of acute uncomplicated Plasmodium falciparum malaria in children 1–4 years old. Here, we studied if this effect was accompanied by changes in plasma cytokine levels. The 104 children were treated with either chloroquine or sulfadoxine/pyrimethamine (SP) alone, SP+chloroquine or SP+paracetamol for 4 days. Cytokine levels were determined days 0, 2 and 3, body temperature every sixth hour until 72h and parasitemia once daily for 4 days. At admission, body temperature correlated with levels of IL-10, IFN-γ and IL-6, and parasitemia correlated with IL-10 and IL-6. Except for TNF-α and IL-1β, where no significant effect was found, all cytokine levels (IL-10, IFN-γ, IL-6, IL-12, IL-13, IL-18 and IL-4) decreased up to day 2 (p <0.05). IL-6 levels continued to fall from days 2 to 3 (p <0.05), whereas increased levels were found for several cytokines (IL-12, IL-13, IL-18 and IL-1β) (p <0.05). The antipyretic effects of chloroquine and paracetamol could not be related to any specific changes in the evaluated cytokine production or in Th1/Th2 or inflammatory/anti-inflammatory cytokine ratios. Alternative mechanisms for antipyretic effects and associations between fever and cytokine levels during uncomplicated P. falciparum malaria are therefore discussed. [Copyright &y& Elsevier]

Background & Aims: Earlier studies indicate a protective effect of smoking against celiac disease (CD), but have been based on small numbers and retrospective collection of smoking data. Methods: We linked the Swedish national inpatient register and the medical birth register to study the association between smoking status during pregnancy and CD (diagnosed or undiagnosed at delivery) in women who were pregnant from 1983 to 2001. We adjusted for civil status, age, and year when smoking data were collected. We identified 873 cases of CD (636 diagnosed and 237 undiagnosed). Results: Of 249,967 smokers, 67 (.27%) had undiagnosed CD (vs 170 of 794,912 nonsmokers [.21%]) (odds ratio [OR], 1.25; 95% confidence interval [CI], .94–1.66; P = .118). Point estimates remained unchanged when adjusting for civil status, age, and year of smoking data collection (adjusted OR [AOR], 1.25; 95% CI AOR, .94–1.67). There were no associations between smoking and future (undiagnosed at delivery) CD when we adjusted for potential confounders and stratified for comorbidity or time to diagnosis (<5 vs ≥5 y after infant birth). In women with diagnosed CD, smoking was more common than in women who never had a diagnosis of CD (AOR, 1.36; 95% CI AOR, 1.12–1.64; P = .002). Conclusions: Smoking seems to have little effect on the risk for future CD in pregnant women. [Copyright &y& Elsevier]

Background: There is indirect evidence that an increased infectious burden is associated with a decreased prevalence of IgE-mediated allergy during childhood. Objective: To determine whether there is a relation between the serostatus of 13 different viruses and parentally reported infections and IgE sensitization in 2-year-old children. To investigate whether there is an interaction between cytomegalovirus (CMV) and Epstein-Barr virus (EBV) in relation to IgE sensitization. Methods: A total of 246 infants were followed prospectively to 2 years of age with clinical examinations, skin prick test, and specific IgE analyses and through analysis of seropositivity against adenovirus, influenza, parainfluenza, respiratory syncytial virus, CMV, EBV, herpes simplex virus, human herpesvirus 6, and varicella-zoster virus. Results: There was some evidence that IgE sensitization (24%) tended to be more common among children who were seropositive against few compared with children who were seropositive against many viruses, but this was not statistically significant, and there was no consistent trend across the groups. IgE sensitization was statistically significantly less prevalent at 2 years of age among infants who were seropositive against EBV but not other viruses (adjusted odds ratio, 0.34; 95% CI, 0.14-0.86). The interaction of seropositivity against both CMV and EBV antibodies indicated a further reduction in the risk for IgE sensitization (adjusted odds ratio for interaction, 0.10; 95% CI, 0.01-0.92), indicating effect modification associated with seropositivity against CMV. Conclusion: Our results indicate that acquisition of EBV infection during the first 2 years of life is associated with a reduced risk of IgE sensitization, and this effect is enhanced by CMV coinfection. [Copyright &y& Elsevier]

