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Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Background: Infectious complications (IC) caused by bacterial strains often impede anticancer therapy. The study aimed to retrospectively analyze bacterial IC that could help predict the risk and o...

Introduction: Surgeries that spare the adrenal cortex during adrenalectomy have profound justification. Indications for this type of surgery are fairly strict, and more than 30 years of observations continuously verify the results of the procedure. Material and methods: Of a total of 650 adrenalectomies, 22 (3.4%) were adrenal cortex-sparing surgeries. There were 16 women and six men in this group. In 10 cases, surgery was performed for pheochromocytoma, eight cases involved Conn’s syndrome, and in four cases — paragangliomas located in the para-adrenal region. Secretory activity was identified in all cases. Results: Laparoscopic partial adrenalectomy was performed in 20 patients. Conversion to open laparotomy was necessary in two cases. In patients after bilateral resection of pheochromocytoma surgery, glucocorticoids were supplemented for six weeks. No significant surgical complications were observed in this group. Conclusions: Partial adrenalectomy for minor lesions should be a much more commonly utilised treatment method (of choice). Where bilateral adrenalectomy is necessary, a sparing procedure on one side protects patients from the need for hormonal substitution. The remaining part of the adrenal gland undertakes satisfactory secretory function after six weeks at the latest.

Purpose The purpose of this study was to identify modifiable factors associated with research activity among residents working in orthopedic surgery and traumatology. Methods Residents at 796 university-affiliated hospitals in Austria, Germany, and Switzerland were invited to participate. The online survey consisted of questions that ascertained 13 modifiable and 17 non-modifiable factors associated with the residents’ current research activities. Responses of 129 residents were analyzed. Univariate linear regression was used to determine the association of individual factors with the current research activity (hours per week). The impact of significant non-modifiable factors (with unadjusted p values Results The univariate analysis demonstrated six non-modifiable factors that were significantly associated with the current research activity: a University hospital setting (p p = 0.024), Swiss residents (p = 0.0012), the completion of a dedicated research year (p = 0.007), female gender (p = 0.016), and the department’s size (p = 0.048). Multivariate regression demonstrated that the number of protected research days per year (p p p Conclusions As hypothesized, more frequent and predictable protected research days were associated with higher research activity among residents in orthopedic surgery and traumatology. Level of evidence III.

Introduction: Regenerative capacity of the heart is limited, and the post-infarct left ventricle (LV) dysfunction is associated with poor prognosis. Administration of stem/progenitor cells (SPCs) is a promising approach for cardiac regeneration. Objectives: In the study, we assessed LV function and post-infarcted remodeling in patients with ST-elevated myocardial infarct (STEMI) who received autologous lineage-negative (LIN-) SPCs. Patients and methods: Patients with STEMI and one-vessel coronary artery disease treated with percutaneous revascularisation were divided into study group (LIN- group, 15 patients) that received standard therapy and autologous BM-derived LIN- SPCs and control group (standard therapy group, 19 patients). The cells were administered intracoronary 24 hours after STEMI. The follow-up was 12 months with subsequent non-invasive tests and laboratory parameter evaluation on days 1st, 3rd, and 7th as well as at 1st, 3rd, 6th and 12th month after STEMI. Results: All procedures related to SPCs administration were well tolerated by the patients. In 12-month follow-up, there were no major adverse cardiac events connected with LIN- SPCs administration. During 12-month follow-up, 9 patients from LIN- group (Responders) achieved an improvement in LV ejection fraction (>10% after 12 months) with no signs of unfavorable LV remodeling. Laboratory parameters analysis showed that Troponin T levels were significantly lower until day 7th in the Responders group, while brain natriuretic peptide (BNP) level remained significantly lower from day 3rd to 12th month respectively. Conclusions: Intracoronary infusion of autologous BM-derived LIN- stem/progenitor cells is feasible and safe for patient. Improvement in LV function and prevention of unfavorable remodeling in the 60% of study group seems relatively promising. Stem cell-based therapy for cardiac regeneration still needs more accurate and extensive investigations to estimate and improve their efficacy.

To report the clinical and structural outcomes for non-pseudoparalytic irreparable posterosuperior rotator cuff tears treated with superior capsule reconstruction (SCR) using dermal allograft (DA).Patients who underwent SCR using DA with a mean thickness of 3 mm for irreparable posterosuperior rotator cuff tears and underwent surgery at least 2 years earlier were included. Outcomes were assessed prospectively by the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; patient satisfaction; and visual analog scale for pain. Structurally, acromiohumeral distances (AHDs) were assessed both preoperatively and postoperatively (standard radiographs). Graft integrity was assessed by magnetic resonance imaging. Clinical failures were reported.We included 22 patients with a mean age of 56 years (range, 41-65 years) and a mean follow-up period of 2.1 years (range, 2-3 years). The ASES score improved from 54.0 to 83.9 (P.001); the Single Assessment Numeric Evaluation score improved from 44.9 to 71.4 (P.001); and Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH) improved from 37.6 to 16.2 (P = .001). Of the patients, 85% achieved an improvement in the ASES score that exceeded the minimal clinically important difference (11.1 points). The median patient satisfaction rating was 8.5 (range, 1-10). The median preoperative visual analog scale score decreased from 4 to 0 (range, 0-3) postoperatively (P.001). Complete radiographs of 19 of 22 patients (86%) were obtained at a mean of 5.2 months (range, 1.4-10 months) postoperatively and showed a significant increase in the mean AHD from 7.0 mm preoperatively to 8.3 mm postoperatively (P = .029). Postoperative magnetic resonance imaging scans were obtained in 95% of the patients (21 of 22) at a mean of 2.5 months (range, 0.3-10.2 months) postoperatively and showed graft integrity rates of 100% (21 of 21) on the tuberosity side, 76% (16 of 21) at the midsubstance, and 81% (17 of 21) on the glenoid side. No significant differences in clinical outcome scores (P0.930) were found in patients with intact grafts versus those with torn grafts. The number of previous shoulder surgical procedures was a negative predictor of clinical outcome. There was 1 clinical failure.SCR using DA for irreparable tears improves outcomes with high satisfaction and high graft integrity at short-term follow-up. Graft integrity, although correlated with an increased AHD, had no correlation with clinical outcomes at final follow-up.Level IV, case series.

Fat-soluble vitamin deficiency remains a challenge in cystic fibrosis (CF), chronic pancreatitis, and biliary atresia. Liposomes and cyclodextrins can enhance their bioavailability, thus this multi-center randomized placebo-controlled trial compared three-month supplementation of fat-soluble vitamins in the form of liposomes or cyclodextrins to medium-chain triglycerides (MCT) in pancreatic-insufficient CF patients. The daily doses were as follows: 2000 IU of retinyl palmitate, 4000 IU of vitamin D3, 200 IU of RRR-α-tocopherol, and 200 µg of vitamin K2 as menaquinone-7, with vitamin E given in soybean oil instead of liposomes. All participants received 4 mg of β-carotene and 1.07 mg of vitamin K1 to ensure compliance with the guidelines. The primary outcome was the change from the baseline of all-trans-retinol and 25-hydroxyvitamin D3 concentrations and the percentage of undercarboxylated osteocalcin. Out of 75 randomized patients (n = 28 liposomes, n = 22 cyclodextrins, and n = 25 MCT), 67 completed the trial (89%; n = 26 liposomes, n = 18 cyclodextrins, and n = 23 MCT) and had a median age of 22 years (IQR 19–28), body mass index of 20.6 kg/m2 [18.4–22.0], and forced expiratory volume in 1 s of 65% (44–84%). The liposomal formulation of vitamin A was associated with the improved evolution of serum all-trans-retinol compared to the control (median +1.7 ng/mL (IQR −44.3–86.1) vs. −38.8 ng/mL (−71.2–6.8), p = 0.028). Cyclodextrins enhanced the bioavailability of vitamin D3 (+9.0 ng/mL (1.0–17.0) vs. +3.0 ng/mL (−4.0–7.0), p = 0.012) and vitamin E (+4.34 µg/mL (0.33–6.52) vs. −0.34 µg/mL (−1.71–2.15), p = 0.010). Liposomes may augment the bioavailability of vitamin A and cyclodextrins may strengthen the supplementation of vitamins D3 and E relative to MCT in pancreatic-insufficient CF but further studies are required to assess liposomal vitamin E (German Clinical Trial Register number DRKS00014295, funded from EU and Norsa Pharma).

Introduction: Extraperitoneal, abdominal paragangliomas most commonly originate from the sympathetic nervous system. Typical features include catecholamine overproduction and the potential for malignancy. Lesions are usually located paravertebrally, but when growing in a more expansive manner they may also appear between the inferior vena cava and aorta. In the authors’ opinion this site excludes laparoscopic tumourectomy. Material and methods: Twenty-eight patients were selected for surgical management of abdominal paragangliomas in the past eight years at our endocrine surgical centre. This group consisted of 21 (75%) women and seven (25%) men, aged 14 to 84 years (mean 47.9). In 13 (46.4%) cases paroxysmal hypertension was observed. Type 2 diabetes was noted in another 10 (35.7%) patients, and Takotsubo acute coronary syndrome in two (7.1%). Patients were preoperatively qualified for either open surgery or laparoscopic tumourectomy based on visualisation and location of the tumours in imaging studies. Results: All patients were successfully operated. Eleven (39.3%) patients qualified for laparoscopy, while the remaining 17 (60.7%) were treated with an open surgical approach due to difficult access to the lesion. The mean operative time was 130 minutes for laparoscopy and 120 minutes for laparotomy (p = 0.2). There were no local or general complications after either type of procedure. Conclusions: The use of laparoscopic access is practically excluded in the treatment of paragangliomas located between the inferior vena cava and aorta, especially at the level of the renal vessels and extending superiorly to the diaphragm.

