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Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age60 years and surgery within 48 hours of stroke onset.The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes.A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient620 on diffusion-weighted imaging.Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age60 years, and multivessel distribution did not significantly affect 90-day mRS score (P = 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P = 0.163).Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.

BACKGROUND Spontaneous osteonecrosis of the knee has recently been termed subchondral insufficiency fracture of the knee (SIFK) to appropriately recognize the etiology of mechanical overloading of the subchondral bone. The purpose of this study was to assess clinical outcomes of SIFK based on progression to surgical treatment and arthroplasty, and to evaluate the risk factors that increase the progression to arthroplasty. METHODS A retrospective review was performed on patients with a diagnosis of SIFK, as confirmed with use of magnetic resonance images (MRIs). Baseline and final radiographs were reviewed. Baseline MRIs were also reviewed for injury characteristics. Failure was defined as progression to surgical treatment or conversion to arthroplasty. RESULTS Two hundred twenty-three patients (71% female) with a mean age of 65.1 years were included. SIFK affected 154 femora (69%) and 123 tibiae (55%), with medial compartment involvement in 198 knees (89%); 74% of medial menisci had root or radial tears, with a mean extrusion of 3.6 mm. Varus malalignment was identified in 54 (69%) of 78 knees. Seventy-six (34%) of all patients progressed to surgical intervention at 2.7 years, and 66 (30%) underwent arthroplasty at 3.0 years. The rates of conversion to surgical intervention and arthroplasty increased to 47% (37 of 79; p = 0.04) and 37% (29 of 79; p = 0.09), respectively, in patients with >5 years of follow-up. The 10-year survival rate free of arthroplasty for patients with SIFK on the medial femoral condyle (p < 0.01), SIFK on the medial tibial plateau (p < 0.01), medial meniscal extrusion (p = 0.01), varus alignment (p = 0.02), and older age (per year older; p = 0.003) was significantly higher than the survival rates of those without each respective condition. CONCLUSIONS Subchondral insufficiency fractures predominantly involve the medial compartment of the knee and commonly present with medial meniscal root and radial tears. Approximately one-third of patients progressed to total knee arthroplasty. Baseline arthritis, older age, location of the insufficiency fracture on both the medial femoral condyle and medial tibial plateau, meniscal extrusion, and varus malalignment were all associated with progression to arthroplasty. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To determine (1) the demographic characteristics as well as radiographic findings of medial versus lateral meniscal root tears at time of presentation, (2) treatment decisions and clinical outcomes of patients undergoing medial versus lateral root repair, and (3) risk factors for worse clinical and radiographic outcomes.A retrospective review was performed to identify patients with symptomatic, medial, or lateral meniscus posterior root tears with a minimum 2-year follow-up. Radiographs were graded using Kellgren-Lawrence scores. Subanalysis was performed on 62 patients who underwent root repair. Tegner, Lysholm, International Knee Documentation Committee scores, and progression to arthroplasty were analyzed in the repair groups. Patient demographics, radiographic findings, and clinical outcomes were compared between medial meniscus posterior horn root tear (MMRT) and lateral meniscus root repair (LMRT).Of the 141 root tears, 109 were MMRTs, 30 were LMRTs, and 2 patients had both. At the time of injury, patients with MMRTs had a significantly higher age (MMRT = 51.4 vs LMRT=24.6, P.0001), body mass index (MMRT = 32.1 vs LMRT 25.8, P.0001), Kellgren-Lawrence score (MMRT = 1.3 vs LMRT=0.6, P.0001), and higher rate of major meniscal extrusion (MMRT = 72% vs LMRT = 20%, P.0001). Of the 30 LMRT, 30/30 (100.0%) were treated with meniscal repair. With MMRT, 52/109 (48%) were treated nonoperatively, 27/109 (25%) with partial meniscectomy, and 30/109 (27%) with meniscal repair. Sixty-two patients underwent meniscus root repair with an average 41-month follow-up. LMRT had significantly increased International Knee Documentation Committee (LMRT = 89.5, MMRT = 80.4, P = .02) and Tegner scores (LMRT = 6.5, MMRT = 5.1, P.05) compared with MMRT.Compared with MMRTs, LMRTs occur in younger male patients with lower body mass index, less cartilage degeneration, less extrusion on magnetic resonance imaging, and more commonly with a ligament injury. Although good to excellent clinical outcomes were attained in select patients for both medial and lateral meniscus root repair, LMRTs may have better results after repair, suggesting that differences in injury and patient characteristics may contribute to differences in these outcomes.Retrospective comparative study, Level III.

Objective To analyze the clinical outcomes, knee function, and activity level of patients after treatment of full-thickness cartilage defects involving the patellofemoral compartment of the knee with cryopreserved osteochondral allograft. Design Nineteen patients with cartilage defects involving the patellofemoral compartment were treated. The average age was 31 years (range 15-45 years), including 12 females and 7 males. Patients were prospectively followed using validated clinical outcome measures including Veterans RAND 12-item Health Survey (VR-12), International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Tegner activity scale. Graft incorporation was evaluated by magnetic resonance imaging (MRI) or second-look arthroscopy. Results The cartilage defects included the patella ( n = 16) and the femoral trochlea ( n = 3). Mean VR-12 scores increased from 31.6 to 46.3 ( P < 0.01), mean IKDC increased from 40.0 to 69.7 ( P < 0.01), mean KOOS increased from 53.9 to 80.2 ( P < 0.01), and mean Tegner scores increased from 3.0 to 4.9 ( P < 0.01), at average follow-up of 41.9 months (range 24-62 months). Of the 3 patients who underwent second-look arthroscopy, all demonstrated a well-incorporated graft. Mean MOCART score for the 6 patients with follow-up MRI was 62.5 (range 25-85). The reoperation rate was 21.1% and 2 patients (12.5%) experienced progressive patellofemoral osteoarthritis requiring conversion to patellofemoral arthroplasty. Conclusion Patients with unipolar cartilage defects involving the patellofemoral compartment of the knee can have positive outcomes at minimum 2-year follow-up after surgical treatment with a cryopreserved osteochondral allograft when concomitant pathology is also addressed, but the reoperation rate is high and bipolar cartilage lesions may increase the failure rate.