Background & Aims: Studies of maternal celiac disease (CD) and fetal outcome are inconsistent, and low statistical power is likely to have contributed to this inconsistency. We investigated the risk of adverse outcomes in women with CD diagnosed prior to pregnancy and in women who did not receive a diagnosis of CD until after the delivery. Methods: A national register-based cohort study restricted to women aged 15–44 years with singleton live born infants was used. We identified 2078 offspring to women who had received a diagnosis of CD (1964–2001): 1149 offspring to women diagnosed prior to birth and 929 offspring to women diagnosed after infant birth. Main outcome measures were: intrauterine growth retardation, low birth weight (<2500 g), very low birth weight (<1500 g), preterm birth (<37 gestational weeks), very preterm birth (<30 gestational weeks), and caesarean section. Results: Undiagnosed CD was associated with an increased risk of intrauterine growth retardation (OR = 1.62; 95% CI: 1.22–2.15), low birth weight (OR = 2.13; 95% CI: 1.66–2.75), very low birth weight (OR = 2.45; 95% CI: 1.35–4.43), preterm birth (OR = 1.71; 95% CI: 1.35–2.17), and caesarean section (OR = 1.82; 95% CI: 1.27–2.60). In contrast, a diagnosis of CD made before the birth was not associated with these adverse fetal outcomes. Conclusions: Undiagnosed maternal CD is a risk factor for unfavorable fetal outcomes, but the risks are reduced when CD has been diagnosed. CD diagnosed prior to pregnancy does not constitute a great a risk as undiagnosed CD. [Copyright &y& Elsevier]

Immunological characteristics were assessed for prospective risk of clinical malaria in a longitudinally followed population in a holoendemic area of Tanzania. Baseline characteristics including crude Plasmodium falciparum extract-specific IgE and IgG; total IgE; and parasitological indices, e.g. number of P. falciparum clones, were investigated among 700 asymptomatic individuals. Cox regression analysis estimated the risk of succumbing to a new clinical episode during a 40 weeks follow up. High anti-P. falciparum IgE levels were associated with reduced risk of acute malaria in all age groups independently of total IgE levels. Statistically significant reduced odds ratio of 0.26 (95% CI, 0.09–0.72, P=0.010) and 0.44 (95% CI, 0.19–0.99, P=0.047) for the two highest fifths, respectively was observed after adjustment for age, sex, total IgE, numbers of parasite clones per infection and HIV-1 seropositivity. In contrast, high levels of malaria specific IgG or total IgE were not associated with reduced risk to succumb to a new clinical episode. A protective effect of asymptomatic multiclonal P. falciparum infections was also confirmed. For the first time, anti-malarial IgE levels in asymptomatic individuals in endemic area are found to be associated with reduced risk for subsequent malaria disease. Specific IgE antibodies may play role in maintaining anti-malarial immunity, or indicate other aspects of immune function relevant for protection against malaria. [Copyright &y& Elsevier]