Epidemiologic data of proximal hamstring avulsions have mainly been reported in relatively small patient cohorts. Detailed information on patient demographics, injury mechanism, and injury patterns is lacking in the literature. Since these injuries are rare and frequently misdiagnosed, a better understanding may help to increase awareness and to improve diagnosis of proximal hamstring avulsions. A chart review was performed to identify all patients who had undergone surgical repair for complete proximal hamstring avulsions between 01/2006 and 02/2019 at the authors’ institution. The following demographic and injury-specific data were obtained: Sex, age, body mass index (BMI), cause of injury (sports, activities of daily living, and others), presence of neurologic symptoms referable to the sciatic nerve, time to surgery, injury pattern (affected tendons), tendon retraction, and type of injury according to Wood et al.`s classification (Type 1: osseous avulsions, Type 2: tear at the musculotendinous junction, Type 3: incomplete avulsion from bone, Type 4: complete avulsion with only minimal retraction, and Type 5: complete avulsion with retraction > 2 cm). Data were analyzed for the entire study population and group comparison was performed with regard to sex, cause of injury, and the type of injury. A total of 263 patients were included (53% male). The mean age was 49 ± 13 years with most patients (56%) aged between 45–59 years. Most injuries occurred while participating in sports (52%) and injury type 5 was most commonly diagnosed (66%). Five percent of patients had sensory deficits referable to the sciatic nerve. Gender comparison showed that female patients were significantly older, predominantly represented in the age group 45–59 years, and most commonly injured during activities of daily living, whereas male patients were significantly more often represented in younger age groups, and the most common cause of injury was sports. Compared to Type 4 and 5 injuries, patients with a Type 1 injury were significantly younger and had a significantly longer time to surgery. Proximal hamstring avulsion occurs predominately in the middle-aged patient and only rarely in patients under the age of 30 years. No gender dominance exists. Female patients are typically older and get injured during activities of daily living, whereas male patients are younger and get injured more often during sports. These epidemiologic data may help physicians to make an accurate and early diagnosis. IV.

Background The interest in cystic fibrosis (CF) dyslipidaemia as a potential risk factor for cardiovascular disease is increasing with patients' survival. This study aimed to investigate CF dyslipidaemia, its clinical correlates and links to oxidized low-density lipoprotein (oxLDL), adiponectin, and apolipoprotein E (APOE). Methods This cross-sectional study assessed clinical characteristics of CF, as well as the serum lipid profile, oxLDL, adiponectin, and APOE. Results In total, 108 CF subjects were enrolled in this study, with a median age of 22 years, BMI of 20.5 kg/m2, FEV1% of 61%, of which 81% were pancreatic insufficient (PI). Healthy subjects (HS; n = 51) were in similar age. Hypocholesterolaemia occurred in 31% of CF subjects and in no HS. Hypertriglyceridaemia concerned 21% of patients (HS: 8%, p = .04), and low HDL-C 45% (HS: 6%, p Conclusions CF dyslipidaemia is highly prevalent and heterogenous. The lipid profile weakly associates with the clinical characteristics of CF as well as oxLDL, adiponectin, and APOE. Further research is needed, especially regarding HDL function in CF, the causes of hypertriglyceridaemia, and the value of essential fatty acid supplementation for CF dyslipidaemia.

Implantation of an acellular dermal allograft between glenoid and humerus to restore a stable glenohumeral center of rotation in cases of irreparable posterosuperior rotator cuff tears.Irreparable posterosuperior rotator cuff tears with low-grade cuff tear arthropathy (Hamada grade 1 and 2) and isolated pseudoparesis for flexion.Absolute: Infection, nerve lesions (brachial plexus, axillary nerve), concomitant irreparable subscapularis tendon tear, anterosuperior subluxation of the humeral head ("anterosuperior escape"). Relative: Cuff tear arthropathy ≥ Hamada grade 3, fatty infiltration of the infraspinatus muscle ≥ Goutallier grade 2, deficiency of the deltoid muscle, inability to adhere to the rehabilitation program, poor compliance.Arthroscopic fixation of a 6 mm thick acellular dermal allograft with three suture anchors at the superior glenoid rim and a double-row construct at the greater tuberosity. Dorsal and ventral interval closure with side-to-side sutures.Abduction brace for 6 weeks with passive mobilization. Active motion exercises are commenced at 6 weeks with progression to strengthening exercises after 12 weeks.Between April 2019 and September 2020, 15 patients (5 women and 10 men) underwent arthroscopic superior capsule reconstruction using a 6 mm thick acellular dermal allograft for treatment of irreparable posterosuperior rotator cuff tears. After a mean follow-up of 15.4 ± 5.5 months, there was a significant improvement in active flexion (102° ± 37°OPERATIONSZIEL: Wiederherstellung eines stabilen glenohumeralen Rotationszentrums bei irreparablen Rupturen der posterosuperioren Rotatorenmanschette durch Implantation eines azellulären dermalen Allografts zwischen Glenoid und Humerus.Irreparable posterosuperiore Rotatorenmanschettenrupturen mit niedriggradiger Defektarthropathie (Stadium 1 und 2 nach Hamada) und isolierter Pseudoparese für Flexion.Absolut: Infekt, Nervenschädigung (Plexus brachialis, N. axillaris), begleitende irreparable Ruptur der Subskapularissehne, anterosuperiore Subluxation des Humeruskopfes („anterosuperiorer Escape“). Relativ: Defektarthropathie ≥ Stadium 3 nach Hamada, fettige Infiltration des M. infraspinatus ≥ Grad 2 nach Goutallier, Insuffizienz des M. deltoideus, Unfähigkeit, das Rehabilitationsprogramm einzuhalten, mangelnde Compliance.Arthroskopische Fixation eines 6 mm dicken azellulären dermalen Allografts mit 3 Fadenankern am oberen Glenoidrand und einer Doppelreihenkonstruktion am Tuberculum majus. Dorsaler und ventraler Intervallverschluss mit Seit-zu-Seit-Nähten.Abduktionsorthese für 6 Wochen mit passiver Mobilisation. Ab 7. Woche aktive, belastungsfreie Mobilisation und nach 12 Wochen Belastungsaufbau.Zwischen April 2019 und September 2020 wurde bei 15 Patienten (5 Frauen und 10 Männer) eine arthroskopische superiore Kapselrekonstruktion mit einem 6 mm dicken azellulären dermalen Allograft zur Behandlung einer irreparablen Ruptur der posterosuperioren Rotatorenmanschette durchgeführt. Nach einem durchschnittlichen Nachuntersuchungszeitraum von 15,4 ± 5,5 Monaten zeigte sich eine signifikante Verbesserung der aktiven Flexion (102° ± 37°

Background Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) currently constitutes the leading and overwhelming health issue worldwide. In comparison with adults, children present milder symptoms, with most having an asymptomatic course. We hypothesized that COVID-19 infection has a negative impact on the continuation of chemotherapy and increases nonrelapse mortality. Material and methods This study was performed to assess the course of SARS-CoV-2 among children with hematological or oncological malignancies and its impact on cancer therapy. Records of SARS-CoV-2 infection in 155 children with malignancies from 14 Polish centers for pediatric hematology and oncology were collected and analyzed. Results SARS-CoV-2 replication was observed in 155 patients. Forty-nine patients were symptomatic, with the following being the most common manifestations: fever (31 patients), gastrointestinal symptoms (10), coryza (13), cough (13) and headache (8). In children who were retested, the median time of a positive PCR result was 16 days (range 1–70 days), but 12.7% of patients were positive beyond day + 20. The length of viral PCR positivity correlated with the absolute neutrophil count at diagnosis. Seventy-six patients did not undergo further SARS-CoV-2 testing and were considered convalescents after completion of isolation. Antibiotic therapy was administered in 15 children, remdesivir in 6, convalescent plasma in 4, oxygen therapy in 3 (1—mechanical ventilation), steroids in 2, intravenous immunoglobulins in 2, and heparin in 4. Eighty patients were treated with chemotherapy within 30 days after SARS-CoV-2 infection diagnosis or were diagnosed with SARS-CoV-2 infection during 30 days of chemotherapy administration. Respiratory symptoms associated with COVID-19 and associated with oxygen therapy were present in 4 patients in the study population, and four deaths were recorded (2 due to COVID-19 and 2 due to progressive malignancy). The probability of 100-day overall survival was 97.3% (95% CI 92.9–99%). Delay in the next chemotherapy cycle occurred in 91 of 156 cases, with a median of 14 days (range 2–105 days). Conclusions For the majority of pediatric cancer patients, SARS-CoV-2 infection does not result in a severe, life-threatening course. Our data show that interruptions in therapy are common and can result in suboptimal therapy.

Background Lung resection is a controversial and understudied therapeutic modality in Primary Ciliary Dyskinesia (PCD). We assessed the prevalence of lung resection in PCD across countries and compared disease course in lobectomised and non-lobectomised patients. Methods In the international iPCD cohort, we identified lobectomised and non-lobectomised age and sex-matched PCD patients and compared their characteristics, lung function and BMI cross-sectionally and longitudinally. Results Among 2896 patients in the iPCD cohort, 163 from 20 centers (15 countries) underwent lung resection (5.6%). Among adult patients, prevalence of lung resection was 8.9%, demonstrating wide variation among countries. Compared to the rest of the iPCD cohort, lobectomised patients were more often females, older at diagnosis, and more often had situs solitus. In about half of the cases (45.6%) lung resection was performed before presentation to specialized PCD centers for diagnostic work-up. Compared to controls (n = 197), lobectomised patients had lower FVC z-scores (− 2.41 vs − 1.35, p = 0.0001) and FEV1 z-scores (− 2.79 vs − 1.99, p = 0.003) at their first post-lung resection assessment. After surgery, lung function continued to decline at a faster rate in lobectomised patients compared to controls (FVC z-score slope: − 0.037/year Vs − 0.009/year, p = 0.047 and FEV1 z-score slope: − 0.052/year Vs − 0.033/year, p = 0.235), although difference did not reach statistical significance for FEV1. Within cases, females and patients with multiple lobe resections had lower lung function. Conclusions Prevalence of lung resection in PCD varies widely between countries, is often performed before PCD diagnosis and overall is more frequent in patients with delayed diagnosis. After lung resection, compared to controls most lobectomised patients have poorer and continuing decline of lung function despite lung resection. Further studies benefiting from prospective data collection are needed to confirm these findings. Background Primary Ciliary Dyskinesia (PCD) is a genetically heterogeneous disorder characterized by laterality defects and recurrent respiratory infections [1]. Bronchiectasis may develop already in childhood [2] and it is usually present in most adult PCD patients [3]. Late diagnosis is associated with worse clinical picture, [4,5,6] although even early diagnosis is followed by variable courses of lung function that are not linked to the level of lung function at diagnosis [7]. Management varies considerably between centers, as there are no evidence-based therapeutic guidelines for PCD [8]. Most of the current treatment protocols are extrapolated from Cystic Fibrosis (CF) studies.

