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Up to 20% of patients are dissatisfied following total knee arthroplasty (TKA), most often due to pain and/or stiffness. The differential diagnosis includes immune reaction to the prosthesis. However, there is no consensus on diagnostic criteria for immune failure, an allergic reaction, to a TKA. Histologic evaluation could provide evidence as to whether an allergic reaction caused TKA failure. A recent study showed an increase in CD4+ lymphocytes compared to CD8+ lymphocytes in patients lymphocyte transformation testing (LTT) + for Ni. This finding is consistent with Ni sensitization, but can lymphocyte subsets be used to diagnose immune failure on a case-by-case basis?Periprosthetic tissues from 18 revision cases of well-fixed, aseptic, but painful and/or stiff primary TKAs were analyzed. Six patients LTT- for Ni were matched as a cohort for age, sex, and body mass index (BMI), to 12 patients LTT + for Ni. Periprosthetic tissue biopsies underwent immunohistochemical IHC staining for CD4+ and CD8+ lymphocyte subsets and were compared by LTT status. The immunohistochemicalIHC results were also compared with periprosthetic histology.There was no relationship between LTT status and mean CD4+ cells/hpf or CD4+:CD8+ lymphocyte ratio. No relationship was found between LTT stimulation index (continuous or categorical) and CD4+:CD8+ ratio or aseptic lymphocyte-dominant vasculitis-associated lesion ALVAL score.Lymphocytes in periprosthetic tissue are highly variable in number, subtype ratio, and location, and have no relationship to LTT result or ALVAL score on a case-by-case basis. Based on these results, lymphocyte subsets cannot diagnose immune failure. Further work is needed to determine criteria for the diagnosis of immune failure of a TKA.

OBJECTIVE: Standing electric scooters are a relatively new mode of transportation that are becoming increasingly popular in large metropolitan areas. The purpose of this study was to characterize injury patterns and identify risk factors for craniomaxillofacial injuries in standing electric scooter accidents. METHODS: This retrospective cohort study utilized a Clinical Data Warehouse (CDW) search engine to identify patients who sustained standing electric scooter accidents from 2017-2019 using the International Classification of Diseases 10(th) revision (ICD-10) codes. Predictors including patient demographics, presence of intoxication, helmet use, mechanism of injury, and other non-craniomaxillofacial injuries sustained at the time of standing electric scooter injury were identified. Patients were grouped according to the presence or absence of craniomaxillofacial injuries so that risk factors could be identified for craniomaxillofacial injuries in standing electric scooter accidents. Logistic regression analysis was performed to identify potential risk factors and association for craniomaxillofacial injuries. RESULTS: The sample was composed of 165 patients with a mean age of 30.3 and 73.9% were male. 38 (23.0%) sustained craniomaxillofacial trauma. They were ten times more likely to have been intoxicated than those who did not have craniomaxillofacial injuries (4.7 vs. 52.6%). Concomitant injuries of the extremities and the craniomaxillofacial region were rare indicating that in many cases the arms and legs were not outstretched to “break the fall”. The high numbers of mandibular fractures to the condylar, subcondylar, and symphyseal regions (23.8, 33.3, and 28.6%, respectively), Le Fort fractures (18.4%), and frontal sinus fractures (15.8%) indicate that falls in the anterior-posterior direction occur with the main point of impact occurring at the the chin, midface, and forehead. CONCLUSION: Intoxication may inhibit or depress protective reflexes that leave the face and head vulnerable during standing electric scooter accidents.