Background:Radiography is the initial imaging modality used to evaluate femoroacetabular impingement (FAI), and diagnostic radiographic findings are well-established. However, the prevalence of these radiographic findings in patients with hip pain is unknown.Purpose:The purpose was 3-fold: (1) to determine the overall prevalence of radiographic FAI deformities in young patients presenting with hip pain, (2) to identify the most common radiographic findings in patients with cam-type FAI, and (3) to identify the most common radiographic findings in patients with pincer-type FAI.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A geographic database was used to identify patients aged 14 to 50 years with hip pain between the years 2000 to 2016. The following were evaluated on radiographs: cam type: typical pistol grip deformity, alpha angle >55°; pincer type: crossover sign (COS), coxa profunda or protrusio acetabuli, lateral center edge angle (LCEA) ≥40°, Tönnis angle Results:There were 1893 patients evaluated, and 1145 patients (60.5%; 1371 hips; 374 male and 771 female; mean age, 28.8 ± 8.4 years) had radiographic findings consistent with FAI. Of these hips, 139 (10.1%) had cam type, 245 (17.9%) had pincer type, and 987 (72.0%) had mixed type. The prevalence of a pistol grip deformity and an alpha angle >55° was 577 (42.1%) and 1069 (78.0%), respectively. The mean alpha angle was 66.9°± 10.5°. The prevalence of pincer-type radiographic findings was the following: COS, 1062 (77.5%); coxa profunda, 844 (61.6%); ISS, 765 (55.8%); PWS, 764 (55.7%); Tönnis angle Conclusion:The overall prevalence of radiographic findings consistent with FAI in young patients with hip pain was 60.5%. Radiographic findings for mixed-type FAI were the most prevalent. The most common radiographic finding for cam-type FAI was an alpha angle >55°. The most common radiographic finding for pincer-type FAI was the COS.

Background:While a large volume of literature has focused on risk factors for anterior shoulder instability, the rates of recurrence are inconsistent and require additional population-based epidemiologic data.Purpose/Hypothesis:The purpose was to report the effect of patient age on the number of instability events before physician consultation, rate of surgical stabilization, recurrent instability, and progression to osteoarthritis in patients Study Design:Descriptive epidemiologic study.Methods:An established geographic database of more than 500,000 patients was used to identify patients Results:The study population consisted of 654 patients with a mean follow-up of 11.1 years (range, 2.0-25.2 years). This resulted in 118 patients (18%) ≤15 years of age at initial instability; 250 (38%), 16 to 20 years; 110 (17%), 21 to 25 years; 80 (12%), 26 to 30 years; and 96 (15%), 31 to 40 years. Of patients ≤15 years old at initial instability 47% had 3+ instability events, compared with 12% of patients aged 31 to 40 years ( P < .001). At 10 years of follow-up, patients ≤15 and 16 to 20 years old demonstrated the highest recurrent instability rates of 38.8% and 47.1% after nonoperative management, respectively. Patients 16 to 20 years old demonstrated the highest rates of both surgical intervention (40.4%) and recurrence after surgery (24.8%). Patients 31 to 40 years of age were significantly more likely to develop clinically symptomatic osteoarthritis (15.6%) than all other age groups.Conclusion:In a US epidemiologic population of patients

Objective To report radiographic and magnetic resonance imaging findings, patient-reported outcomes, and complications and/or reoperations following nonarthroplasty surgical intervention for focal glenohumeral cartilage defects. Design A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Patients were included if they possessed a chondral defect of the humeral head, glenoid, or both, which had been treated with a joint preserving nonarthroplasty procedure. Risk of bias assessment was performed using the Methodological Index for Non-Randomized Studies scoring system. Study demographics, surgical technique, imaging findings, patient-reported outcomes, complications, failures, and reoperations were collected. Results Fourteen studies with 98 patients (100 shoulders) met the inclusion criteria. Patient ages ranged from 7 to 74 years. The nonarthroplasty surgical techniques utilized included microfracture (67 shoulders), osteochondral transplantation (28 shoulders), chondrocyte transplantation (4 shoulders), and internal fixation (1 shoulder). The rates of radiographic union and progression of osteoarthritis ranged between 90% to 100% and 57% to 100%, respectively. Visual analog scores ranged from 0 to 1.9 at final follow-up. Mean postoperative ASES (American Shoulder and Elbow Surgeons) shoulder scores ranged from 75.8-100. Mean postoperative CSS (Constant Shoulder Score) scores ranged from 83.3-94. Mean postoperative SSV (Subjective Shoulder Value) ranged from 70% to 99%. Failure and reoperation rates ranged between 0% to 35% and 0% to 30%, respectively, with the most common reoperation being conversion to prosthetic arthroplasty. Conclusions In this systematic review, nonarthroplasty surgical techniques demonstrated acceptable rates of radiographic healing, improved patient reported outcomes, minimal complications, and low rates of failure or reoperation. Joint preserving techniques are likely viable options to prolong function of the native shoulder and provide short- to midterm pain relief in young and highly active patients. Level of Evidence Level IV.

The meniscal ossicle is observed in clinical practice, yet there currently is limited information on its potential clinical significance. The purpose of this study was to assess the clinical presentation, imaging findings, and clinical treatment and outcomes of a series of patients identified as having a meniscal ossicle. An institutional database was reviewed to identify knees with a meniscal ossicle. Clinical presentation, magnetic resonance imaging (MRI), treatment, and outcomes were analyzed. Radiographs were graded using Kellgren–Lawrence (KL) scores. MRIs were reviewed for the presence and location of meniscal ossicles and additional knee pathology. Knee arthroplasty rates were recorded with the remaining patients contacted to obtain final International Knee Documentation Committee (IKDC) and Tegner's scores. Failure was defined as conversion to arthroplasty or failing IKDC score (

The purpose of this study was to describe meniscus extrusion, present imaging characteristics, and provide clinical correlations for patients with isolated meniscus extrusion. Of the 3244 MRI reports identified as having meniscus extrusion, 20 patients were identified to have isolated meniscus extrusion (0.62%). Patients with moderate to severe chondromalacia, meniscus tears, intra-articular fractures, tumours, and ligament tears were excluded. Radiographs were reviewed and graded using Kellgren–Lawrence (K–L) scores. MRI’s were reviewed for the extent of extrusion and whether or not the meniscotibial ligament was intact. Clinical presentation and management were recorded. The study population consisted of 12 females and 8 males with a mean age of 40.5, diagnosed with meniscus extrusion and minimal concomitant knee pathology. 68% of patients were considered symptomatic as their knee pain correlated with the side of their meniscus extrusion and no other reason for pain was identified. The mean amount of meniscus extrusion was 2.5 mm (SD ± 1.1 mm) with 45% (9 of 20) having 3 + mm of extrusion. Meniscotibial ligament abnormality was identified in 65% of cases (13 of 20). Patients with 3 + mm of meniscus extrusion were much more likely to have associated meniscotibial ligament abnormality (100%, 9 of 9) compared to those with

Objective The purpose of this systematic review was to determine (1) treatment options for bipolar cartilage lesions of the knee, (2) patient-reported outcomes following various surgical treatments, and (3) complication and failure rates following surgery. Design A literature search of PubMed, the Cochrane Library, and CINHAL was performed using PRISMA guidelines. Patients were included if they had bipolar cartilage lesions of the knee treated surgically. Lesion characteristics, surgical technique, patient-reported outcomes, complication rates, failure rates, and survivorship were recorded. Results Fourteen studies yielded 301 knees treated surgically. Patient age ranged from 15 to 74 years. Surgical techniques included 138 autologous chondrocyte implantation (ACI), 156 osteochondral allograft transplantation (OCA), and 7 osteochondral autograft transfer system (OATS). Seven studies reported a concomitant procedure rate that ranged from 0% to 88%. Eight studies reported that both reciprocal lesions received surgical treatment, while 6 studies did not specify. Lesion size ranged from 1 to 41 cm2. All reported postoperative improvements in patient-reported outcomes, but the measures were very heterogeneous. There were no major complications and the rate of minor complications ranged from 0% to 50%. Survivorship ranged from 40% to 100% for OCA, 76% to 95% for ACI, and 100% for the 1 study evaluating OATS. Conclusions Bipolar cartilage lesions of the knee typically involve a large surface area and are most commonly treated with ACI or OCA, while OATS may be an option for smaller lesions. Improvements in mid-term patient-reported outcomes were reported for all surgical procedures and they can be performed safely with a low rate of major complications.