PurposeTo analyze whether preoperative patellofemoral anatomy is associated with clinical improvement and failure rate after isolated patellofemoral arthroplasty (PFA) using a modern inlay-type trochlear implant.MethodsProspectively collected 24 months data of patients treated with isolated inlay PFA (HemiCAP®Wave, Arthrosurface, Franklin, MA, USA) between 2009 and 2016, and available digitalized preoperative imaging (plain radiographs in three planes and MRI) were retrospectively analyzed. All patients were evaluated using the WOMAC score, Lysholm score, and VAS pain. Patients revised to TKA or not achieving the minimal clinically important difference (MCID) for the total WOMAC score or VAS pain were considered failures. Preoperative imaging was analyzed regarding the following aspects: Tibiofemoral OA, patellofemoral OA, trochlear dysplasia (Dejour classification), patellar height (Insall–Salvati index [ISI]; Patellotrochlear index [PTI]), and position of the tibial tuberosity (TT–TG and TT–PCL distance).ResultsA total of 41 patients (61% female) with a mean age of 48 ± 13 years could be included. Fifteen patients (37%) were considered failures, with 5 patients (12%) revised to TKA and 10 patients (24%) not achieving MCID for WOMAC total or VAS pain. Failures had a significantly higher ISI, and a significantly lower PTI. Furthermore, the proportion of patients with a pathologic ISI (> 1.2), a pathologic PTI (ConclusionPreoperative patellofemoral anatomy is significantly associated with clinical improvement and failure rate after isolated inlay PFA. Less improvement and a higher failure rate must be expected in patients with patella alta (ISI > 1.2 and PTI 21 mm). Concomitant procedures such as tibial tuberosity transfer may, therefore, be considered in such patients.Level of evidenceLevel III, retrospective analysis of prospectively collected data.

Background: Amyotrophic lateral sclerosis (ALS) is one of the most frequently occurring neurodegenerative diseases affecting speech and swallowing. This preliminary study aimed to investigate whether an autologous lineage-negative stem/progenitor cell therapy applied to ALS patients affects the level of selected trophic and proinflammatory factors, and subsequently improves the articulation. Methods: We enrolled 12 patients with sporadic ALS, who underwent autologous bone marrow-derived lineage negative (LIN-) cells administration into cerebrospinal fluid (CSF). We evaluated patients' articulation using the Frenchay Dysarthria Assessment on days 0 and 28 following the LIN- cells administration. Concentrations of various factors (BDNF, NGF, ANGP-2, VEGF, PDGF-AA, PEDF, COMP-FH, CRP, C3, C4) in CSF were quantified by multiplex fluorescent bead-based immunoassays in the samples collected on the day of LIN- cells administration and 28 days later. On top of this, we assessed levels of BDNF and NGF in the patients' plasma on the day of the injection, three, seven days and three months after the treatment. Results: Of the 12 patients who received the LIN- cell therapy 8 showed short-termed improvement in articulatory functions (group I), which was particularly noticeable in better phonation time, lips and soft palate performance, swallowing reflex and voice loudness. Four patients (group II) did not show substantial improvement. CSF concentrations of BDNF, ANGP-2 and PDGF-AA in group I decreased significantly 28 days after LIN- cells administration. The highest concentration levels of BDNF in group II and NGF in both groups in blood plasma were observed on day 3 following the injection. Conclusions: The outcomes of the LIN- cell application in ALS treatment of articulatory organs are promising. The procedure proved to be safe and feasible. A short-lasting trophic effect of autologous LIN- administration could encourage repeated cell's application in order to sustain their beneficial effects, however this approach needs further investigation.

Background: The arthroscopic “bony Bankart bridge” (BBB) repair technique was recently shown to successfully restore shoulder stability at short-term follow-up, but longer-term outcomes have not yet been described. Purpose: To report the outcomes at minimum 5-year follow-up after BBB repair for anterior shoulder instability with a bony Bankart lesion. Study Design: Case series; Level of evidence, 4. Methods: Patients were included if they sustained a bony Bankart lesion, were treated with a BBB technique, and were at least 5 years postoperative. Patients were excluded if they underwent concomitant rotator cuff repair or an open bone fragment reduction. All patients were assessed with the following measures preoperatively and at final evaluation: QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand), American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and 12-Item Short Form Health Survey (SF-12) Physical Component Summary. Results: From 2008 to 2012, 13 patients who underwent BBB met the inclusion criteria with a mean age of 39.6 years (range, 19.1-68.8 years) and a mean follow-up of 6.7 years (range, 5.1-9.0 years). Mean time from most recent injury to surgery was 6.3 months (range, 1 day–36 months). The mean glenoid bone loss was 22.5% (range, 9.1%-38.6%). Mean SF-12 scores demonstrated significant improvement from 45.8 (SD, 9.7) preoperatively to 55.1 (SD, 5.9) at a mean follow-up of 6.7 years. At final follow-up, the mean American Shoulder and Elbow Surgeons score was 93.1 (range, 68.3-100); the mean QuickDASH score, 6.2 (range, 0-25); and the mean Single Assessment Numeric Evaluation score, 92.8 (range, 69-99). None of the patients progressed to further shoulder surgery. Three of 13 patients (23%) reported subjective recurrent instability. At final follow-up, 9 of 12 (75%) patients indicated that their sports participation levels were equal to their preinjury levels. Median patient satisfaction at final follow-up was 10 of 10 points (range, 3-10). Conclusion: The arthroscopic BBB technique for patients with anterior bony Bankart lesions can restore shoulder stability, yield durable improvements in clinical outcomes, and provide a high return-to-sport rate at a minimum 5-year follow-up. Three of 13 patients experienced postoperative symptoms of instability but did not undergo further stabilization surgery.

Purpose The risk of vitamin E deficiency is of primary concern in cystic fibrosis patients. However, early diagnosis and routine vitamin E supplementation can lead to its normal or even high levels. In the present study, we assessed vitamin E status in a large group of cystic fibrosis patients. Moreover, we also aimed to establish determinants of its body resources in cystic fibrosis patients. Material and methods The study group comprised 211 cystic fibrosis patients aged from 1 month to 48 years. In all of them serum α-tocopherol concentration was analyzed using high-performance liquid chromatography. Results Median vitamin E concentration was 9.9 μg/ml (1st–3rd quartile: 7.5–13.5). Vitamin E deficiency was found in 17 (8.0%) and high levels were documented in 24 (11.4%) participants. Patients with and without vitamin E deficiency did not differ significantly with respect to age, standardized body weight and height, FEV1, albumin concentration and vitamin E supplementation dose. However, vitamin E deficiency appeared more frequently in participants without vitamin E supplementation. Moreover, in multiple linear regression analysis pancreatic insufficiency, severe CFTR gene mutation and vitamin E dose, were potentially defined as determinants of vitamin E concentration. Conclusions Vitamin E deficiency in cystic fibrosis patients is rather rare nowadays. Excessive vitamin E levels seem to be more frequent. Vitamin E status wasn’t documented to be strictly related to clinical determinants. Beyond vitamin E supplementation, exocrine pancreatic function and CFTR gene mutations may have had an impact on the vitamin E body resources in cystic fibrosis patients.

BACKGROUND The extracellular actin scavenging system (EASS) is composed of plasma Gc-globulin and gelsolin, and is responsible for the elimination of toxic actin from the bloodstream. OBJECTIVES In this study, we assessed the actin-free Gc-globulin concentrations in blood plasma and cerebrospinal fluid (CSF) obtained from subjects with neurodegenerative and inflammatory diseases of the central nervous system (CNS) as well as in a control group. MATERIAL AND METHODS Using an enzyme-linked immunosorbent assay (ELISA), we measured the actinfree Gc-globulin concentrations in blood plasma and CSF obtained from subjects diagnosed with Alzheimer's disease (AD) (n = 20), amyotrophic lateral sclerosis (ALS) (n = 12), multiple sclerosis (MS) (n = 42), tick-borne encephalitis (TBE) (n = 12), and from a control group (n = 20). RESULTS The concentrations of free Gc-globulin in plasma collected from patients diagnosed with AD (509.6 ±87.6 mg/L) and ALS (455.5 ±99.8 mg/L) did not differ significantly between each other, but were significantly higher compared to the reference group (311.7 ±87.5 mg/L) (p < 0.001 and p < 0.006, respectively) as well as to MS (310.8 ±66.6 mg/L) (p < 0.001 and p < 0.001, respectively) and TBE (256.7 ±76 mg/L) (p < 0.001 and p < 0.003, respectively). In CSF collected from patients diagnosed with AD and ALS, the concentrations of free Gc-globulin were 2.6 ±1.1 mg/L and 2.7 ±1.9 mg/L, respectively. They did not differ significantly between each other and were significantly higher compared to the reference group (1.5 ±0.9 mg/L) (p < 0.005 and p < 0.041, respectively). Interestingly, in patients with AD, significantly higher values of Gcglobulin were detected compared to multiple sclerosis patients (1.7 ±0.9 mg/L) (p < 0.013). CONCLUSIONS Higher concentrations of free Gc-globulin in blood plasma and CSF collected from patients suffering from neurodegenerative diseases may indicate a potential role of this protein in their pathogenesis, and represent a potential tool for the diagnosis of CNS diseases.