The opioid crisis has illuminated the risks of opioid use for pain management, with renewed interest in reducing opioid consumption after common orthopedic procedures. Anti-inflammatory medication is an important component of multimodal pain management for patients undergoing orthopedic surgery. The purpose of this study was to evaluate the effect of celecoxib on pain control and opioid use after shoulder surgery.Patients scheduled for either total shoulder replacement (group 1) or rotator cuff repair (group 2) were candidates for the study. The exclusion criteria included allergy to celecoxib, coagulopathy, use of anticoagulants, baseline use of long-acting opioids, and a history of medical conditions such as myocardial infarction or stroke. Consenting patients were randomized by type of procedure using block randomization to receive either placebo or celecoxib 1 hour prior to the procedure and for 3 weeks postoperatively. The primary outcome measure assessed was opioid utilization as measured by morphine-equivalent dose (MED). Secondary outcome measures included pain scores at 3 and 6 weeks postoperatively. Data were analyzed using multiple linear regression.Of 1081 patients scheduled for either total shoulder replacement or rotator cuff repair from February 2014 to February 2018, 78 were enrolled for arthroplasty (group 1, with 39 receiving celecoxib and 39 receiving placebo) and 79 were enrolled for rotator cuff repair (group 2, with 40 receiving celecoxib and 39 receiving placebo). Compared with the placebo arm, patients prescribed celecoxib took fewer MEDs by -168 (95% confidence interval [CI], -272 to -64; P.01) at 3 weeks in the total population and by -197.7 (95% CI, -358 to -38; P = .02) in the arthroplasty group. Similarly, at 6 weeks, total MEDs used was -199 (95% CI, -356 to -42; P.01) in the total population and -270 (95% CI, -524 to -16; P = .04) in the arthroplasty group. No statistically significant differences in opioid consumption were found between study arms in the cuff repair group, at either 3 or 6 weeks. Of note, preoperative opioid use was statistically associated with higher levels of opioid use in the total population and group 1 at 3 and 6 weeks (P.01 for all) but not in group 2 (P.05 for both).Use of morphine equivalents was statistically significantly less at 3 and 6 weeks in patients who took celecoxib in the total population and in the arthroplasty group. Patients prescribed celecoxib for 3 weeks after shoulder surgery took less opioid medication for pain at 3 and 6 weeks. Multimodal pain control using celecoxib is an effective way to reduce postoperative opioid use in shoulder arthroplasty patients. Preoperative opioid use is associated with higher levels of opioid use after shoulder arthroplasty.

Background Reported blood transfusion rates after total shoulder arthroplasty (TSA) range from 4.5% to 43%, and reported risk factors include race, female sex, prosthesis type (reverse), revision, age, anemia, low preoperative hemoglobin, and number of comorbidities. The purpose of this study was to develop a predictive model for transfusion in anatomic/hemi and reverse shoulder arthroplasty patients and to estimate the transfusion rate in a community hospital setting. Methods A retrospective cohort of 265 shoulder arthroplasties (79 anatomic, 182 reverse, and 4 hemiarthroplasties) performed consecutively by 1 surgeon at 1 institution from May 2013 to May 2016 was assembled. Two patients were excluded for insufficient data, leaving 263 patients for analysis. Sensitivity, specificity, area under the curve, and cut points using estimated blood loss (EBL), history of anemia, and preoperative hemoglobin level were calculated, based on a logistic regression model. Results The overall transfusion rate was 2.3% (6/265). Higher EBL (P = .003), lower preoperative hemoglobin level (P = .030), and history of anemia (P = .088) were predictive of transfusion with a sensitivity of 80.0% and a specificity of 99.6%. In this cohort, patients with a history of anemia had transfusion risk when an EBL of ≥300 mL was combined with a preoperative hemoglobin level

Objectives: Hypertensive Disorders of Pregnancy (HDP) encompass a spectrum of disorders that affect 6-8% of US pregnancies. We aim to determine the impact of self-reported history of HDP as a risk factor for screening positive for Posttraumatic Stress Disorder (PTSD), which results from exposure to a traumatic event, and to evaluate whether the risk of PTSD differed by severity of HDP.Study design: We conducted an online survey on the Preeclampsia Foundation website that is accessed worldwide by women who have experienced HDP, as well as their friends and family. 1448 women in total responded to the survey, including 1076 women who reported a history of HDP in at least one prior pregnancy and 372 women who reported no history of HDP during any prior pregnancy.Main outcome measures: We measured PTSD outcome with the Breslau Short Screening Scale for DSM-IV PTSD. We used logistic regression to model the relationship between PTSD and HDP.Results: Women who reported a history of HDP were more than four times as likely to screen positive for PTSD than women who reported having a normotensive pregnancy history (ORadj = 4.46, 95% CI: 3.20- 6.20). In addition, there was a marked trend toward increasing risk of screening positive for PTSD as the severity of HDP increased from gestational hypertension to eclampsia (p Conclusions: Women with a history of HDP may be at increased risk of PTSD, with severe cases most likely to suffer from symptoms. Clinicians should consider implementing routine screenings during post-partum visits in this vulnerable population. (C) 2013 International Society for the Study of Hypertension in Pregnancy Published by Elsevier B.V. All rights reserved.