Objective The purpose of this systematic review is to determine (1) current reported treatment options for isolated tibial plateau (TP) cartilage lesions, (2) patient reported outcomes following various treatments, and (3) complication rate and survivorship following various treatments. Design A literature search of PubMed, the Cochrane Library, and CINAHL was conducted adhering to PRISMA guidelines. Patients were included if they had TP cartilage lesions treated with surgery. Lesion characteristics, surgical procedure details, patient reported outcomes, complication, and failure rates were collected. Results Thirteen studies yielded 205 knees with TP cartilage lesions treated surgically. Ages ranged from 12 to 77 years. Surgical techniques included 138 treated with osteochondral allograft transplantation (OCA), 37 treated with osteochondral autograft transfer system (OATS), 11 treated with microfracture, 11 treated with an osteochondral scaffold, and 8 treated with autologous chondrocyte implantation (ACI). The patient-reported outcome measures were heterogeneous, but all reported improvements with the notable exception of one study evaluating microfracture. The rate of complications ranged from 0% to 4.6%. Failure rate ranged from 22% to 46% for OCA and 0% to 16% for OATS. No failures were reported for the additional techniques. Conclusions Various surgical techniques have been utilized for the treatment of TP cartilage lesions. Patient-reported outcome measures were heterogeneous, but improvements were reported following all surgical treatments except for microfracture, which resulted in decreased scores at mid-term follow-up. The complication rate was low for all techniques described. However, the failure rate was higher following unicondylar OCA for salvage treatment of posttraumatic deformities.

Background:Hip arthroscopy is becoming more advanced and commonly performed. However, significant controversy exists regarding whether high-grade acetabular cartilage lesions should be treated with debridement/abrasion or microfracture. In addition, patients treated with microfracture are subject to extended protected weightbearing rehabilitation to mitigate risk of subchondral plate fracture and to protect fibrocartilage tissue formation.Purpose:To determine the midterm patient-reported outcomes and failure rate of patients with grade 3 and 4 acetabular labrum articular disruption (ALAD) lesions managed with debridement/abrasion or microfracture.Study Design:Cohort study; Level of evidence, 3.Methods:Primary arthroscopic labral repair cases at 2 centers from November 2008 to April 2016 were reviewed for patients aged Results:A total of 113 hips in 110 patients (66 males, 44 females; mean age, 34.5 ± 1.1 years) undergoing debridement/abrasion (n = 82) or microfracture (n = 31) were followed for a mean of 4.9 years (range, 2.0-8.5 years). Lesion size was not statistically different between the debridement/abrasion (1.3 ± 1.0 cm2) and microfracture cohorts (1.4 ± 1.0 cm2) ( P = .47). Patients undergoing debridement/abrasion achieved 3.6-point mean improvements in VAS ( P < .01), 21.2-point improvements in mHHS ( P < .01), and 25.4-point improvements in HOS-SSS ( P < .01), which were not significantly different from those observed in microfracture patients ( P≥ .20). The 5-year rate of survival free of revision surgery was 84.0% in the debridement/abrasion group and 85.6% in the microfracture group ( P = .78). The cartilage treatment technique was found not to be predictive of revision risk during both univariate (hazard ratio [HR], 1.01; P = .98) and multivariate (HR, 0.93; P = .90) analysis accounting for patient age, lesion grade, and acetabular coverage.Conclusion:Patients undergoing debridement/abrasion of high-grade unipolar acetabular cartilage lesions demonstrate similar outcome scores and revision rates compared with those of patients undergoing microfracture. These outcomes support the consideration of preferential debridement/abrasion at the discretion of the treating surgeon to optimize recovery while maintaining established positive outcomes after hip arthroscopy.

Color vision has evolved multiple times in both vertebrates and invertebrates and is largely determined by the number and variation in spectral sensitivities of distinct opsin subclasses. However, because of the difficulty of expressing long-wavelength (LW) invertebrate opsins in vitro, our understanding of the molecular basis of functional shifts in opsin spectral sensitivities has been biased toward research primarily in vertebrates. This has restricted our ability to address whether invertebrate G(q) protein-coupled opsins function in a novel or convergent way compared to vertebrate G(t) opsins. Here we develop a robust heterologous expression system to purify invertebrate rhodopsins, identify specific amino acid changes responsible for adaptive spectral tuning, and pinpoint how molecular variation in invertebrate opsins underlie wavelength sensitivity shifts that enhance visual perception. By combining functional and optophysiological approaches, we disentangle the relative contributions of lateral filtering pigments from red-shifted LW and blue short-wavelength opsins expressed in distinct photoreceptor cells of individual ommatidia. We use in situ hybridization to visualize six ommatidial classes in the compound eye of a lycaenid butterfly with a four-opsin visual system. We show experimentally that certain key tuning residues underlying green spectral shifts in blue opsin paralogs have evolved repeatedly among short-wavelength opsin lineages. Taken together, our results demonstrate the interplay between regulatory and adaptive evolution at multiple G(q) opsin loci, as well as how coordinated spectral shifts in LW and blue opsins can act together to enhance insect spectral sensitivity at blue and red wavelengths for visual performance adaptation.