OBJECTIVE: The use of glucocorticoids for secondary (salvage/rescue) therapy of idiopathic sudden hearing loss (ISSHL), including controlled and uncontrolled studies with intratympanic injections or continuous, catheter mediated applications, were evaluated by means of a meta-analysis in an attempt to define optimal local drug delivery protocols for ISSHL. STUDY DESIGN: A total of 30 studies with 33 treatment groups between January 2000 and June 2014 were selected based on sufficiently detailed description of application protocols. Cochlear drug levels were calculated by a validated computer model of drug dispersion in the inner ear fluids based on the concentration and volume of glucocorticoids applied, the time drug remained in the middle ear, and on the specific timing of injections. Various factors were compared with hearing outcome, including baseline data, individual parameters of the application protocols, calculated peak concentration (C(max)), and total dose (Area under the curve, AUC). RESULTS: There was no dependence of hearing outcome on individual parameters of the application protocol, C(max) or AUC. Hearing gain and final hearing thresholds were independent of treatment delay. CONCLUSION: Based on the available data from uncontrolled and controlled randomized and non-randomized studies no clear recommendation can be made so far for a specific application protocol for either primary or secondary (salvage) intratympanic steroid treatment in patients with ISSHL. For meta-analyses, change in pure tone average (PTA) may not be an adequate outcome parameter to assess effectiveness of the intervention especially with inhomogeneity of patient populations. Final PTA might provide a better outcome parameter.

The purpose of this study was to investigate clinical outcomes following Achilles tendon allograft-augmented latissimus dorsi tendon transfer (LDTT) for the treatment of irreparable posterosuperior rotator cuff tears with a minimum of 2 years post-operative follow-up. We hypothesized that patients would show significant improvement in outcomes scores with a low failure rate. Patients who were treated with Achilles tendon allograft-augmented LDTT for irreparable posterosuperior rotator cuff tears with a minimum follow-up of 2 years were included. Patient-reported outcomes scores, including ASES, QuickDASH, SANE, SF-12 PCS, and satisfaction, were collected pre- and post-operatively. Pre- and post-operative scores were compared with a Wilcoxon test. Revision to reverse total shoulder arthroplasty (RTSA) was considered as failure. Between March 2006 and November 2014, a total of 16 patients with a mean age of 49 years (range 34–57 years) were included. Minimum 2-year outcomes data were available for 14 of the 16 patients (87.5%) with a mean follow-up of 5.5 years (range 2.1–10.5 years). Two patients (12.5%) advanced to RTSA at a mean of 1.1 years following LDTT. Postoperative median subjective outcomes scores improved, but did not reach statistical significance (SF-12 PCS: 35.4–46.4, P = 0.182; ASES: 47.5–69.9, P = 0.209; QuickDASH: 57.9–31.8, P = 0.176; SANE: 40.0–39.5, P = 0.273). Median post-operative patient satisfaction was 5 on a 10-point scale (range 1–10). Patients with irreparable rotator cuff tears treated with Achilles tendon allograft-augmented latissimus dorsi tendon transfer did not experience significant post-operative improvement in patient-reported outcomes. Thus, the use of an additional allograft-augmentation remains questionable. Retrospective case series, level IV.

Despite evidence suggesting that parent involvement was beneficial for infant and parent outcomes, the Family Integrated Care (FICare) programme was one of the first pragmatic approaches to enable parents to become primary caregivers in the neonatal intensive care unit (NICU). We aimed to analyse the effect of FICare on infant and parent outcomes, safety, and resource use.In this multicentre, cluster-randomised controlled trial, we stratified 26 tertiary NICUs from Canada, Australia, and New Zealand by country and size, and assigned them, using a computer-generated random allocation sequence, to provide FICare or standard NICU care. Eligible infants were born at 33 weeks' gestation or earlier, and had no or low-level respiratory support; parents gave written informed consent for enrolment. To be eligible, parents in the FICare group had to commit to be present for at least 6 h a day, attend educational sessions, and actively care for their infant. The primary outcome, analysed at the individual level, was infant weight gain at day 21 after enrolment. Secondary outcomes were weight gain velocity, high frequency breastfeeding (≥6 times a day) at hospital discharge, parental stress and anxiety at enrolment and day 21, NICU mortality and major neonatal morbidities, safety, and resource use (including duration of oxygen therapy and hospital stay). This trial is registered with ClinicalTrials.gov, number NCT01852695.From Oct 1, 2012, 26 sites were randomly assigned to provide FICare (n=14) or standard care (n=12). One site assigned to FICare discontinued because of poor site enrolment. Parents and infants were enrolled between April 1, 2013, and Aug 31, 2015, with 895 infants being eligible in the FICare group and 891 in the standard care group. At day 21, weight gain was greater in the FICare group than in the standard care group (mean change in Z scores -0·071 [SD 0·42] vs -0·155 [0·42]; p0·0002). Average daily weight gain was significantly higher in infants receiving FICare than those receiving standard care (mean daily weight gain 26·7 g [SD 9·4] vs 24·8 g [9·5]; p0·0001). The high-frequency exclusive breastmilk feeding rate at discharge was higher for infants in the FICare group (279 [70%] of 396) than those in the standard care group (394 [63%] of 624; p=0·016). At day 21, parents in the FICare group had lower mean stress scores than did parents in the standard care group (2·3 [SD 0·8] vs 2·5 [0·8]; p0·00043), and lower mean anxiety scores (70·8 [20·1] vs 74·2 [19·9]; p=0·0045). There were no significant differences between groups in the rates of the secondary outcomes of mortality, major morbidity, duration of oxygen therapy, and duration of hospital stay. Although the safety assessment was not completed, there were no adverse events.FICare improved infant weight gain, decreased parent stress and anxiety, and increased high-frequency exclusive breastmilk feeding at discharge, which together suggest that FICare is an important advancement in neonatal care. Further research is required to examine if these results translate into better long-term outcomes for families.Canadian Institutes of Health Research Partnerships for Health System Improvement, and Ontario Ministry of Health and Long-Term Care.

Purpose To investigate if patients younger than 50 years old had improved functional outcomes after subpectoral biceps tenodesis (BT) for the treatment of biceps reflection pulley (BRP) lesions at minimum 2-year postoperative follow-up. Methods Patients who had arthroscopically confirmed BRP tears that were treated with subpectoral BT and were at least 2 years out from surgery were included; patients were excluded if they had concomitant reconstructive or reparative procedures at index surgery. Patient-centered outcomes including return to activity, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores, and patient satisfaction were collected. The pre- and postoperative scores were compared with a Wilcoxon test. Failure was defined as revision BT. Results Between January 2006 and July 2014, of 1,184 patients who underwent open subpectoral BT, 14 patients (6 male, 8 female) with mean age 37 (range, 16-49 years) met the inclusion criteria. Minimum 2-year outcomes data were available for all 14 patients (100% follow-up). The mean follow-up was 3.6 ± 1.3 years. There were significant improvements postoperatively for all outcome scores ( P = .017 ASES, P = .002 QuickDASH, P = .003 SF-12 PCS). There was no correlation between age and outcome scores ( P > .05). Median patient satisfaction was 9 of 10. Five patients (36%) reported return to recreational activity with no modifications; 9 (64%) indicated a return to activity with modifications. The 5 patients who returned to recreational activity with no modification had significantly less time from initial injury/onset of symptoms until surgery in comparison with the 9 patients who modified their activity ( P = .028). No complications or reoperations were reported. Conclusions Patients younger than 50 years old with a symptomatic isolated BRP lesion experienced excellent results, high return to recreational activity, little postoperative pain, and high degrees of satisfaction when treated with subpectoral BT. Level of Evidence Level IV, therapeutic case series.

Background Routine administration of vitamin A, recommended in CF patients, can help to prevent its deficiency. However, high vitamin A supplementation may lead to its excessive level and possible toxicity. Therefore, the aim of the present study was to assess the status of vitamin A and the determinants of its body resources in CF patients. Methods In 196 CF patients aged from 4 months to 47 years, the following parameters were analysed: nutritional status (standardized body weight and height, serum albumin concentration) and clinical expression of disease (lung function - spirometry; biochemical markers of liver function - ALT, AST, GGT; respiratory tract colonization by Pseudomonas aeruginosa; diabetes; cirrhosis, non-cirrhotic liver disease; exocrine pancreatic function - fecal elastase-1 concentration; blood clotting - INR and vitamin A supplementation). Results Median vitamin A concentration in the study group was 383.0 ng/ml (1st-3rd quartile: 316.5-457.0). Vitamin A deficiency was found in 32 (16.3%) subjects studied. Vitamin A concentrations above the reference range were observed only in 3 (1.5%) CF patients. CF patients with vitamin A deficiency were significantly older and had lower values of FEV1 compared to CF subjects with normal vitamin A status. Moreover, vitamin A deficiency occurred more frequently in CF patients with diabetes, Pseudomonas aeruginosa colo- nization, worse lung function and in those without vitamin A supplementation. However, in multiple linear regression analyses, none of the independent variables was documented to be important for predicting vita- min A status. Conclusions Vitamin A body resources in CF patients are mostly normal. Moreover, there are no good de- terminants of vitamin A status in these patients. Further studies targeted at exploring potential toxicity and deficiencies of vitamin A in CF patients are needed.

Purpose As life expectancy in cystic fibrosis (CF) increases, questions regarding its potential impact on cardiovascular health arise. Soluble vascular cell adhesion molecule 1 (sVCAM-1), P-selectin (sP-selectin) are proposed as biomarkers of cardiovascular disease. We aimed to: compare their concentrations in clinically stable CF patients and healthy subjects (HS) and verify whether they independently correlate with CF characteristics. Methods Serum sVCAM-1 and sP-selectin levels were measured using ELISA. CF was characterized using: forced expiratory volume in 1 s, exocrine pancreatic and CF-related liver disease status, Pseudomonas aeruginosa colonization, serum high-sensitivity C-reactive protein, and body mass index (BMI). CFTR genotypes were classified as severe (classes I and II) or other. Results 108 CF patients and 51 healthy subjects volunteered for the study. In the CF group BMI was lower (median [IQR]: 20.5 kg/m2 [18.4–22.2] vs. 21.6 kg/m2 [19.9–23.4], p = 0.02) and hsCRP levels were higher (3.6 mg/L [1.1–7.1] vs. 0.5 mg/dL [0.3–1.0], p

The available data on the influence of liver cirrhosis on vitamin K status in CF patients is scarce. Therefore, the aims of the present study were to assess the prevalence of vitamin K deficiency in cirrhotic CF subjects and to determine whether it correlates with liver cirrhosis. The study group comprised of 27 CF patients with and 63 without liver cirrhosis. Vitamin K status was assessed using prothrombin induced by vitamin K absence (PIVKA-II) and the percentage of undercarboxylated osteocalcin (u-OC). PIVKA-II concentrations were higher in cirrhotic than in non-cirrhotic CF patients (median [1st-3rd quartile]: 3.2ng/ml [1.0-10.0] vs. 1.3ng/ml [0.2-2.6], p=0.0029). However, the differences in u-OC percentages between the studied groups did not reach the level of significance (49.4% [7.0-73.8] vs. 8.0% [2.6-59.1], p=0.0501). Based on multiple linear regression analysis the dose of vitamin K and F508del mutation were potentially defined as determinants of vitamin K deficiency. Liver cirrhosis was not documented to be an independent risk factor. In CF patients with liver cirrhosis vitamin K deficiency is not only more frequent, but also more severe. However, not liver cirrhosis, but the presence of a F508del CFTR mutation constitutes an independent risk factor for vitamin K deficiency.