Objectives: Previously preeclamptic women may express cognitive difficulties, which have largely been unappreciated or attributed to stresses of a complicated pregnancy. This study aimed to explore the scope of perceived neurocognitive and psychosocial problems as well as quality of life following preeclampsia.Study design: Observational study. Through website promotion and e-mail, registrants of the USA-based Preeclampsia Foundation who experienced preeclampsia in the past 20 years were invited to complete a web-based survey. Participants were requested to ask an acquaintance that had a normotensive pregnancy to also complete the survey (controls).Main outcome measures: The Cognitive Failures Questionnaire (CFQ), abbreviated WHO Quality Of Life questionnaire (WHOQOL-BREF), Social Functioning Questionnaire (SFQ) and Breslau Short Screening Scale for DSM-IV Posttraumatic Stress Disorder were used in the survey. Analysis was performed using Mann-Whitney U tests and linear regression.Results: 966 cases and 342 controls completed the survey (median age 34, median time since first pregnancy 4 vs. 5 years). Cases scored significantly worse on CFQ (median 35 vs. 27), WHOQOL-BREF domains physical health (15 vs. 17), psychological (13 vs. 15), social relationships (13 vs. 15) and environment (15 vs. 16), and SFQ (8 vs. 7). All p Conclusions: Previously preeclamptic women appear to perceive more cognitive and social problems, and report poorer quality of life compared to a group of women with normotensive pregnancies. Research relating to the origin and management of these issues is needed. (C) 2013 International Society for the Study of Hypertension in Pregnancy Published by Elsevier B.V. All rights reserved.

Exposure to ambient air pollution is linked to adverse pregnancy outcomes. Previous reports examining the relationship between ambient air pollution and Hypertensive Disorders of Pregnancy have been inconsistent.We evaluated the effects of ambient air pollution on the odds of Hypertensive Disorder of Pregnancy and whether these associations varied by body mass index (BMI).We conducted a retrospective, case-control study among 298 predominantly Hispanic women (136 clinically confirmed cases) who attended the Los Angeles County+University of Southern California Women's and Children's Hospital during 1996-2008. Trimester-specific carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), and particulate matter with aerodynamic diameter10 μm and2.5 μm (PM10, PM2.5) exposure were estimated based on 24-hour exposure level at residential address. Logistic regression models were fitted to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for two standard deviation increase in exposure levels.Exposures to CO and PM2.5 in the 1st trimester were significantly associated with Hypertensive Disorders of Pregnancy, and these associations were modified by BMI. In non-obese women (BMI30), 1st trimester exposures to PM2.5 and CO were significantly associated with increased odds of Hypertensive Disorder of Pregnancy (ORs per 2-standard deviation increase in PM2.5 (7 μg/m(3)) and CO (1 ppm) exposures were 9.10 [95% CI: 3.33-24.6] and 4.96 [95% CI: 1.85-13.31], respectively). Additionally, there was a significantly positive association between exposure to O3 in the 2nd trimester and Hypertensive Disorder of Pregnancy (OR per 15 ppb=2.05; 95% CI: 1.22-3.46).Among non-obese women, 1st trimester exposure to PM2.5 and carbon monoxide are associated with increased odds of Hypertensive Disorder of Pregnancy.

DEFINING DOSE-RESPONSE OF COPPER SURFACE AREA ON SPERM MOTILITY. AN EVALUATION OF THE COPPER CONTAINED IN THE COPPER INTRAUTERINE DEVICE (Cu-IUD). M. Gualtieri, R. Steward, M. Wilson, R. Paulson, D. Mishell. Reproductive Endocrinology and Infertility, University of Southern California, Los Angeles, CA; Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Preventive Medicine, University of Southern California, Los Angeles, CA.

