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A spectrum of anatomic variants of the conventional single patellar tendon have been described however a double patellar tendon is a highly rare finding, which has only been described once before where a cross-over tendon morphology was illustrated. We report the case of a 46-year-old man with a 3 month history of left knee pain who was found to have an incidental double patellar tendon without cross-over, with one deep bundle demonstrating a more conventional patellar tendon course, paralleled by a second anatomically-distinct superficial bundle of differing morphology coursing anterolateral to the deep conventional bundle, explicitly connecting patella to tibial tuberosity. A comprehensive understanding of the anatomic variations of the patellar tendon is essential for both radiologist and clinician to deliver safe clinical practice. We present a rare case of an uncrossed-doubled patellar tendon, which to our knowledge, has never been reported. Keywords: Anatomic variant, Cross-over, Doubled patellar tendon, Knee, MRI

Small interfering RNAs (siRNAs) conjugated to N-acetylgalactosamine (GalNAc) ligands have been used to treat disease in patients. However, conjugates with other ligands deliver siRNA less efficiently, limiting the development of new targeted therapies. Most approaches to enhancing the potency of such conjugates have concentrated on increasing ligand effectiveness and/or the chemical stability of the siRNA drug. One complementary and unexplored alternative is to increase the number of siRNAs delivered per ligand. An ideal system would be a single chemical entity capable of delivering multiple copies of an oligonucleotide drug and/or several such drugs simultaneously. Here we report that siRNAs can be stably linked together under neutral aqueous conditions to form chemically defined siRNA “multimers,” and that these multimers can be delivered in vivo by a GalNAc ligand. Conjugates containing multiple copies of the same siRNA showed enhanced activity per unit of ligand, whereas siRNAs targeting different genes linked to a single ligand facilitated multigene silencing in vivo; this is the first demonstration of silencing several genes simultaneously in vivo using ligand-directed multimeric siRNA. Multimeric oligonucleotides represent a powerful and practical new approach to improve intracellular conjugate delivery.

Infection is one of the most feared complications following knee arthroplasty and soft tissue arthroscopic procedures. This article summarizes the current understanding on the management of this rare but devastating problem. The healthcare and economic burden of periprosthetic joint infection (PJI) is highlighted, together with how the classification of infection and host staging can aid decision-making. Surgical treatment options will be described. These consist of ‘debridement, antibiotics and implant retention’ (DAIR), revision arthroplasty (single- or two-stage), as well as salvage procedures (arthrodesis, permanent resection, and amputation). In selected cases, chronic antibiotic suppression may be the only viable option. All implant-related orthopaedic infections must be managed using a multidisciplinary team (MDT) approach, ideally within dedicated bone infection units, in order to optimize clinical outcomes.

This case series reports familial cases of nodular oncocytic hyperplasia (NOH) diagnosed in a mother and her son, 15 years apart. A 39-year-old man presented in 2003 with a lump below his left ear. Magnetic resonance imaging (MRI) performed showed multifocal parotid nodules and a diagnosis of NOH was histopathologically confirmed following left total parotidectomy. Two years later, he represented with similar symptoms on the right side. NOH was diagnosed following excision of his right parotid gland. In 2018, his 73-year-old mother presented with left ear pain and a lump below her left ear. An MRI scan showed multiple lesions within both parotid glands and bilateral NOH was once again diagnosed following a left superficial parotidectomy and right total parotidectomy. We believe that this is the first reported case of bilateral familial NOH.