Data on the long-term outcomes of nonoperative treatment of anterior shoulder instability are lacking, particularly for the US population. The purpose was to (1) describe the characteristics of patients with anterior shoulder instability treated nonoperatively, (2) assess the long-term outcomes of nonoperative management in a US population, and (3) identify risk factors for poor outcomes following nonoperative management.A geographic cohort of500,000 subjects was used to identify patients treated nonoperatively for anterior shoulder instability. Only patients aged40 years at the time of initial instability with minimum 10-year follow-up were included. Medical records were reviewed to obtain demographic characteristics, physical examination findings, clinical history data, imaging results, treatment details, and clinical and/or radiographic progression. Recurrent pain, recurrent instability, and the development of symptomatic osteoarthritis (OA) were the primary outcomes evaluated.The study included 254 patients (73% male) with a median age of 19 years (range, 16-26 years) at the time of initial instability. At median 17-year follow-up, 37.5% experienced recurrent instability, 58.4% had recurrent pain, and 12.2% had symptomatic OA development. Factors associated with recurrent pain at final follow-up were multiple instability events prior to presentation (hazard ratio [HR], 2.43; P.01) and increased pain at the initial visit (HRs of 0.79 for mild, 1.74 for moderate, and 1.39 for severe; P.01); patients with multiple instability events prior to presentation also had an increased risk of recurrence (P.01). Factors increasing the risk of the development of symptomatic OA included increased pain at the initial visit (P = .05), seizure disorder (HR, 27.01; P .01), and smoking (HR, 5.15; P.01).At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. Overall, 37.5% of patients experienced recurrent shoulder instability, 58.4% had recurrent shoulder pain, and 12.2% had symptomatic OA development. Risk factors associated with adverse clinical outcomes included increased pain at the initial visit, recurrent instability prior to presentation, seizure disorder, and smoking.

Background:Femoroacetabular impingement (FAI) is a well-known cause of hip pain in adolescents and young adults. However, the incidence in the general population has not been clearly defined.Purpose:To (1) define the population-based incidence of diagnosis of FAI in patients with hip pain, (2) report the trends in diagnosis of FAI over time, and (3) determine the changes in the rate and type of surgical management over time.Study Design:Cohort study; Level of evidence, 3.Methods:A geographic database was used to identify patients who were 14 to 50 years old with hip pain between the years 2000 and 2016. Chart and radiographic review was performed to determine which patients had FAI. To be included, patients had to have a triad of clinical symptoms, physical examination signs, and imaging findings consistent with FAI. Medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Statistical analysis determined the overall age- and sex-adjusted annual incidence of FAI diagnosis and trends over time.Results:There were 1893 patients evaluated with hip pain, and 716 (38%; 813 hips) had diagnosed FAI. The mean ± SD age was 27.2 ± 8.4 years, and 67% were female. The incidence of FAI diagnosis was 54.4 per 100,000 person-years. Female patients had a higher incidence than male patients (73.2 vs 36.1 per 100,000 person-years; P < .01). Incidence of FAI diagnosis were higher from 2010 to 2016 (72.6 per 100,000 person-years; P < .01) as compared with 2005 to 2009 (45.3) and 2000 to 2004 (40.3). Hip arthroscopy, surgical hip dislocation, and periacetabular osteotomy utilization increased from the 2000-2004 to 2010-2016 periods, respectively: 1 (1%) to 160 (20%; P = .04), 2 (1%) to 37 (5%; P = .01), and 1 (1%) to 22 (3%; P = .58).Conclusion:The overall incidence of FAI diagnosis was 54.4 per 100,000 person-years, and it consistently increased between 2000 and 2016. Female patients had a higher incidence than male patients. The utilization of joint preservation operations, including hip arthroscopy, surgical hip dislocation, and anteverting periacetabular osteotomy, increased over time.

Purpose To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long-term outcomes of nonoperative treatment after the index traumatic anterior instability event. Methods The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long-term outcomes (recurrence rate, pain at last follow-up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan-Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. Results A total of 379 patients met the study criteria, with an average follow-up period of 10.2 years (range, 0.53-25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow-up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow-up (HR, 4.21; P Conclusions Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. Level of Evidence Level III, retrospective database review.

Background:Femoroacetabular impingement (FAI) is a common cause of hip pain and a known risk factor for hip osteoarthritis (OA) and total hip arthroplasty (THA) at a young age. Unfortunately, little is known about the specific factors associated with an increased risk of OA.Purpose:To (1) report the overall rate of symptomatic hip OA and/or THA in patients with FAI without surgical intervention and (2) identify radiographic features and patient characteristics associated with hip OA.Study Design:Case-control study; Level of evidence, 3.Methods:A geographic database was used to identify all patients with hip pain and radiographs between 2000 and 2016. Chart review was performed to identify patients with FAI. Patient medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Kaplan-Meier analysis was used to determine the rate of hip OA. Univariate and multivariate proportional hazard regression models were performed to determine risk factors for OA.Results:The study included 952 patients (649 female; 303 male; 1104 total hips) with FAI. The majority of hips had mixed type (n = 785; 71.1%), 211 (19.1%) had pincer type, and 108 (9.8%) had cam type. Mean age at time of presentation was 27.6 ± 8.7 years. Mean follow-up time was 24.7 ± 12.5 years. The rate of OA was 13.5%. THA was performed in 4% of patients. Male sex, body mass index (BMI) greater than 29, and increased age were risk factors for OA (male sex: hazard ratio [HR], 2.28; P < .01; BMI >29: HR, 2.11; P < .01; per year of increased age: HR, 1.11; P < .01.). Smoking and diabetes mellitus were not significant risk factors. No radiographic morphological features were found to be significant risk factors for OA.Conclusion:At mean follow-up of 24.7 years, 14% of hips had symptomatic OA and 4% underwent THA. BMI greater than 29, male sex, and increased age at the time of presentation with hip pain were risk factors for hip OA. The cohort consisted of a large percentage of mixed-type FAI morphologies, and no specific radiographic risk factors for OA were identified.

OBJECTIVE To report the injury characteristics, radiographic findings, and long-term outcomes of nonoperative management for posterior shoulder instability (PSI). DESIGN A retrospective review of 143 patients with PSI using a large geographic database. SETTING Single county between January 1994 and July 2012. PATIENTS A clinical history and diagnosis of PSI, one confirmatory imaging study to support the diagnosis, and a minimum of 5 years follow-up were required for inclusion. Patients with seizure disorders, anterior-only instability, multidirectional instability, and superior labrum from anterior to posterior diagnosis were excluded. INTERVENTIONS Patients with PSI were managed nonoperatively or operatively. MAIN OUTCOME MEASURES Pain, recurrent instability, and progression into glenohumeral osteoarthritis at long-term follow-up. RESULTS One hundred fifteen patients were identified. Thirty-seven (32%) underwent nonoperative management. Twenty (54%) patients were diagnosed with posterior subluxation, 3 (8%) with a single dislocation, and 7 (19%) with multiple dislocations. Symptomatic progression of glenohumeral arthritis was observed in 8% (3) of patients. Pain improved in 46% (17) of patients and worsened in 19% (7). Recurrent instability and progression to osteoarthritis occurred in 15% (3/20) of patients with a traumatic instability event compared with 0% of atraumatic patients after nonoperative management (P = 0.234). Pain at follow-up was more common in nonoperative than operative patients (P = 0.017). CONCLUSIONS Nonoperative management is a viable option for many patients with posterior shoulder instability; however, many may continue to have posterior shoulder pain.