A 41-year-old female with history of Graves' disease, bilateral cataract, paroxysmal atrial fibrillation was admitted because of muscle weakness, daytime sleepiness, fatigability, drowsiness, bilateral eyelid ptosis, descending of head and lower jaw. On neurological examination the patient was presented with muscle weakness, muscle atrophy (in face and sternocleidomastoid muscles), features of myotonia and apocamnosis (orbicular muscles). Electromyography revealed myopathic changes, myotonic and pseudomyotonic discharges, positive repetitive nerve stimulation test in proximal muscles. Myotonic dystrophy (MD) diagnosis was confirmed by genetic testing and myasthenia gravis (MG) by a positive titer of cholinergic receptor autoantibodies. In the CSF concentration of hypocretin was significantly decreased.

Background: Osteoarthritis of the sternoclavicular (SC) joint is a rare condition that leads to decreased function and persistent pain, ultimately altering the function of the shoulder and keeping individuals from their desired activities. SC resection in the setting of primary and posttraumatic osteoarthritis is the most common surgical treatment for these patients, but midterm results are lacking. Purpose/Hypothesis: The purpose was to assess the clinical outcomes, pain levels, return to sports rate, and survivorship after open SC joint resection in the setting of painful primary SC joint osteoarthritis. We hypothesized that an SC joint resection of maximum 10 mm would result in a significant improvement in clinical outcomes, decreased pain levels, a high rate of return to sports, and a high survivorship. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent SC joint resection (maximum 10 mm) by a single surgeon between the years 2006 and 2013 with minimum 5-year follow-up were reviewed. The following clinical outcomes were collected prospectively during this time period: 12-Item Short Form Health Survey Physical Component Score (SF-12 PCS), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and patient satisfaction. Return to sports and pain were assessed through use of a customized questionnaire. Survivorship of SC joint resection was defined as not requiring further surgery on the affected joint. Results: A total of 21 SC joints were treated with resection of the medial clavicle and intra-articular disk and capsulorrhaphy for SC joint osteoarthritis in 19 patients with a mean age of 39.4 years (range, 12.5-66.7 years). At minimum 5-year follow-up, 19 SC joint resections were assessed in 16 of 19 patients (84%) with a mean follow-up of 6.7 years (range, 5.0-10.4 years). All outcome scores improved significantly from pre- to postoperative assessments: ASES (from 54 to 90.5; P = .003), SANE (from 61.8 to 90.4; P = .004), QuickDASH (from 43.1 to 13.8; P = .004), and SF-12 PCS (from 39.8 to 51.3; P = .004). Median satisfaction with surgical outcomes was 9 (range, 2-10), and pain levels improved from a score of 8 out of 10 to 3 out of 10 (scale of 0 to 10 with 0 being pain free and 10 worst possible pain). Of the 13 patients who answered the optional sports participation question, 13 (100%) patients had participated in sports before their injury. A total of 14 patients answered the question on sports participation after injury, with 12 (86%) indicating successful return to sports. Pain at its worst ( P = .003) and pain with competition ( P = .017) significantly decreased pre- to postoperatively. Resection survivorship at final follow-up was 84.2% at 5 years. We found that 3 patients (15%) had recurrent SC joint pain and were treated with revision surgery. Conclusion: Open SC resection arthroplasty with capsulorrhaphy in the setting of pain for SC osteoarthritis results in significant improvement in clinical outcomes, patient satisfaction, return to sports, and pain reduction at minimum 5-year follow-up.

International audience; Marbling is one of the primary carcass attributes utilized in most beef grading systems for eating quality evaluation. In Europe, the current beef grading system is the EUROP grid, which is focused on carcass commercial value and production yield rather than eating quality estimation. The aim of this study was to investigate the relationship between marbling and the most common scores for carcass classification in Europe. If there are strong associations between marbling and European classification scores, marbling score may be estimated from the carcass characteristics. However, this study indicated that European classification scores explain only a slight proportion of the variance in marbling score (32%, 46%, 34% and 21% for the entire cattle group, young bulls, females and steers, respectively). Therefore, whereas the EUROP grid is well adapted to estimate yield, it does not reflect marbling at all. The European beef industry should take into account additional indicators related to beef palatability to assist the determination of the commercial value of carcasses.

Changes in the liver and bile ducts observed in patients diagnosed with cystic fibrosis result from inflammatory processes as well as fibrosis, remodeling, apoptosis, and cholestasis. As a consequence, portal hypertension, cirrhosis, and hepatic failure may develop. So far, the complexity of these processes has not been elucidated. Study Objectives. The aim of the study was to evaluate the selected parameters of hepatitis and fibrosis (Fibrotest, Actitest, and APRI) in patients diagnosed with cystic fibrosis. Material and Methods. The study included 79 patients with cystic fibrosis, aged 1 to 20 years (mean age 9.8 years), 49 girls (62%) and 30 boys (38%). The analysis involved the following: age, sex, clinical manifestations, laboratory tests evaluating pancreas function, parameters of liver damage, and cholestasis. Fibrotest, Actitest, and APRI were performed in all subjects. Results. Elevated parameters of hepatic cell damage (hypertransaminasemia) were found in 31/79 (39.2%) patients, while abnormal cholestasis parameters in 21/79 (26.6%). The abnormal results of Fibrotest were reported in 15% of patients (12/79), while of Actitest in 10% (8/79). In contrast, elevated APRI values were found in only 7.6% (6/79) of subjects. There was a statistically significant correlation between APRI and age (higher values were observed in younger children) and between Fibrotest and Actitest and pancreatic insufficiency (higher values were found in subjects without this abnormality). Moreover, Fibrotest values were significantly higher in girls. There was no correlation between Fibrotest, Actitest, and APRI values and the type of mutation. Conclusion. It appears that Fibrotest may be used as an early marker of liver fibrosis in patients with cystic fibrosis. Increased APRI values were only found in subjects with advanced hepatic lesions, most often in the form of portal hypertension.

INTRODUCTION Despite the widespread use of arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair (RCR) techniques, midterm outcome data are limited. The purpose of this article was to assess midterm clinical outcomes of patients following arthroscopic TOE RCR using either a knotless tape bridge (TB) repair or knotted suture bridge (SB) repair technique. We hypothesized that there would be significant improvements in patient-reported outcomes with TOE RCR that would be durable over time. We also hypothesized that the knotless TB technique would yield equivalent clinical results to the knotted SB technique, but that there would be differences in retear types between the two TOE techniques. METHODS Patients included were a minimum of 5 years from an index arthroscopic double-row TOE repair using either a knotless TB or knotted SB technique for one, two, or three tendon full-thickness rotator cuff tears involving the supraspinatus tendon. Preoperative and postoperative American Shoulder and Elbow Surgeons, Short-Form 12 Physical Component Summary, Quick Disabilities of the Arm, Shoulder, and Hand, Single Assessment Numeric Evaluation, and satisfaction scores were collected. Scores were also stratified and compared based on primary and revision repair, tear location, and tear chronicity. Outcomes between techniques were contrasted, and survivorship analysis was conducted, with failure defined as progression to revision surgery. RESULTS One-hundred ninety-two shoulders were included with a mean follow-up of 6.6 years (range, 5.0 to 11.0 years). Fifteen shoulders (7.8%) underwent revision cuff repair. All scores improved significantly for TB repair (P < 0.001). For SB repair, all scores improved, but only American Shoulder and Elbow Surgeons and Short-Form 12 Physical Component Summary scores (P < 0.05) demonstrated statistical significance. No statistically significant differences were found between the repair techniques when stratified by primary and revision repairs, tear location, or chronicity. Postoperative clinical survivorship was 96.6% and 93.6% for knotted SB repairs and 96.7% and 93.9% for knotless TB repairs at 2 and 5 years, respectively. CONCLUSION TOE RCR results in significant clinical improvement and excellent survivorship at a minimum of 5 years of follow-up, using either knotted SB or knotless TB repair techniques in primary and revision cases and in small and large tears. Equivalent results were obtained with both TOE techniques. Patients undergoing repair with a TOE showed significant improvements in patient-reported outcomes that were durable at a minimum of 5 years postoperatively.

Objectives This study aimed to assess the effect of air pollution and weather conditions on the frequency of hospital admissions due to acute coronary syndrome (ACS) in the population of Bialystok, known as the capital of the Green Lungs of Poland. Materials and methods The study analyzed the medical records of 2,645 patients living within the borders of Bialystok who were treated for ACS between 2009 and 2017 and the data on air pollutants—nitrogen dioxide (NO2), sulfur dioxide (SO2), and particulate matter with a diameter of 2.5 μm or less (PM2.5) and 10 μm or less (PM10)—and the basic meteorological factors (temperature, humidity, and atmospheric pressure). A time-stratified case-crossover study design was applied to assess the effects of particulate matter, the concentration of gases, and weather conditions on ACS. Results The number of patients admitted for ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA) was 791, 999, and 855, respectively. The daily concentration norm for PM2.5 recommended by the World Health Organization (WHO) was exceeded in 692 days (i.e., 24.58% of the observation period). The significant increase in the number of ACS hospitalizations was associated with an interquartile-range increase in NO2 concentration, with an odds ratio of 1.08 (95% confidence interval (CI): 1.02–1.15, P = 0.01), 1.09 (95% CI: 1.01–1.18, P = 0.03), and 1.11 (95% CI: 1.00–1.22, P = 0.048) for patients with ACS, NSTEMI, and UA, respectively. Conclusion The study showed that the effects of air pollution and weather conditions on the number of ACS hospitalizations are also observed in cities with moderately polluted or good air quality. NO2 was identified as the main air pollutant affecting the incidence of ACS.