This book explores the material religion of contemporary Shimla, a vibrant postcolonial city, famed for its colonial heritage, set against the backdrop of the North-Western Himalayas. Jonathan Miles-Watson demonstrates that this landscape is able to peacefully reconcile the apparent tensions of faith, heritage and identity in a way that unseats traditional theories of religion, politics and heritage. It presents a mystery that is written in space through time; the key to unlocking this mystery lies in clear view, at the city's heart, in the contemporary material religion that surrounds nominally Christian sacred sites. Although the material religion centres on landscapes that are identifiable as Christian, the book demonstrates that Hindus, atheists and Sikhs all have a role to play in the mutually constitutive relations that lie at the centre of these knots of sacred entanglement. This book builds upon over a decade of research to present an ethnographic account of devotional practices that speaks to contemporary developments in both the anthropology of Christianity and material religion. Through this exploration the book answers the mystery of Shimla's postcolonial harmony, while complicating established theories in the anthropology of religion, postcolonial studies, mythography, heritage studies and material culture.

Introduction: Chronic cough is a key symptom that plagues the lives of IPF patients, indeed, it is often the reason the disease is initially diagnosed. The aim of this project was to develop a pre-clinical model of IPF-associated cough and compare the mediator profiles with clinical samples, to aid in the search for effective treatments. Methods: Male guinea pigs (around 325g) were intratracheally dosed with vehicle (saline) or bleomycin (6 USP/kg) and coughs were quantified through manual observation of in-cage video footage, by watching 4.5 hours a day, for 3 weeks. Lung tissue, bronchoalveolar lavage fluid (BALF) and blood was harvested from a parallel group of animals. These were used to assess the extent of fibrosis and measure mediator production (e.g. a marker of oxidative stress: 8-isoprostane). Human BALF was obtained from IPF patients and healthy controls. Results: Spontaneous coughing was recorded in guinea pigs given bleomycin, which was associated with an increase in lung fibrosis and BALF 8-isoprostane (a marker of oxidative stress). We noted similar increases in BALF 8-isoprostane levels in the clinical samples. Conclusions: We have developed a preclinical model to aid in the search for a treatment for IPF-associated coughing. Furthermore, initial data suggests that an increase in oxidative burden (a known trigger of coughing) could be an attractive target.

Background Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making. Aim To provide guidelines for surgeons and units delivering revision KR services. Methods A formal consensus process was followed by BASK’s Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data. Results There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model. Conclusions Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

This article is an expansion of a lecture given in the British Orthopaedic Association (BOA) Congress in Liverpool in 2019 as part of a symposium on infected knee replacement. It is designed to provide pointers and advice to surgeons on how these patients can be referred, investigated, and managed. The management of periprosthetic infection necessitates many decisions to be made to provide the patient with the best advice and treatment. This is a discussion of the philosophies of periprosthetic knee infection. It is not a definitive guide nor a metanalysis of scientific papers. These are the subjective views of the author and generalise decision making. All decisions should remain tailored to the patient's needs.

This article presents the case for a rethinking of the academy’s approach to sacred space through a demonstration of the way that a focus on unskilled actors reconfigures established approaches and interpretations. The article opens with an auto-ethnographic account of the powerful effect of Shimla’s Tara Devi temple on personal wellbeing and from this starting point spirals out to explore how Tara (and her sacred places) are connected to wellbeing both in the Himalayan region of Shimla and beyond. Through this process, arguments that I have previously made, concerning both the relation of sacred places to happiness (2010) and the way that sacred places operate in Himalayan North India (2012), are significantly complicated, leading to a reappraisal of the role that unskilled actors play in the constitution of sacred space. The article concludes by drawing these ethnographic reflections and theoretical considerations together to develop a key set of recommendations that call for policy-makers to engage sensitively with sacred places in the contemporary, post-secular city.