• Interferon-beta exposure in pregnancy did not increase adverse pregnancy outcomes. • The result remained after stratification by maternal characteristics. • The result also remained, when stratifying by newborn characteristics. • Interferon-beta exposure in pregnancy does not appear to be harmful for the newborn. Previous studies reported no increase in the prevalence of adverse pregnancy outcomes after exposure to interferon-beta (IFN-beta). However, no study has investigated if the prevalence of these outcomes after IFN-beta exposure is modified by maternal and newborn characteristics. Our objective was to describe the stratified prevalence of adverse pregnancy outcomes among women with multiple sclerosis (MS) exposed only to IFN-beta or unexposed to any MS disease modifying drugs (MSDMDs). This population-based cohort study using Finnish (1996-2014) and Swedish (2005-2014) register data included pregnancies of women with MS exposed only to IFN-beta 6 months before or during pregnancy (n=718) or unexposed to MSDMDs (n=1397). The outcome prevalences were described stratified by maternal and newborn characteristics, with 95% confidence intervals (CIs). Confounder-adjusted analyses were performed if the prevalence results indicated modified effect of IFN-beta in specific strata. The stratified analysis indicated that the prevalence of serious (anomaly or stillbirth) and other adverse pregnancy outcomes was similar among the exposed and unexposed, with no statistically significant difference. Among women treated for MS >5 years, serious adverse pregnancy outcomes occurred in 4.3% (95%CI: 1.9-8.3%) of pregnancies exposed only to IFN-beta 6 months before or during pregnancy and in 2.7% (95%CI: 1.2-5.0%) of unexposed pregnancies. The confounder adjusted analyses did not support the hypothesis that MS treatment duration before pregnancy would modify the risk of adverse pregnancy outcomes after exposure to IFN-beta 6 months before or during pregnancy. The prevalence of adverse pregnancy outcomes was not increased after IFN-beta exposure, when pregnancies of women with MS were stratified by maternal and newborn characteristics. The stratified results were similar to the unstratified results in the same population. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether a 5-mm and/or 10-mm arthroscopic lateral acromioplasty (ALA) would weaken the structural and mechanical integrity of the lateral deltoid.Methods: The acromion and lateral deltoid origin were harvested from 15 pairs (n = 30) of fresh-frozen human cadaveric shoulder specimens. One side of each specimen pair (left or right) was randomly assigned to either a 5-mm (n = 7) or 10-mm (n = 8) ALA group, and the contralateral sides (n = 15) were used as matched controls. Acromion thickness and width were measured pre- and postoperatively. After ALA, specimens were inspected for damage to the lateral deltoid origin. Each specimen was secured within a dynamic testing machine, and the deltoid muscle was pulled to failure. Statistical analysis was performed to determine whether ALA reduced the lateral deltoid's failure load.Results: There was no significant difference in failure load between the 5-mm ALA group (661 ± 207 N) and its matched control group (744 ± 212 N; mean difference = 83 N; 95% confidence interval [CI], -91 to 258; P = .285) nor between the 10-mm ALA group (544 ± 210 N) and its matched control group (598 ± 157 N; mean difference = 54 N; 95% CI, -141 to 250; P = .532). There was no correlation found between the amount of bone resected (measured by percent thickness and width of the acromion after ALA) and the failure load of the deltoid. Visual evaluation of the acromion after ALA revealed the lateral deltoid origin had no damage in any case.Conclusions: ALA did not weaken the structural or mechanical integrity of the lateral deltoid origin. Neither a 5-mm nor a 10-mm ALA significantly reduced the deltoid's failure load. The lateral deltoid origin was not macroscopically damaged in any case.Clinical Relevance: ALA can be performed without the potential risk of macroscopically damaging the lateral deltoid origin or reducing its failure load. [ABSTRACT FROM AUTHOR]

Background & Aims: Studies on pregnancy characteristics and mode of delivery and risk of later celiac disease in offspring are inconsistent. In recent decades rates of cesarean delivery and preterm birth survival have increased while at the same time the prevalence of celiac disease has doubled. Methods: In this population-based case-control study we examined the risk of celiac disease in individuals exposed to cesarean delivery and adverse fetal events (ie, low Apgar score, small for gestational age, low birth weight, preterm birth, and neonatal infections). Prospectively recorded pregnancy data were obtained from the Swedish Medical Birth Register between 1973 and 2008. Study participants consisted of 11,749 offspring with biopsy-verified celiac disease identified through histopathology reports from Sweden''s 28 pathology departments, and 53,887 age- and sex-matched controls from the general population. Results: We found a positive association between elective cesarean delivery and later celiac disease (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.04–1.26), but no increased risk of celiac disease after emergency (adjusted OR, 1.02; 95% CI, 0.92–1.13) or any cesarean delivery (adjusted OR, 1.06; 95% CI, 0.99–1.13). Infants born small for gestational age were at a 21% increased risk of celiac disease (95% CI, 1.09–1.35), whereas other pregnancy exposures did not increase the risk of future celiac disease. Conclusions: The positive association with elective, but not emergency, cesarean delivery is consistent with the hypothesis that the bacterial flora of the newborn plays a role in the development of celiac disease. [Copyright &y& Elsevier]