The standard of care in squamous cell carcinoma of the head and neck (SCCHN) has recently undergone some major shifts in prevention, diagnostics, staging, prognostication and therapy.Prevention: Subtypes of the human papilloma virus (HPV) have been identified as causative agent for HPV-driven oropharyngeal carcinomas nearly two decades ago. Vaccination against HPV is now recommended for all girls and boys at the age of 9 to 14 years by the Standing Committee on Vaccination at the Robert Koch Institute (STIKO).Diagnostics: 18F-FDG PET/CT allows for a reduction of surgical procedures and is now reimbursed by the german health care system in certain indications. In N2/N3-disease after definitive chemoradiotherapy a FDG PET/CT is indicated to prevent neck dissection in PET negative patients. Moreover, a FDG PET CT is indicated in case of suspected recurrence of laryngeal carcinoma and as staging procedure in patients with cervical manifestation of CUP syndrome.Staging/prognostication: The favorable prognosis of HPV-driven oroparhyngeal carcinomas is now reflected by the 8PRäVENTION: Die Aufklärung der Bevölkerung über den gesicherten Zusammenhang von Alkohol- und Tabakkonsum mit der Entstehung von Kopf-Hals-Tumoren ist weiterhin dringend erforderlich. Zur Prävention der HPV-assoziierten Tumoren stehen Vakzine zur Verfügung. Gemäß der Empfehlung der STIKO sollten alle Jungen und Mädchen im Alter zwischen 9 und 14 Jahren geimpft werden.Die FDG-PET/CT ermöglicht die Verringerung operativer Eingriffe. Bei N2/N3-Status nach definitiver Radiochemotherapie (RCT) sollte eine Neck Dissection nur bei positivem/unklarem PET-Befund durchgeführt werden. Bei Verdacht auf ein Rezidiv eines Larynxkarzinoms kann die FDG-PET/CT helfen, eine Larynxbiopsie zu vermeiden. Bei zervikalem CUP-Syndrom (d.h. bei unklarem Primärtumor) ist sie zudem zur Primarius- und Ausbreitungsdiagnostik indiziert.HPV-induzierte Oropharynxkarzinome weisen eine bessere Prognose auf. Die 8. Version der TNM-Klassifikation umfasst daher eine klinische und eine pathologische Klassifikation für diese Tumorentität. Die Therapieplanung erfolgt auch weiterhin nach den etablierten Kriterien der 7. Version.Zur Reduktion therapieassoziierter Toxizität wird derzeit eine Therapiedeeskalation bei HPV-assoziierten Oropharynxkarzinomen (HPV-OPC) evaluiert. Bisherige Studien waren jedoch negativ, sodass derzeit keine Anpassung der Therapie anhand des HPV-Status im klinischen Alltag erfolgt.Die Immuncheckpointinhibitoren Nivolumab und Pembrolizumab stellen den neuen Standard nach Versagen einer platinhaltigen Therapie dar. In der Keynote-048-Studie demonstrierte Pembrolizumab als Monotherapie für Patienten mit Expression von PD-L1 (CPS ≥ 1) sowie in der Kombination mit Platin + 5-FU in der unselektierten Patientenpopulation seine Überlegenheit gegenüber dem bisherigen Erstlinienstandard PFC.

Air pollution is a documented risk factor for cardiovascular diseases.The aim of the study was to assess the effect of air pollution on the number of hospital admissions for acute coronary syndrome (ACS) in elderly patients.The medical records of 26 695 patients hospitalized for ACS between 2008 and 2017 were examined. Weather conditions and the following components of air pollution were analyzed: sulfur dioxide, nitrogen dioxide, and particulate matter with a diameter of 2.5 μm or less (PM2.5) and a diameter of 10 μm or less (PM10).The study included 1618 inhabitants of Białystok in Poland (mean [SD] age, 75 [6.4] years; men, 52.6%). The norm for PM2.5 was exceeded on 23.5% of days, while for PM10, on 5.3% of days. Elevated PM10 levels were associated with a higher number of hospitalizations for ACS on the day of exposure (mean [SD], 0.61 [0.78] vs 0.44 [0.69]; P0.001), and this effect persisted in the subsequent days (mean [SD], 1.07 [1.07] vs 0.88 [1.00]; P = 0.02). An increase of PM10 concentrations by 10 μg/m3 was associated with an increase in the number of hospitalizations due to unstable angina, and significant effects were observed even after 6 days (rate ratio, 1.16; 95% CI, 1.03-1.32; P = 0.02).Increased exposure to air pollution, in particular, elevated PM10 levels, is associated with a higher incidence of ACS both on the day of exposure and over the following days.

Clavicle fractures are among the most common fractures occurring in the general population, and the vast majority are localized in the midshaft portion of the bone. Management of midshaft clavicle fractures remains controversial. Although many can be managed nonoperatively, certain patient populations and fracture patterns, such as completely displaced and shortened fractures, are at risk of less optimal outcomes with nonoperative management; surgical intervention should be considered in such cases. The purpose of this article is to demonstrate our technique of midshaft clavicle fixation using minimally invasive intramedullary fixation.

Meat Standards Australia (MSA) methodology was used to evaluate the sensory categorization of beef by Polish consumers. A significant quality range was created by utilisation of 3 muscles, M. psoas major, M. longissimus thoracis et lumborum, and M. semimembranosus from 22 divergent bull carcasses (Holstein-Friesian crosses with Limousine, Hereford). Consumers evaluated every sample for selected sensory traits and chose a grade. A trend was observed for 6 mm preparation to reduce the proportion of unsatisfactory SM, with a consequent increase in 3star counts, in contrast to reducing the proportion of PM 5star and LTL 4star with an increase in the lower categories. Within each thickness Polish consumers clearly distinguished between grades, defined by MQ4 (Meat Quality, 4 variables) boundaries derived from discriminant analysis. Similar accuracy was achieved for both thicknesses. It was concluded that the MQ4 score could be successfully used to support a meat quality grading system in Poland.

Primary ciliary dyskinesia (PCD) is a motile ciliopathy, whose symptoms include airway infections, male infertility andTo elucidate the role of motile cilia defects in the respiratory phenotype of PCD patients with C-terminal OFD1 mutations.Whole-exome sequencing in a group of 120 Polish PCD patients, mutation screening of theFour novel hemizygousConsistent with the literature, truncations of the C-terminal part of

To compare sagittal and coronal tibial slopes between anterior cruciate ligament (ACL) injured subjects with and without posterolateral meniscus root tear (PLRT). A chart review was conducted to identify patients with isolated ACL tears and patients with an associated PLRT. Patients with other concomitant injuries and patients who underwent surgery > 6 months after the injury were excluded. Magnetic resonance image data were used to compare the medial and lateral sagittal tibial slope (MTS and LTS), lateral-to-medial slope asymmetry (LTS–MTS), and coronal slope of the tibial plateau between both groups. Mean LTS and standard deviation (SD) of the control group were calculated, and a value of > mean + 1 SD was considered an abnormal LTS. Interobserver reproducibility was assessed by calculating interclass correlation coefficients (ICCs) of measurements independently obtained by two reviewers. Fifty-nine patients met the in- and exclusion criteria. Thirty nine (66%) had an isolated ACL tear and 20 (34%) had an associated PLRT. Interrater ICCs for LTS, MTS, and coronal slope were 0.930, 0.884 and 0.825, respectively, representing good to excellent interobserver reproducibility. Patients with a PLRT had significantly steeper LTS (8.0 ± 3.2 vs. 4.0 ± 2.0; p

Background: Septic arthritis (SA) of the knee after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating condition. In certain cases, graft removal becomes necessary. Purpose: To evaluate clinical, subjective, and radiologic outcomes of patients with SA after ACLR and assess whether graft retention has superior clinical results as compared with graft removal. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who were at least 12 months out from arthroscopic treatment of SA after isolated ACLR at our institution were eligible for inclusion. Patients were categorized into 2 groups: group 1, patients with initial graft retention; group 2, patients with initial graft removal. Group 2 was subdivided into 2 groups: group 2a, patients with graft reimplantation; group 2b, patients without graft reimplantation. Objective and subjective assessments were obtained at follow-up, including the International Knee Documentation Committee (IKDC) knee examination form, KT-1000 arthrometer measurements, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, Lysholm score, and IKDC subjective evaluation. Radiologic assessment was performed with pre- and postoperative magnetic resonance imaging. Results: Of the 41 patients included, 33 (81%) were available for follow-up at a mean ± SD 54.7 ± 24.4 months at an age of 28.4 ± 9.3 years. When compared with patients from group 2 (n = 12), patients from group 1 (n = 21) obtained significantly better results on the objective IKDC score (normal or nearly normal: group 1, 66.6%; group 2, 36.4%; P = .047) and KT-1000 measurements (group 1, 1.3 ± 1.0 mm; group 2, 2.9 ± 1.5 mm; P = .005). Group 1 also scored better than group 2 on the Lysholm ( P = .007), IKDC subjective ( P = .011), and WOMAC ( P = .069) measures. Between groups 2a (n = 4) and 2b (n = 8), no significant differences in outcomes could be detected ( P values, .307-.705), although patients with anterior cruciate ligament graft reimplantation showed a clear tendency toward better results in objective and not subjective parameters. Magnetic resonance imaging evaluation showed higher rates of cartilage damage and meniscal tears among patients with graft resection versus graft retention. Conclusion: Patients with graft retention showed superior postoperative results when compared with patients who underwent initial graft resection, although subanalysis showed comparable outcomes between graft retention and reimplantation. Thus, while graft-retaining protocols should have the highest priority in the treatment of SA after ACLR, graft reimplantation should be performed in cases where graft resection becomes necessary, to avoid future cartilage and meniscal lesions. Finally, further studies with larger numbers of patients are needed to gain a better understanding of the outcomes of patients with SA after ACLR.