Background and purpose — Muscle atrophy is seen in patients with metal-on-metal (MOM) hip implants, probably because of inflammatory destruction of the musculo-tendon junction. However, like pseudotumors, it is unclear when atrophy occurs and whether it progresses with time. Our objective was to determine whether muscle atrophy associated with MOM hip implants progresses with time. Patients and methods — We retrospectively reviewed 74 hips in 56 patients (32 of them women) using serial MRI. Median age was 59 (23–83) years. The median time post-implantation was 83 (35–142) months, and the median interval between scans was 11 months. Hip muscles were scored using the Pfirrmann system. The mean scores for muscle atrophy were compared between the first and second MRI scans. Blood cobalt and chromium concentrations were determined. Results — The median blood cobalt was 6.84 (0.24–90) ppb and median chromium level was 4.42 (0.20–45) ppb. The median Oxford hip score was 34 (5–48). The change in the gluteus minimus mean atrophy score between first and second MRI was 0.12 (p = 0.002). Mean change in the gluteus medius posterior portion (unaffected by surgical approach) was 0.08 (p = 0.01) and mean change in the inferior portion was 0.10 (p = 0.05). Mean pseudotumor grade increased by 0.18 (p = 0.02). Interpretation — Worsening muscle atrophy and worsening pseudotumor grade occur over a 1-year period in a substantial proportion of patients with MOM hip implants. Serial MRI helps to identify those patients who are at risk of developing worsening soft-tissue pathology. These patients should be considered for revision surgery before irreversible muscle destruction occurs.

Background A two-stage revision remains the gold standard to eradicate deep infection in total knee arthroplasty. Higher failure rates are associated with a number of factors including poly-microbial infections, multiresistant organisms and previous operations. The aims are to investigate [1] the overall success rate of a two-stage revision for infections in TKA, [2] the outcome of repeat two-stage revisions in recurrent infections and [3] the factors affecting the outcomes of such cases. Methods We present the outcomes of a consecutive, retrospective case series of 51 periprosthetic joint infections managed with a two-stage revision knee arthroplasty over a three year period. Results Forty-six (90%) of 51 were referred from other hospitals. Infection was successfully eradicated in 24 (65%) of 37 patients undergoing an initial two-stage procedure. Following a failed two-stage revision, a repeat two-stage revision was performed in 19 patients eradicating infection in 8 (42%). A third two-stage was performed in five of these patients eradicating infection in three with an average follow-up of 43months. Multidrug resistance was present in 69%, and 47% of the patients were infected with multiple organisms. All unsuccessful outcomes involved at least one multidrug-resistant organism compared to 43% in the successful cohort ( P =0.0002). Serological markers prior to a second-stage procedure were not significantly different between successful and unsuccessful outcome groups. Conclusion Single or multiple two-stage revisions can eradicate infection despite previous failed attempts. In this series, failure is associated with multidrug resistance, previous failed attempts to eradicate infection and a less favourable host response. Level of evidence IV

OBJECTIVE The purpose of this study was to compare the effectiveness of detecting proximal carious lesions utilizing a new near-infrared transillumination (NIRTI) system (CariVu, Dexis) to traditional digital bitewing radiography (BWXR). MATERIALS AND METHODS Thirty patients received four posterior BWXRs and all premolars and molars were individually imaged with the NIRTI device. Sixty-seven proximal carious lesions were classified based on their depth into enamel or dentin for both BWXR and NIRTI images. RESULTS The caries depth classification between the two systems were strongly correlated (rs = 0.66; Spearman range: 0.60-0.79 = strong) and significant (P

Arthroscopic debridement of infected knee arthroplasty is rarely used. Currently, it has a limited role as complete biofilm clearance is theoretically impossible. It is most effective in the very early phase of acute presentations of infected knee arthroplasty. It can be of use in cases where the organism is not associated with strong biofilm, in patients of extreme frailty, as an adjunct to suppressive antimicrobial medical therapy or as part of a diagnostic workup. If performed, high volumes of fluid and accessory portals should be used.