genes in developing placentae Jennifer King, Kai Wang, Huaiyu Mi, Nicole Bender, Rachel Steward, Sue Ingles, Joseph Ouzounian, Melissa Wilson University of Southern California, Department of Obstetrics and Gynecology, Los Angeles, CA, University of Southern California, Department of Psychiatry and The Behavioral Sciences, Los Angeles, CA, University of Southern California, Department of Preventive Medicine, Los Angeles, CA OBJECTIVE: Genomic imprinting has been demonstrated to be integral to fetal development and placentation. The majority of studies on imprinted gene expression in humans have involved term placentas, while placental imprinting is known to be a dynamic process, which evolves during human pregnancy. For these reasons, the distinct imprinted gene expression profile displayed in the early human placenta remains largely unknown. Our objective was to investigate the pattern of imprinted gene expression across first and early second trimester placental development. STUDY DESIGN: We sequenced complementary cDNA from placental villi obtained at 7, 8, 9, and 15 weeks gestation using massively parallel next-generation sequencing (RNA-seq). We used the PANTHER classification system (http://www.pantherdb.org/about.jsp) to evaluate imprinted gene expression at each gestational age in reference to the human genome. We performed a pathway analysis to determine important processes at each time point that differ from the human genome using the Wilcoxon Rank Sum test. We did not use a Bonferroni correction due to the exploratory nature of the analysis. We report the top 15 pathways for each gestational age. RESULTS: Table includes top 15 pathways for each gestational age, none of which are statistically significant after Bonferroni correction. CONCLUSION: Similarities between global gene expression pathways and imprinted gene pathways speak to the importance of imprinted genes in the developing placenta. Imprinted genes have variable expression in early placental development. The top pathway for gestational ages of 8 and 9 weeks appear remarkably similar. At 15 weeks, the molecular pathways of the imprinted genes are notably different compared to earlier gestational age. These observations may reflect changes in imprinted gene expression that occur with changes in oxygen pressure or may be a result of small sample size. Larger studies are required to differentiate. 581 A pathway analysis of the developing placentome Jennifer King, Kai Wang, Huaiyu Mi, Ian Tilley, Rachel Steward, Sue Ingles, Joseph Ouzounian, Melissa Wilson University of Southern California, Department of Obstetrics and Gynecology, Los Angeles, CA, University of Southern California, Department of Psychiatry and The Behavioral Sciences, Los Angeles, CA, University of Southern California, Department of Preventive Medicine, Los Angeles, CA OBJECTIVE: The creation of a suitable intrauterine environment for fetal development is dependent on the proper functioning of placental chorionic villi. Chorionic villi require well-coordinated expression of several transcription factors, cytokines and their receptors, growth factors, and cell cycle regulators. Disruption of the expression of these regulatory factors may lead to placental growth and development disorders. However, gene expression levels across gestatational age have not been fully delineated. Our objective was to investigate the pattern of global gene expression across first and early second trimester placental development. STUDY DESIGN: In the present investigation, we sequenced complementary cDNA from placenta villi obtained at 7, 8, 9, and 15 weeks gestation, using massively parallel next-generation sequencing (RNAseq). We used the PANTHER classification system (http://www.pantherdb.org/about.jsp) to evaluate global gene expression at each gestational age in reference to the human genome. We performed a pathway analysis to determine important processes at each time point that differ from the human genome using the Wilcoxon Rank Sum test with a Bonferroni correction for multiple comparisons. RESULTS: See Table. CONCLUSION: Pathways involved in protein degradation, and regulation of trophoblast invasion are important at all four gestational ages. However, the relative importance of different pathways diverges after that point among the four gestational ages. The possible clinical significance of the ubiquitin proteasome pathway may be underappreciated to date. Additional analyses with a larger sample size are required to understand how these pathways may play a role in predisposing to diseases of placental etiology, such as preeclampsia or intrauterine growth restriction. Pathway description, ( )over or ( )under represented vs human genome (reference) Poster Session IV Academic Issues, Antepartum Fetal, Clinical Ob, Fetus, Genetics, Hypertension, Med-Surg-Diseases, Operative Ob, U/S www.AJOG.org

disease. Hazard rates (risk) of SB were calculated for each week of gestation. RESULTS: Women R40 y had a significantly increased risk of SB across all gestational ages, which was greatest at R37 weeks (Figure). Women in the 3539 y group had an increased risk of SB only at R37 weeks, with a relative risk (RR) of 1.25 (95% CI = 1.17, 1.33) compared to women !35 y. The risk of SB for women R40 y at R37 weeks was approximately 1 in 450 ongoing pregnancies, RR being 1.83 fold greater (95% CI = 1.61, 2.05) when compared to women !35 y. 85% of the excess risk of SB for women R40 y at R37 weeks was not directly related to maternal medical disease.