To prospectively evaluate the clinical and radiographic outcomes and survivorship at 2 and 5 years after isolated contemporary patellofemoral inlay arthroplasty. Thirty-four patients were prospectively enrolled in the study and were evaluated preoperatively and at 2 and 5 years postoperatively. Clinical outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and the visual analogue scale (VAS) for pain. Kellgren-Lawrence grading was used to assess the progression of tibiofemoral osteoarthritis and the Caton-Deschamps Index to determine patellar height. A Kaplan–Meier survival analysis was used to investigate the implant survivorship. Preoperative patient characteristics were compared among failures and success to determine potential risk factors and patient satisfaction was rated postoperatively. Five of the 34 patients were lost to follow-up resulting in a final follow-up rate of 86%. The total WOMAC subscores of pain and function and the VAS Pain improved significantly at 2- and 5-years, with no significant difference between the two time points. The WOMAC stiffness subscale reached significant improvement at 2-year follow-up alone. No significant progressions of tibiofemoral arthritis or changes in patellar height were observed. A total of six patients (17.1%) failed leaving a survival rate of 91% after 2 years and 83% after 5 years. The main cause for postoperative failure was persistent knee pain; however, no significant preoperative risk factor in patient characteristics could be identified. Patellofemoral inlay arthroplasty shows high patient satisfaction with significant improvement in knee function and pain relief after mid-term follow-up with no radiographic progression of tibiofemoral OA. Prospective case series, Level III.

Therapeutic options for amyotrophic lateral sclerosis (ALS) are still limited. Great hopes, however, are placed in growth factors that show neuroprotective abilities (e.g., nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and vascular endothelial growth factor (VEGF)) and in the immune modulating features, in particular, the anti-inflammatory effects. In our study we aimed to investigate whether a bone marrow-derived lineage-negative (Lin-) cells population, after autologous application into cerebrospinal fluid (CSF), is able to produce noticeable concentrations of trophic factors and inflammatory-related proteins and thus influence the clinical course of ALS. To our knowledge, the evaluation of Lin- cells transplantation for ALS treatment has not been previously reported. Early hematopoietic Lin- cells were isolated from twelve ALS patients’ bone marrow, and later, the suspension of cells was administered into the subarachnoid space by lumbar puncture. Concentrations of selected proteins in the CSF and plasma were quantified by multiplex fluorescent bead-based immunoassays at different timepoints post-transplantation. We also chose microRNAs (miRNAs) related to muscle biology (miRNA-1, miRNA-133a, and miRNA-206) and angiogenesis and inflammation (miRNA-155 and miRNA-378) and tested, for the first time, their expression profiles in the CSF and plasma of ALS patients after Lin- cells transplantation. The injection of bone marrow cells resulted in decreased concentration of selected inflammatory proteins (C3) after Lin- cells injection, particularly in patients who had a better clinical outcome. Moreover, several analyzed miRNAs have changed expression levels in the CSF and plasma of ALS patients subsequent to Lin- cells administration. Interestingly, the expression of miR-206 increased in ALS patients, while miR-378 decreased both in the CSF and plasma one month after the cells’ injection. We propose that autologous lineage-negative early hematopoietic cells injected intrathecally may be a safe and feasible source of material for transplantations to the central nervous system (CNS) environment aimed at anti-inflammatory support provision for ALS adjuvant treatment strategies. Further research is needed to evaluate whether the observed effects could significantly influence the ALS progression.

To determine the feasibility of conducting a longitudinal prospective study to evaluate functional recovery and predictors of impaired functional recovery in critically ill children.Prospective pilot study.Single-center PICU at McMaster Children's Hospital, Hamilton, Canada.Children aged 12 months to 17 years, with at least one organ dysfunction, limited mobility or bed rest during the first 48 hours of PICU admission, and a minimum 48-hour PICU length of stay, were eligible. Patients transferred from a neonatal ICU prior to ever being discharged home, already mobilizing well or at baseline functional status at time of screening, with an English language barrier, and prior enrollment into this study, were excluded.None.The primary outcome was feasibility, as defined by the ability to screen, enroll eligible patients, and execute the study procedures and measurements on participants. Secondary outcomes included functional status at baseline, 3 and 6 months, PICU morbidity, and mortality. Functional status was measured using the Pediatric Evaluation of Disability Inventory and the Participation and Environment Measure for Children and Youth. Thirty-three patients were enrolled between October 2012 and April 2013. Consent rate was 85%, and follow-up rates were 93% at 3 months and 71% at 6 months. We were able to execute the study procedures and measurements, demonstrating feasibility of conducting a future longitudinal study. Functional status deteriorated following critical illness. Recovery appears to be influenced by baseline health or functional status and severity of illness.Longitudinal research is needed to understand how children recover after a critical illness. Our results suggest factors that may influence the recovery trajectory and were used to inform the methodology, outcomes of interest, and appropriate sample size of a larger multicenter study evaluating functional recovery in this population.

Aim To estimate changes in home participation among critically ill children in the first 6 months after discharge from a pediatric intensive care unit (PICU), and to explore the effect of child, service, and environmental factors on change in home participation. Method This was a prospective bi-center, longitudinal cohort study. Caregivers of 180 children, aged 1 to 17 years, who were admitted into the PICU for at least 48 hours were included. Patient-reported outcomes were used to capture caregivers' perspectives of their child's participation and environmental supports for participation in home activities. Data were collected at enrollment, and 3 and 6 months after discharge. Results There were no significant changes in home participation frequency or involvement, but involvement rates across time were moderated by functional status. Age significantly predicted participation frequency. Pre-PICU functional status and capabilities were significant predictors of participation frequency and involvement, and home environmental support significantly predicted home involvement. Interpretation Results suggest relatively stable participation trajectories in the 6 months after PICU admission. Children with abnormal baseline function experienced a greater increase in home involvement after PICU. Rehabilitation interventions targeting functional capabilities and home environment may be viable approaches during the early phase of recovery. Environmental interventions may be more time-efficient after PICU stay and merit further study. What this paper adds Children's pre-pediatric intensive care unit (PICU) functional status and capabilities impact their participation after critical illness. Children's trajectories of home involvement may differ over time based on their pre-PICU functional status. Caregiver perceptions of environmental support impact a child's home involvement after discharge from a PICU.

To assess the effectiveness of early unilateral laparoscopic adrenalectomy in ACTH-independent and subclinical hypercor-tisolaemia.We conducted a unicentric, retrospective study. Between 2010 and 2015, 356 laparoscopic adrenalectomies were performed in the Department of General and Endocrine Surgery of the MUW. Hypercortisolaemia was found in 50 (14%) patients, while overt hypercortisolaemia was found in 31 patients. In the hypercortisolaemia group, ACTH-dependent hypercortisolaemia was diagnosed in five (10%) and ACTH-independent hypercortisolaemia in 25 patients (50%). One patient with overt hypercortisolaemia had cancer of the adrenal cortex. The remaining 19 (38%) patients had subclinical Cushing's syndrome. For our study, we compared patients with ACTH-independent hypercortisolaemia (n = 25) with those with Cushing's syndrome (n = 19). Patients with ACTH-dependent hyper-cortisolaemia (n = 5) and the patient with cancer of the adrenal cortex (n = 1) were excluded.Patients from both groups (n = 44) underwent a unilateral transperitoneal adrenalectomy. Good early outcomes were observed in 42 patients (93.3%). In one patient, an additional laparoscopic surgery was necessary on postoperative day 0 due to bleeding. In another patient, on day 22 post-surgery, we found an abscess in the site of the excised adrenal gland, which was drained under laparoscopic guid-ance. In three patients (6.8%) with substantial obesity, temporary respiratory insufficiency of varying degrees occurred. We did not observe any thromboembolic complications. All patients with overt hypercortisolaemia and nine patients with subclinical hypercortisolaemia had secondary adrenal insufficiency postoperatively.Transperitoneal unilateral laparoscopic adrenalectomy is an efficient and safe treatment option in patients with ACTH- -independent hypercortisolaemia, both overt and subclinical.

Background:Superior capsular reconstruction (SCR) was recently introduced as a treatment for irreparable superior rotator cuff tears in younger patients.Purpose/Hypothesis:The purpose was to assess the biomechanical strength of 3 methods for fixation of the graft to the glenoid for SCR. It was hypothesized that a 4-anchor technique would provide greater load to failure than 3-anchor techniques.Study Design:Controlled laboratory study.Methods:Thirty-six cadaveric specimens were randomized into 3 groups of previously established glenoid-side graft fixation techniques: (1) three 3.5-mm knotless screw-in anchors, (2) three 3.0-mm knotless push-in anchors, and (3) a 4-anchor hybrid construct with two 3.0-mm knotted push-in anchors and two 2.9-mm knotless push-in anchors. The repairs were cyclically loaded at 0.5 Hz from 10 to 200 N, then pulled to failure. Elongation, stiffness, maximum load at failure, and mode of failure were recorded and calculated.Results:There were no significant differences in graft elongation or stiffness among the 3 techniques ( P > .37 and P > .26, respectively). Maximum load to failure was significantly greater in technique 1 (mean ± SD, 427.85 ± 119.70 N) than technique 3 (319.5 ± 57.60 N) ( P = 0.024). There were no significant differences in load to failure between techniques 1 and 2 or between techniques 2 and 3.Conclusion:Glenoid-side graft fixation with 3 threaded 3.5-mm suture anchors showed a significant superior pull-out strength when compared with a 4-anchor hybrid technique and thus might be recommended in SCR for patients with irreparable superior rotator cuff tears to achieve maximum stability.Clinical Relevance:SCR presents a novel alternative for treatment of irreparable superior rotator cuff tears in younger patients. Glenoid fixation is essential to provide adequate fixation of the graft to prevent the humeral head from rising and to restore normal biomechanics.