BACKGROUND Elevated body mass index (BMI) is a well-known risk factor for surgical complications in lumbar surgery. However, its effect on surgical effectiveness independent of surgical complications is unclear. OBJECTIVE To determine increasing BMI's effect on functional outcomes following lumbar fusion surgery, independent of surgical complications. METHODS We retrospectively analyzed a prospectively built, patient-reported, quality of life registry representing 75 hospital systems. We evaluated 1- to 3-level elective lumbar fusions. Patients who experienced surgical complications were excluded. A stepwise multivariate regression model assessed factors independently associated with 1-yr Oswestry Disability Index (ODI), preop to 1-yr ODI change, and achievement of minimal clinically important difference (MCID). RESULTS A total of 8171 patients met inclusion criteria: 2435 with class I obesity (BMI 30-35 kg/m2), 1328 with class II (35-40 kg/m2), and 760 with class III (≥40 kg/m2). Increasing BMI was independently associated with worse 12-mo ODI (t = 8.005, P

Reversible cerebral vasoconstriction syndrome (RCVS) presents with a thunderclap headache, often prompting brain imaging. Most patients fully recover with supportive care and time, but oral calcium channel blockers are often used in patients with severe vasoconstriction. In this case report, we present a patient with severe vasoconstriction leading to weakness refractory to oral calcium channel blockers. Intrathecal nicardipine was administered via an external ventricular drain and the patient subsequently showed improvement of her weakness and significant improvement of vasospasm on Computed Tomography Angiography. We suggest further studies to determine the efficacy of intrathecal nicardipine in patients with RCVS not responsive to oral calcium channel blockers.

Objectives: An individualized stroke care program was developed to match patients' education with their needs regarding stroke knowledge, secondary prevention and rehabilitation. Our purpose was to assess feasibility of in-hospital and post-discharge, personalized stroke coaching service. Methods: Acute ischemic stroke patients enrolled in ASTRAL-B stroke registry (Sint-Lucashospital, Bruges Belgium) with: (a) hospitalization between 12/2014-12/2015, (b) hospital-to-home discharge, and (c) without cognitive decline, were selected. The stroke coach contacted patients individually twice during hospitalization (2 x 20 min) and post-discharge via phone calls using the standardized WSO Post-Strokechecklist. Risk factor management, review of therapy and clinical evolution were discussed. Participants were contacted at 2 weeks, followed by repeat calls if necessary and ambulatory with the vascular neurologist at 1, 3, 6 and 12 months. Results: Of all 255 patients meeting the inclusion criteria, 152 (59.7%) received individualized education during hospitalization by the stroke coach. Median age of our population was 74 years and median NIHSS 5. Majority of patients had at least two cardiovascular risk factors. Patients were not coached because of palliative care/decease (10%), unfavorable life expectancy (2%), dementia (8.5%) and lack of time due to short hospitalization (22%). A quarter of all patients were contacted at least once by phone, 12% were contacted at least twice after discharge. At three months, low stroke recurrence (5%) and mortality rates (4%) were identified, probably linked to improved adherence. Conclusions: We demonstrated feasibility of an individualized coaching service executed by well-trained stroke nurse. Future research will focus on developing an online portal delivering post-discharge services to patients and caregivers. (C) 2017 Elsevier B.V. All rights reserved.

Purpose To systematically evaluate the outcomes and complications of osteochondral autograft transfer (OAT) and osteochondral allograft transplantation (OCA) for the surgical treatment of capitellar osteochondritis dissecans (OCD). Methods A literature search was conducted across 3 databases (PubMed, Cochrane, and CINAHL [Cumulative Index to Nursing and Allied Health Literature]) from database inception through December 2019 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Individual study quality was assessed using the Methodological Index for Non-randomized Studies scale. Studies were published between 2005 and 2019. Results Eighteen studies consisting of 446 elbow OCD lesions treated with OAT surgery were included. There was a single OCA study eligible for inclusion. Patient ages ranged from 10 to 45 years. Of the OAT studies, 4 used autologous costal grafts whereas the remainder used autografts from the knee. Outcome measures were heterogeneously reported. A significant improvement in Timmerman-Andrews scores from preoperatively to postoperatively was reported in 9 of 10 studies. Return-to-play rates to the preinjury level of competitive play ranged from 62% to 100% across 16 studies. Significant improvement in motion, most often extension, was noted in most studies. Reported complication, reoperation, and failure rates ranged from 0% to 11%, 0% to 26%, and 0% to 20%, respectively. When used, knee autografts resulted in low donor-site morbidity (Lysholm scores, 70-100). Conclusions OAT surgery for large, unstable OCD lesions of the capitellum reliably produced good outcomes, few complications, and a high rate of return to competitive play. Complications are relatively uncommon, and donor-site morbidity is low. Less is known about the performance of OCA given the paucity of available literature. Level of Evidence Level IV, systematic review of Level II to IV studies.

The purpose of this study was to create a predictive model utilizing baseline demographic and radiographic characteristics for the likelihood that a patient with subchondral insufficiency fracture of the knee will progress to knee arthroplasty with emphasis on clinical interpretability and usability. A retrospective review of baseline and final radiographs in addition to MRIs were reviewed for evaluation of insufficiency fractures and associated injuries. Patient and radiographic factors were used in building predictive models for progression to arthroplasty with Train: Validation: Test subsets. Multiple models were compared with emphasis on clinical utility. Total of 249 patients with a mean age of 64.6 (SD 10.5) years were included. Knee arthroplasty rate was 27% at mean of 4 years of follow-up. Lasso Regression was non-inferior to other models and was chosen for ease of interpretability. In order of importance, predictors for progression to arthroplasty included lateral meniscus extrusion, Kellgren–Lawrence Grade 4, SIFK on MFC, lateral meniscus root tear, and medial meniscus extrusion. The final SIFK Score stratified patients into low-, medium-, and high-risk categories with arthroplasty rates of 8.8%, 40.4%, and 78.9% (p

The main indication for performing a distal femoral osteotomy is valgus malalignment of the knee joint. The ideal candidates are young and active individuals with isolated lateral compartment arthritis. The goal of the procedure is to create a neutral mechanical axis of the limb to relieve pain and preserve the knee joint. The amount of correction is calculated from a preoperative, high-quality, weight-bearing radiograph from the hip to ankle. This technically challenging operation is a viable option for patients with valgus malalignment because early survivorship is strong and patient-reported outcome scores are significantly improved.