Total knee arthroplasty (TKA) in limbs affected by poliomyelitis is a technically challenging procedure. These patients often demonstrate acquired articular and metaphyseal angular deformities, bone loss, narrowness of the intramedullary canals, impaired quadriceps strength, flexion contractures and ligamentous laxity producing painful hyperextension. Thus, using condylar knee designs in these patients will likely result in early failure because of instability and abnormal load distribution. The aim of this study was to assess the outcomes associated with use of the customised (SMILES) rotating-hinge knee system at our institution for TKA in poliomyelitis-affected limbs. We retrospectively reviewed the outcome of 14 TKAs using the (SMILES) prosthesis in 13 patients with limbs affected by poliomyelitis. All patients had painful unstable knees with hyperextension. There were ten females and three males with a mean age of 66 years (range 51–84) at time of surgery. Patients were followed up clinically, radiologically and functionally with the Oxford knee score (OKS). Mean follow-up was 72 months (16–156). There were no immediate or early complications. One patient fell and sustained a peri-prosthetic fracture at seven months requiring revision to a longer stem. Radiological evaluation showed satisfactory alignment with no signs of loosening in all cases. Mean OKS improved from 11.6 (4–18) to 31.5 (18–40) postoperatively (p

I Brage finner du siste tekst-versjon av artikkelen, og den kan inneholde sma forskjeller fra forlagets pdf-versjon. Forlagets pdf-versjon finner du pa www.wiley.com: http://dx.doi.org/10.1111/j.2047-6310.2014.220.x / In Brage you'll find the final text version of the article, and it may contain minor differences from the journal's pdf version. The original publication is available at www.wiley.com: http://dx.doi.org/10.1111/j.2047-6310.2014.220.x

This article explores two seemingly contrasting types of Christian worship (one led by the pipe organ and the other by satsang), which I repeatedly experienced (between 2006 and 2010) during my fieldwork in Shimla, North India. Although it is often assumed that the pipe organ speaks more to colonial worship and satsang to postcolonial worship, this article demonstrates that both of these styles of worship are actually postcolonial attempts to negotiate colonial history. This suggests a need to complicate contemporary external discussions of the inculturation of Christian worship in India. Furthermore, by focusing on the way that contemporary Christians work with missionary histories to create living landscapes of worship, this article demonstrates that Christian worship is central to the identity of many non-Christian residents and tourists, who are also central to the formation of Christian landscapes of worship. The article concludes by suggesting that these groups also need to be brought into debates about the nature of Christian worship in contemporary India.

Due to an increasing lifespan, patients with osteogenesis imperfecta have a high incidence of hip osteoarthritis. The presence of recurrent fractures and deformities make primary and particularly revision total hip arthroplasty challenging. We present a series of patients with osteogenesis imperfecta undergoing total hip arthroplasty at a tertiary referral centre with a median follow-up of 7.6 years (4 to 35 years). There were four primary total hip arthroplasties and eight revision total hip arthroplasties performed in four patients. Three femoral components were custom computer assisted design computer assisted manufactured. The survival rate of the primary total hip arthroplasty was 16% and there were ten complications: five intraoperative fractures, one case of septic loosening and four cases of aseptic loosening. Patients with pre-operative acetabular protrusio were significantly more likely to require revision surgery (p = 0.02). At latest follow-up, the median Oxford hip score was 41 (37 to 46). As the largest series of primary and revision total hip arthroplasty performed in patients with osteogenesis imperfecta, we report good medium to long-term outcomes. Pre-Operative planning and consideration of custom made prostheses have an important role in these complex cases.

For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven.To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion.A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013.Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]).Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%).Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20).Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy.isrctn.org Identifier: ISRCTN33288337.

We conducted a prospective single-blinded randomised controlled trial to compare the functional and quality of life outcomes in two groups of patients between 60 and 80 years of age undergoing THR; the first receiving a small head (28–32 mm) metal on polyethylene (MoP) articulation, and the second receiving a large head (44–54 mm) metal on metal (MoM) articulation. We recruited 49 patients and randomised them into one of the two groups (22 MoP and 27 MoM). The results demonstrated no statistical difference in any of the assessed functional outcomes at any follow-up point (p>0.05). There were no dislocations or revisions in either group. Although it has been suggested that large head MoM articulations in THA offer superior stability and function, our results suggest that small head MoP articulations can achieve comparable ROM, function and quality of life at short-term follow-up.