Background & Aims: Celiac disease (CD) is an important cause of hypertransaminasemia. CD might also be associated with severe forms of liver disease. We investigated the risk of liver disease in 13,818 patients with CD (1964–2003) and 66,584 age- and sex-matched reference individuals from a general population cohort. Methods:: We used Cox regression to estimate hazard ratios (HRs) for later liver disease and conditional logistic regression to estimate the risk of CD in individuals with liver disease before study entry. Results:: CD was associated with an increased risk of acute hepatitis (HR, 5.21; 95% confidence interval [CI], 1.88–14.40; P = .001), chronic hepatitis (HR, 5.84; 95% CI, 2.89–11.79; P < .001), primary sclerosing cholangitis (HR, 4.46; 95% CI, 2.50–7.98; P < .001), fatty liver (HR, 6.06; 95% CI, 1.35–27.16; P = .018), liver failure (HR, 3.30; 95% CI, 2.22–4.88; P < .001), liver cirrhosis or liver fibrosis (HR, 2.23; 95% CI, 1.34–3.72; P < .001), and primary biliary cirrhosis (HR, 10.16; 95% CI, 2.61–39.49; P < .001). There was no increased risk of liver transplantation (HR, 1.07; 95% CI, 0.12–9.62; P = .954). Adjustment for socioeconomic index or diabetes mellitus had no notable effect on the risk estimates. Prior liver disease was associated with a statistically significant 4-fold to 6-fold increased risk of later CD. Conclusion:: This study suggests that individuals with CD are at increased risk of both prior and subsequent liver disease. [Copyright &y& Elsevier]

Background & Aims: Primary sclerosing cholangitis (PSC) is associated with increased mortality. Cardiovascular disease is a leading cause of death in the Western world. We examined the risk of cardiovascular disease and diabetes (type 1 and type 2) in patients with PSC and their first-degree relatives. Methods: This prospective multicentre cohort study included 678 individuals with PSC diagnosed between 1970 and 2004, and 6347 non-PSC reference individuals matched for age, and sex. Through linkage of the Swedish Multigeneration Register we identified 3139 first-degree relatives to PSC patients and 30,953 first-degree relatives to the matched comparison cohort. We retrieved data on cardiovascular disease and type 1 and type 2 diabetes (T1D and T2D) from the National Patient Register, and then examined the association with PSC or having a family history of PSC using Poisson regression. Results: During 125,127 person-years of follow-up, 203 individuals with PSC had a diagnosis of cardiovascular disease. This corresponded to a 3.34-fold increased relative risk (RR) of cardiovascular disease in individuals with PSC (95% CI=2.86–3.91). The highest risk estimates were seen for diseases of the arteries, veins, and lymphatic vessels while the RR was neutral for ischemic heart disease (0.90) or only slightly elevated for cerebrovascular disease (1.74). Meanwhile, PSC first-degree relatives were at no increased risk of cardiovascular disease (RR=0.87; 95% CI=0.80–0.95). Individuals with PSC (RR=7.95; 95% CI=4.82–13.12), and to some extent also their first-degree relatives (RR=1.73; 95% CI=1.19–2.52) were at increased risk of T1D. Also for T2D were the RR is higher in individuals with PSC (RR=2.54; 95% CI=1.56–4.13) than in PSC first-degree relatives (RR=0.81; 95% CI=0.65–1.02). Conclusions: PSC was associated with T1D, T2D, and non-ischemic cardiovascular disease. In contrast, first-degree relatives to PSC patients were only at a moderately increased risk of T1D, and at no increased risk of either cardiovascular disease or T2D. [Copyright &y& Elsevier]