The purpose of this study was to evaluate the effect of preoperative patella alta on clinical outcomes, survivorship, and complication and reoperation rates on patellofemoral arthroplasty (PFA).All patients who underwent PFA for isolated patellofemoral arthritis by a single surgeon at our institution were identified. Preoperative radiographs were measured by two independent observers for patellar height using the Caton Deschamps (CD), Insall-Salvati (IS), and Blackburne-Peele (BP) methods. Patients were classified as either "patella alta" or "non-patella alta" for all three measurement methods. Clinical scores including KSS Pain, KSS Function, and Tegner Activity Scores were collected pre- and post-operatively. Failure was defined as conversion to total knee arthroplasty (TKA). Clinical outcomes and survivorship were compared between patients with "patella alta" and "non-patella alta" height measurements.There were 119 patients with 153 knees (86% female) included in the study with a mean age of 55.8 years. Outcome scores improved from pre-operative to post-operative for both patella alta and non-patella alta patients for Tegner, KSS pain and KSS function scores. The mean change in Tegner scores for patella alta and non-patella alta patients were not significantly different for CD (p = 0.24), IS (p = 0.25) or BP measurements (p = 0.39). The mean change in KSS pain scores between groups were not significantly different for CD (p = 0.33) or IS measurements (p = 0.22), but was improved more significantly in patella alta patients vs non-patella alta patients (21.2 and 14.4; p = 0.02) for BP measurement. The mean change in KSS function scores between groups was not significantly different for CD (p = 0.61) IS (p = 0.90) or BP measurements (p = 0.79). The overall survivorship from conversion to total knee arthroplasty (TKA) was 94.1% at a mean follow-up time of 5.0 (SD 2.6) years. There were no significant differences in survivorship from TKA between patella alta and non-patella alta groups (CD: p = 0.72, IS: p = 0.63, BP: p = 0.66).This study suggests that there are no significant differences in clinical outcome scores or survivorship from TKA between patella alta and non-patella alta patients who underwent onlay design PFA. Both patella alta and non-patella alta patients demonstrated excellent improvement in outcome scores from pre-operative to post-operative.IV.

Purpose To report the rate of radiographic union, patient-reported outcomes, complications, and reoperations after internal fixation of unstable osteochondritis dissecans (OCD) in the skeletally mature knee. Methods A literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Patients were included if they were skeletally mature and underwent internal fixation of an unstable OCD lesion of the knee. Risk of bias assessment was performed using the Methodological Index for Non-randomized Studies scoring system. Surgical technique, rate of union, patient-reported outcomes, complications, and reoperations were collected. Results Thirteen studies resulted in 148 patients (150 knees) for inclusion. Patient age ranged from 14 to 45 years. Numerous fixation procedures were used, including biodegradable devices (rods, pins, nails, and screws), metal screws, Kirschner wire, and autologous bone sticks. Overall, reported outcome measures were heterogeneous in nature. The rate of radiographic healing ranged from 67% to 100% across 6 studies. Improved subjective results and Hughston criteria on final follow-up ranged from 83% to 100% across 4 studies each. Mean postoperative Lysholm scores ranged from 42 to 98 in studies that reported them. Both complication and reoperation rates ranged from 0% to 44%. The most commonly performed reoperations were loose body excision and cartilage resurfacing procedures. Conclusions A variety of surgical techniques are available for treatment of unstable OCD lesions in the skeletally mature knee. In this systematic review, internal fixation of the native fragment showed acceptable rates of radiographic union and improved patient-reported outcomes relative to other techniques. Level of Evidence Level IV, systematic review of level III-IV studies.

Haploinsufficiency of transcriptional regulators causes human congenital heart disease (CHD); however, the underlying CHD gene regulatory network (GRN) imbalances are unknown. Here, we define transcriptional consequences of reduced dosage of the CHD transcription factor, TBX5, in individual cells during cardiomyocyte differentiation from human induced pluripotent stem cells (iPSCs). We discovered highly sensitive dysregulation of TBX5-dependent pathways-including lineage decisions and genes associated with heart development, cardiomyocyte function, and CHD genetics-in discrete subpopulations of cardiomyocytes. Spatial transcriptomic mapping revealed chamber-restricted expression for many TBX5-sensitive transcripts. GRN analysis indicated that cardiac network stability, including vulnerable CHD-linked nodes, is sensitive to TBX5 dosage. A GRN-predicted genetic interaction between Tbx5 and Mef2c, manifesting as ventricular septation defects, was validated in mice. These results demonstrate exquisite and diverse sensitivity to TBX5 dosage in heterogeneous subsets of iPSC-derived cardiomyocytes and predicts candidate GRNs for human CHDs, with implications for quantitative transcriptional regulation in disease.

Literature suggests that alterations in the inflammatory and immune systems are involved in the pathogenesis of schizophrenia. Specifically, patients diagnosed with schizophrenia exhibit increased IL-18, a pleiotropic proinflammatory cytokine in type 1 T-helper (Th1) responses. The functional 607A/C promoter polymorphism of the IL-18 gene is also associated with the psychopathology of this disorder. However, no current study has explored its role in the clinical symptoms of schizophrenia as mediated through IL-18 levels. We recruited 772 inpatients with schizophrenia and 775 healthy controls in a Han Chinese population and genotyped the IL-18-607A/C polymorphism. Patient psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS). Serum IL-18 levels were measured in 80 patients and 93 healthy controls. Our results showed that there were no significant differences in the distribution of the allele and genotype frequencies between the patients and controls. Both increased IL-18 serum level and the IL-18-607A/C polymorphism were positively associated with the PANSS general psychopathology subscore and the PANSS total score. Moreover, interaction of increased IL-18 serum level and the IL-18-607A/C polymorphism influenced the clinical psychopathological symptoms, indicating that association of IL-18 level with the PANSS general psychopathology subscale or the total scores was present only among patients carrying the C allele. We demonstrate an association between the IL-18-607A/C variant and clinical psychopathological symptoms in schizophrenia. Findings suggest that the association between higher IL-18 levels and clinical symptoms in schizophrenia is dependent on the IL-18-607A/C polymorphism.

SynopsisObjective After pilot and preliminary studies aimed at identifying pertinent biochemical parameters, a multicenter clinical study was performed to evaluate the effect of pollution on human skin. Methods The clinical study was performed in collaboration with the ‘Centre Regional de lutte contre le cancer de Montpellier’ and the ‘National Institute of Public Health of Mexico’ on 96 subjects in Mexico City (exposed to pollution) and 93 subjects in Cuernavaca (less exposed to pollution). Both biochemical and clinical skin parameters were studied. Results The study demonstrated significant quantitative and qualitative modifications of parameters related to sebum excretion in Mexico City compared to Cuernavaca one: An increased level of sebum excretion rate, a lower level of vitamin E and squalene in sebum, an increase of lactic acid and a higher erythematous index on the face of the subjects. In the stratum corneum, a significant higher level of carbonylated proteins and a lower level of IL 1α were noticed, as well as a decrease of ATP concentration with a decrease of chymotrysin like activity, without modifications of corneodesmosin content and trypsin like activity. From a clinical point of view, a higher frequency of atopic and urticarial skins, a higher frequency of red dermographism, an important seborrheic status at the forehead level and a lower level of dandruffs were noted in Mexico City population. The analysis taking into account the sex does not modify the observed results. Conclusion The study demonstrated an important impact of polluted environmental conditions on skin quality, evidencing important modifications of superficial biochemical parameters. The cause/effects relationships of these modifications remain, however, to be further assessed by a complementary in vitro/in vivo approaches.