For youth involved with the child welfare system, accurate assessment of mental-health functioning is a critical factor in case planning. To assess correspondence among multiple reporters of child welfare youths' mental-health difficulties, this study, using data drawn from the National Survey of Child and Adolescent Well-being dataset, examined the caregiver, teacher and youth (aged 11–16 years) reports on the Child Behavior Checklist (n = 464). Perceptions about symptomatology on a variety of externalizing and internalizing behaviour problem scales were measured with a correlation analysis. Subsequently, logistic regression models were created, which explored how each reporter category matched a fourth reporter category: the child welfare investigation caseworkers' identification of youths' mental-health needs. Results show that in several models, the odds of matching caseworkers' determination of youths' mental-health needs significantly increased as youths' perceptions of psychopathology increased. A similar pattern was found for caregivers' perceptions in some of the models, across both internalizing and externalizing domains. Implications for child welfare practice and research with child welfare youth are discussed.

Patients with skeletal dysplasia are prone to developing advanced osteoarthritis of the knee requiring total knee replacement (TKR) at a younger age than the general population. TKR in this unique group of patients is a technically demanding procedure owing to the deformity, flexion contracture, generalised hypotonia and ligamentous laxity. We retrospectively reviewed the outcome of 11 TKRs performed in eight patients with skeletal dysplasia at our institution using the Stanmore Modular Individualised Lower Extremity System (SMILES) custom-made rotating-hinge TKR. There were three men and five women with mean age of 57 years (41 to 79). Patients were followed clinically and radiologically for a mean of seven years (3 to 11.5). The mean Knee Society clinical and function scores improved from 24 (14 to 36) and 20 (5 to 40) pre-operatively, respectively, to 68 (28 to 80) and 50 (22 to 74), respectively, at final follow-up. Four complications were recorded, including a patellar fracture following a fall, a tibial peri-prosthetic fracture, persistent anterior knee pain, and aseptic loosening of a femoral component requiring revision. Our results demonstrate that custom primary rotating-hinge TKR in patients with skeletal dysplasia is effective at relieving pain, with a satisfactory range of movement and improved function. It compensates for bony deformity and ligament deficiency and reduces the likelihood of corrective osteotomy. Patellofemoral joint complications are frequent and functional outcome is worse than with primary TKR in the general population.

A difluorinated analogue of a ring-expanded calystegine B(2) and some N-protected species were prepared via microwave-mediated transannular ring-opening of an epoxyketone. The diastereofacial selectivity of the epoxidation reaction, which delivers the key intermediate, and the regioselectivity of the transannular reactions were analyzed by density functional theory (DFT) methods. The epoxidation stereoselectivity arises from simple steric control, whereas the ring-closure reactions are subject to thermodynamic control.

Pretesting is key in the development of patient-reported outcome (PRO) instruments. We describe a mixed-methods approach based on interviews and Rasch measurement methods in the pretesting of the Pressure Ulcer Quality of Life (PU-QOL) instrument. We used cognitive interviews to pretest the PU-QOL in 35 patients with pressure ulcers with the view to identifying problematic items, followed by Rasch analysis to examine response options, appropriateness of the item series and biases due to question ordering (item fit). We then compared findings in an interactive and iterative process to identify potential strengths and weaknesses of PU-QOL items, and guide decision-making about further revisions to items and design/layout. Although cognitive interviews largely supported items, they highlighted problems with layout, response options and comprehension. Findings from the Rasch analysis identified problems with response options through reversed thresholds. The use of a mixed-methods approach in pretesting the PU-QOL instrument proved beneficial for identifying problems with scale layout, response options and framing/wording of items. Rasch measurement methods are a useful addition to standard qualitative pretesting for evaluating strengths and weaknesses of early stage PRO instruments.