Recurrent instability is a frequent complication following arthroscopic Bankart repair. The purpose of this study was to investigate risk factors for poor patient-reported clinical outcome scores and failure rates.Patients who underwent arthroscopic Bankart repair at least 2 years earlier were included. Preoperative and postoperative Single Assessment Numeric Evaluation; Quick Disabilities of the Arm, Shoulder and Hand; American Shoulder and Elbow Surgeons; and satisfaction scores were collected. The relationship of the following factors with outcomes and failure rates was assessed: (1) previous arthroscopic stabilization, (2) 3 or more dislocations prior to surgery, (3) glenoid labral articular disruption (GLAD) lesion, (4) concurrent superior labral anterior-to-posterior tear repair, and (5) concurrent biceps tenodesis.The study included 72 patients with a median age of 23 years (range, 14-49 years). Subsequent revision was required in 9 (12.5%); 1 additional patient (1.4%) had recurrent dislocation. Outcome data were available at a median follow-up of 3 years (range, 2-9 years). All scores significantly improved from preoperatively to postoperatively (P .05); the mean patient satisfaction score was 9, with a median of 10 (range, 1-10). None of the analyzed factors were associated with worse postoperative outcome scores. GLAD lesions were significantly associated with a higher rate of failure (P = .007). No other analyzed factors had a significant association with failure rates (P .05).Patients with arthroscopic Bankart repair for traumatic anteroinferior shoulder instability had excellent outcomes, even in the context of previous arthroscopic stabilization surgery, 3 or more dislocations prior to surgery, concurrent superior labral anterior-to-posterior tear repair, or concurrent biceps tenodesis. However, GLAD lesions were associated with higher rates of failure, and the presence of a GLAD lesion may herald the presence of changes in the articular version or other as-yet-undetermined factors that could predispose patients to failure.

Background Up to 7% of term and late-preterm neonates in high-income countries receive antibiotics during the first 3 days of life because of suspected early-onset sepsis. The prevalence of culture-proven early-onset sepsis is 0·1% or less in high-income countries, suggesting substantial overtreatment. We assess whether procalcitonin-guided decision making for suspected early-onset sepsis can safely reduce the duration of antibiotic treatment. Methods We did this randomised controlled intervention trial in Dutch (n=11), Swiss (n=4), Canadian (n=2), and Czech (n=1) hospitals. Neonates of gestational age 34 weeks or older, with suspected early-onset sepsis requiring antibiotic treatment were stratified into four risk categories by their treating physicians and randomly assigned [1:1] using a computer-generated list stratified per centre to procalcitonin-guided decision making or standard care-based antibiotic treatment. Neonates who underwent surgery within the first week of life or had major congenital malformations that would have required hospital admission were excluded. Only principal investigators were masked for group assignment. Co-primary outcomes were non-inferiority for re-infection or death in the first month of life (margin 2·0%) and superiority for duration of antibiotic therapy. Intention-to-treat and per-protocol analyses were done. This trial was registered with ClinicalTrials.gov, number NCT00854932. Findings Between May 21, 2009, and Feb 14, 2015, we screened 2440 neonates with suspected early-onset sepsis. 622 infants were excluded due to lack of parental consent, 93 were ineligible for reasons unknown (68), congenital malformation (22), or surgery in the first week of life (3). 14 neonates were excluded as 100% data monitoring or retrieval was not feasible, and one neonate was excluded because their procalcitonin measurements could not be taken. 1710 neonates were enrolled and randomly assigned to either procalcitonin-guided therapy (n=866) or standard therapy (n=844). 1408 neonates underwent per-protocol analysis (745 in the procalcitonin group and 663 standard group). For the procalcitonin group, the duration of antibiotic therapy was reduced (intention to treat: 55·1 vs 65·0 h, p

Purpose To perform a quantitative anatomic evaluation of the (1) coracoid process, specifically the attachment sites of the conjoint tendon, the pectoralis minor, the coracoacromial ligament (CAL), and the coracoclavicular (CC) ligaments in relation to pertinent osseous and soft tissue landmarks; (2) CC ligaments' attachments on the clavicle; and (3) CAL attachment on the acromion in relation to surgically relevant anatomic landmarks to assist in planning of the Latarjet procedure, acromioclavicular (AC) joint reconstructions, and CAL resection distances avoiding iatrogenic injury to surrounding structures. Methods Ten nonpaired fresh-frozen human cadaveric shoulders (mean age 52 years, range 33-64 years) were included in this study. A 3-dimensional coordinate measuring device was used to quantify the location of pertinent bony landmarks and soft tissue attachment areas. The ligament and tendon attachment perimeters and center points on the coracoid, clavicle, and acromion were identified and subsequently dissected off the bone. Coordinates of points along the perimeters of attachment sites were used to calculate areas, whereas coordinates of center points were used to determine distances between surgically relevant attachment sites and pertinent bony landmarks. Results The CAL had a single consistent acromial attachment (mean area 77 mm [51.9, 102.2]) and then bifurcated into 2 bundles, anterior and posterior, that separately inserted on the lateral aspect of the coracoid. The footprint areas were 54.4 mm 2 [31.7, 77.2] and 30.6 mm 2 [23.4, 37.7] for the anterior and posterior CAL bundles, respectively. These anterior and posterior bundles attached 10.6 mm [8.4, 12.9] and 24.8 mm [12.3, 27.4] medial and proximal to the apex of the coracoid process, respectively. The minimum distance between the coracoid apex and the trapezoid ligament was 25.1 mm [22.1, 28.1] and was noted to be different in males (28.1 mm [25.1; 31.2]) and females (22.0 mm [18.2, 25.9]). The most lateral insertion of the CC ligaments on the clavicle the AC joint was 15.7 mm [13.1, 18.3]. The distance between the most medial to the most lateral point of the CC ligaments on the clavicle was 25.6 mm [22.3, 28.9], which accounted for 18.2% [15.8, 20.6] of the clavicle length. Conclusions In contrast to previous findings, 2 different coracoid attachments (anterior and posterior bundles) of the CAL were consistently identified in all specimens. Moreover, a coracoid osteotomy for a bone graft for the Latarjet procedure should be performed at less than 28.1/22 mm from the apex of the coracoid in male/female patients, respectively. The CC ligaments' attachments on the clavicle were located 15.7 mm from the AC joint, which should be considered for reconstruction. Clinical Relevance During the Latarjet technique, to maintain the integrity of the CC ligaments, precise knowledge of differences between male and female anatomy is necessary during a coracoid osteotomy. Furthermore, when reconstructing the AC joint, the distance from the lateral aspect of the clavicle and the size of the attachments areas should be considered to better replicate the native anatomy.

Purpose The purpose of this study was to evaluate outcomes following open subpectoral biceps tenodesis for the treatment of isolated type II SLAP lesions in patients 45 years of age or younger and evaluate the rate of return to sport. Methods All patients included in the study were at least 2 years out from open subpectoral biceps tenodesis for treatment of an isolated type II SLAP lesion and were treated between December 2007 and March 2015. All patients older than 45, those who had prior surgery on the index shoulder, and those who had any concomitant reconstructive shoulder procedures were excluded. American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Single Assessment Numeric Evaluation (SANE), and Short-Form 12 Physical Component Summary (SF-12 PCS) scores were collected pre- and postoperatively along with postoperative patient satisfaction. Patient return to sport was evaluated by questionnaire. Results Twenty patients with a mean age of 38 years (range 21-45) were included, of which 16 were available for follow-up. There was significant improvement in median pre- to postoperative outcome scores (ASES, 66-94 points, P = .001; QuickDASH, 31-8, P = .003; SANE, 60-92, P = .001, SF-12 PCS, 41-52 points, P = .002), with a median patient satisfaction of 8.5 points (range 1-10) at a mean follow-up of 3.4 years (range, 2.0-6.3 years). At final follow-up, all patients had returned to sport, with 73% of patients indicating a return to their previous or comparable level of sports. Subgroup analysis showed 80% of overhead athletes returned to the same or a comparable level postoperatively. Conclusions This study suggests that young patients around their 30s participating in sport at a recreational level may benefit from open subpectoral biceps tenodesis for a primary isolated SLAP II tear and would experience excellent outcomes, high satisfaction, and a high rate of return to sport. Level of Evidence Level IV, therapeutic case study.

Purpose To determine the exact value of side-to-side difference (SSD) in heel height that was associated with combined anterior cruciate ligament (ACL) and fibular collateral ligament (FCL) tears (compared with an isolated ACL tear) and determine the clinical utility of heel height SSD in the assessment of this injury pattern. Methods Two patient groups were identified: (1) patients with isolated ACL tears and (2) patients with combined ACL-FCL tears but without additional collateral or cruciate ligament injuries. Determination of the amount of the heel height SSD was determined during the outpatient clinic visit. Receiver operator characteristic curves were used to evaluate the accuracy of diagnostic tests by plotting the true-positive (sensitivity) rate against the false-positive (1-specificity) rate at various thresholds. In addition, magnetic resonance imaging (MRI) reports were reviewed to calculate the sensitivity of MRI for the detection of FCL injury. MRI sensitivity was then compared with the sensitivity of the heel height examination. Results One hundred and fifty-eight patients (71 men, 87 women) in the isolated ACL tear patient group and 117 patients (60 men, 57 women) in the combined ACL-FCL tear patient group were reviewed. A 3-cm or greater SSD was found in 13 of the 158 (8.2%) isolated ACL tear patients and 84 of the 117 (72%) ACL-FCL tear patients. The sensitivity, specificity, positive predictive value, and negative predictive value of the heel height test were 72%, 92%, 86%, and 86%, respectively. The area under the receiver operator characteristic curve was found to be 0.876. After review of all preoperative MRI musculoskeletal radiology reports for patients in the ACL-FCL patient group, a sensitivity of 48% was found. Conclusions The clinical heel height test resulted in high sensitivity and excellent specificity for the diagnosis of combined ACL-FCL tears compared with the sensitivity and specificity of the MRI detection of FCL injury. The information presented in the current study will improve diagnostic ability through a simple physical examination and avoid missed injuries that are known to compromise surgical outcomes. Level of Evidence Level III, cross-sectional.