We evaluated 4 volume-based automatic image registration algorithms from 2 commercially available treatment planning systems (Philips Syntegra and BrainScan). The algorithms based on cross correlation (CC), local correlation (LC), normalized mutual information (NMI), and BrainScan mutual information (BSMI) were evaluated with: (1) the synthetic computed tomography (CT) images, (2) the CT and magnetic resonance (MR) phantom images, and (3) the CT and MR head image pairs from 12 patients with brain tumors. For the synthetic images, the registration results were compared with known transformation parameters, and all algorithms achieved accuracy of submillimeter in translation and subdegree in rotation. For the phantom images, the registration results were compared with those provided by frame and marker-based manual registration. For the patient images, the results were compared with anatomical landmark-based manual registration to qualitatively determine how the results were close to a clinically acceptable registration. NMI and LC outperformed CC and BSMI, with the sense of being closer to a clinically acceptable result. As for the robustness, NMI and BSMI outperformed CC and LC. A guideline of image registration in our institution was given, and final visual assessment is necessary to guarantee reasonable results.

The HL–A antigens of a Chinese population now living on the island of Taiwan have been investigated with reagents obtained from and characterized in Caucasian populations and with antisera obtained from Chinese multiparous women. Both HL–A2, the most frequent specificity found, and HL–A9 appear highly heterogeneous in this Chinese population since groups of antisera used to define HL–A2 or 9 in Caucasians gave discordant reactions. Moreover, new associations were found using chi-square and cluster analyses, further demonstrating the complexity of HL–A in this Taiwanese population. Fourteen % of 1183 Chinese multipara sera and 237 sera from multiple transfused individuals were lyrnphocytotoxic and could be placed by cluster analysis into three major groups.

The whey prepared from human milk has been shown to contain the HL-A antigens of the milk donor. The inhibition of specific and nonspecific anti-HL-A alloantisera by the antigens in whey was assessed by a microcytotoxicity assay employing 51Cr release. After centrifugation at 100,000 g for 1 h, significant serologic activity could be demonstrated by the antigens contained in both the insoluble fraction and the soluble fraction. The serologic activity of the HL-A antigens in whey was specific and dose-dependent. The HL-A antigens were not equally represented within the soluble fraction when compared to their distribution in the insoluble fraction, and this may indicate some antigen destruction upon solubilization.

SummaryStudies on physiology and pathology as they relate to the immune system draw heavily upon rodent models. With the increasing impetus provided by initiatives in translational medicine, the demand for ever more sophisticated, ‘humanized’ murine models is greater than ever. However, the design and implementation of studies in such mice is far from trivial. Here we provide a technical perspective on the increasing interest in developing humanized mice. We give examples of primary data starting with the routine procurement of human donor material, through CD34+ cell purification prior to engraftment to injection into immunocompromised mice. Our goal is to provide practical advice to the many investigators who may be commencing or considering such studies.

Although the association between trauma exposure and posttraumatic stress disorder (PTSD) symptoms is well established, how such trauma is incorporated into identity, or the centrality of the negative event, is also of considerable importance in understanding the development of psychological symptoms. Alternatively, positive event centrality may have positive effects on well-being in the face of trauma. Thus, the current study examined associations between positive and negative event centrality, and both adaptive and maladaptive outcomes, above and beyond the impact of traumatic experience. A sample of 214 college students completed a series of self-report questionnaires. As anticipated, negative event centrality predicted PTSD and other maladaptive measures of functioning, even after controlling for traumatic experience. High levels of positive event centrality predicted adaptive, as opposed to maladaptive, psychological functioning. Results also suggested that both positive and negative event centrality predicted posttraumatic growth, controlling for traumatic experience. These findings suggest that assessing centrality of trauma may also be valuable in the prediction of psychological symptoms. The implications of these findings and proposals for future work are discussed further.

African-Americans have been found to experience increased rates of post-traumatic stress disorder (PTSD), obesity, and flatter diurnal cortisol slopes compared to other demographic groups. Further exploration, however, is needed to understand how PTSD impacts diurnal cortisol activity in obese African-American women. The purpose of the current study is to examine the relationship between salivary cortisol levels and PTSD in a sample of obese young adult African-American women and to examine how depression and insomnia influence the relationship.Thirty-four young adult African-American women (mean age = 24.0 years; mean BMI = 37.4 kg/m(2), 6/34 of the sample had a score of 40 or above on the PTSD Checklist (PCL) representing clinically significant PTSD) filled out questionnaires assessing PTSD, lifetime exposure to traumatic events, insomnia severity, and depression. A home-based assessment of salivary cortisol was provided upon awakening at 30 min and 1, 3, 6, and 12 h.There was a significant interaction between PTSD status and diurnal cortisol activity (p 0.04). There were trends for higher cortisol levels at awakening (p 0.051) and 30 min post-awakening (p 0.059) with PTSD. The significance of the interaction between PTSD and cortisol was attenuated by co-varying for depression and insomnia (p 0.05).PTSD, influenced by depression and insomnia symptoms, has an impact on diurnal cortisol activity in obese young adult African-American women.

Obesity is highly prevalent and adds greatly to the risk of cardiovascular and metabolic diseases. However, a subset of the obese has been identified who do not appear to carry this risk. Some studies suggest that anthropomorphic correlates of risk, such as waist circumference, differ between African Americans and Whites and features of uncomplicated obesity have not been well characterized in this population. The goal of our study was to determine the prevalence and associated features of uncomplicated obesity, including relationships to waist circumference and the achievement of weight loss in primarily African American patients.A retrospective chart review.Outpatient medically supervised weight loss program located at a teaching hospital in Washington, DC.Predominately adult African American females.Thirty-one percent of our population had no documented metabolic or cardiovascular disease. This group was on average younger, but had similar waist circumference (44 +/- 13.8 vs 44 +/- 6.6 inches) and achieved similar mean weight loss at 3 months (9.9 +/- 10.4 vs 10.3 +/- 12.4 lbs.) as the group with comorbid conditions.Waist circumference was not an indicator of risk among African American women and achieved weight loss did not depend on pre-existing comorbidities.

Critical care testing in a point of care (POC) setting can be very demanding for the laboratory. Lack of continuous monitoring of the normal functioning of POC instruments leads to late response to technical problems, and frequently results in more comprehensive interventions and reduced instrument availability. As most POC instruments lack adequate data transfer capabilities, manual data entry into the medical records with a high error rate is a component of POC programs. To reduce this data handling drawback of POC testing, our hospital opted for the replacement of the existing analysers with network-ready, expandable analysers (ABL700), linked to an integrated management system (RADIANCE). This new set-up enabled us to have continuous instrument control and maximal data management. The implementation of the integrated management system was well accepted by the operators. The network connectivity has led to real time technical support while reducing the workload by automating data collection.

Tumor markers are elevated in a variety of nonneoplastic clinical situations, including liver diseases. Their sensitivity and specificity are lower for tumor screening in these cases. In this study, we investigated the frequency and significance of elevated tumor markers in the pre-orthotopic liver transplantation (OLT) evaluation among patients with end-stage liver disease who did not develop tumors after a long follow-up post-OLT. We performed a retrospective analysis of clinical and biological parameters of 100 OLT candidates comparing data for CA 125, CA 19-9, CA 15-3, and carcinoembryonic antigen (CEA) levels. CA 125, CA 19-9, CA 15-3, and CEA levels were elevated in 59%, 53%, 29%, and 28% of cases, respectively. CA 125, CA 15-3, and CEA were associated with disease severity (Child-Pugh classification). CA 125 was also elevated among patients with ascites, esophageal varices, or alcohol-related cirrhosis. Elevated CA 19-9 levels were associated with increased CA 15-3 and CEA levels. CA 15-3 levels were also increased among patients with elevated alkaline phosphatase, while elevated CEA was related to ascites, bilirubin, and prothrombin time (PT) levels, as well as alcohol-related cirrhosis. There was no association between hepatocellular carcinoma and tumor markers. In conclusion, CA 125, CA 19-9, CA 15-3, and CEA were frequently elevated among end-stage liver disease patients. These elevations were not associated with tumor diseases in this population.

Plasma levels of visceral proteins (VP) are commonly used for evaluation of nutritional status. Low values observed in burn patients are caused by several factors including microvascular hyper-permeability and inflammatory processes. The aim of the study was to define a range of standard values specific to burn patients. Retrospective review: from days post-burn 12 to 43, four VP and three acute phase reactants (APR) were measured twice a week, in the plasma of 107 burn patients. From these data, standard' values were determined in respect with burn surface area (BSA) and post-burn time. The results were that the VP increase and APR decrease linearly during the study. Correlation between plasma proteins and BSA or post-burn day, change from protein to protein. Albumin and transferrin are less sensitive than prealbumin and especially retinol binding protein to variations of APR, but transferrin lacks of specificity. The conclusion of the study was that plasma levels of VP have to be compared to reference standard values. When levels lower than theoretical values are observed, simultaneous APR values (especially C reactive protein) have to be compared to their own reference standard, in order to separate nutritional from inflammatory effects.

The Calgary Depression Scale for Schizophrenia (CDSS) is a nine-item structured interview scale developed by Addington et al. to assess depression in schizophrenics. This paper describes the testing of the reliability and validity of the French version of the CDSS in a population of 70 schizophrenic patients. The validity of the CDSS as a measure of depression was confirmed; a single factor accounted for 41% of the variance of the nine items. The total score on the CDSS was strongly correlated with those on the Montgomery-Asberg Depression Rating Scale (MADRS), the Hamilton Depression Rating Scale (HDRS) and also the G6 item (depression) of the Positive and Negative Syndrome Scale (PANSS). The correlation with the Psychomotor Retardation Scale (ERD) total score was much less significant and was better with the 'subjective' subscore. The internal consistency was good, with a Cronbach's alpha of 0.79. A high level of inter-rater reliability was observed (weighted kappa values were >0.75 in all cases). The CDSS has a lower stability over time than other depression scales. It is a simple, quick and reliable scale for assessing depression in schizophrenic populations.

Aims: Tissue transglutaminase (tTG) was recently identified as the major autoantigen in coeliac disease. The aim of this multicentre study was to evaluate the impact of a new immunoenzymatic assay for the detection of IgA anti-tGT antibodies. Methods: Seventy four Italian and French clinical laboratories participated in this study; anti-tTG IgA with an enzyme linked immunosorbent assay (ELISA) method using guinea pig liver extract as the coating antigen, anti-endomysium IgA autoantibodies (EMA), and total serum IgA were determined in 7948 patients, 1162 of whom had coeliac disease (737 untreated cases and 425 on a gluten free diet). A proportion of the sera were then sent to a reference laboratory for anti-tTG retesting with an ELISA method using recombinant human tTG antigen. Results: Seven thousand four hundred and fifty eight (93.8%) sera were EMA/antiguinea pig tTG concordant (positive or negative); 490 (6.2%) were non-concordant. The sensitivity of EMA and antiguinea pig tTG in the 737 untreated patients with coeliac disease was 92.1% and 94.8%, respectively, and the specificity was 99.8% and 99.2%, respectively. Retesting of the discordant sera showed that of the 162 sera classified as EMA negative/antiguinea pig tTG positive, only 49 were positive for human recombinant anti-tTG, and that 39 of these were also EMA positive. Furthermore, of the 36 sera classified as EMA positive/antiguinea pig tTG negative, only two were confirmed as EMA positive. Conclusions: The antiguinea pig tTG assay is more sensitive but less specific than EMA, whereas the antihuman recombinant tTG assay is far more specific and just as sensitive as antiguinea pig tTG. Testing for EMA presents considerable interpretative problems and is difficult to standardise.

Seronegative spondylarthropathies are disorders with the same predisposing antigen, namely HLA B27, a class I molecule of the HLA system. The mechanisms of the different diseases are unknown, and there is no proof of immune system participation. We have investigated patients with spondylarthropathies in order to search for an immunological component in the pathophysiology of these disorders, by measuring the serum level of two inflammatory cytokines--IL1 beta and TNF alpha--by a radioimmunological assay and the serum level of two soluble T cell activation markers--soluble IL2 receptor and soluble CD8--by an enzyme-linked immunosorbent assay. The choice of soluble CD8 can be explained by the strong link between HLA B27 and spondylarthropathies. Our series compared 24 patients to 24 healthy matched controls. A similar IL1 beta serum level was observed in both groups, while in the patients there was a nonsignificant increase in the TNF alpha level, a significant decrease in the soluble IL2 receptor level and a significant increase in the soluble CD8 serum level. The normal or moderately increased serum IL1 beta and TNF alpha levels in the disease group do not exclude a local role for these cytokines in the synovium or other inflammatory areas. However, we found a higher soluble CD8 serum level in the patient group. Most of these patients were in clinical exacerbation of their disease. As the serum level of soluble CD8 is well correlated with T CD8 lymphocyte activation, our data suggest that this lymphocyte subset is stimulated and consequently probably involved in seronegative spondylarthropathies.

The mothers (n = 100) of consecutive infants admitted to a mothercraft residential facility were asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Only one of the women had been identified prior to the infant's admission as having postnatal depression, but 39% scored above the cut-off point for likely major depressive disorder. No specific infant problem correlated significantly with a higher depression score. The extent of serious mood disorders in the post-partum population has remained generally unacknowledged despite an upsurge of recent research activity in the field. Nevertheless, this problem has considerable public health significance, impinging as it does on the health of all members of the family. Possible screening and intervention strategies are discussed.