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Tim Cheok,1– 3 Matthew Jennings,1,4 Morgan Berman,1 Kanihska Williams,1,3 Jaideep Singh Rawat,1,5,6 Bruce K Foster1,5 1Department of Trauma and Orthopaedics, Alice Springs Hospital, Alice Springs, Northern Territory, Australia; 2Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand; 3College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; 4Department of Plastics and Reconstructive Surgery, Women’s and Children’s Hospital, Adelaide, South Australia, Australia; 5Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia; 6Department of Orthopaedic Surgery, Women’s and Children’s Hospital, Adelaide, South Australia, AustraliaCorrespondence: Tim Cheok, Email tim.cheok@flinders.edu.auCase: We present a case of acute unstable valgus slipped capital femoral epiphysis (SCFE) in an 8-year-old female who presented after a trip and fall. The patient was managed with emergent closed reduction and percutaneous screw fixation and prophylactic fixation of contralateral side after 6 weeks. At 18-month follow-up, the patient was symptom free with a good range of movement and no evidence of slip progression, chondrolysis or avascular necrosis of the femoral head.Conclusion: We demonstrate that, in this case, closed reduction and percutaneous fixation provided satisfactory outcome at 18-month follow-up. This case highlights the need for both anteroposterior and lateral radiographs.Keywords: SCFE, closed reduction, percutaneous pinning, valgus slip

Julia Berman,1,2,* Victoria Furer,2,3,* Mark Berman,2,3 Ofer Isakov,1,2 Devy Zisman,4,5 Amir Haddad,4 Ori Elkayam2,3 1Department of Medicine ‘T’, Sourasky Medical Center, Tel Aviv, Israel; 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3Department of Rheumatology, Sourasky Medical Center, Tel Aviv, Israel; 4Rheumatology Unit, Carmel Medical Center, Haifa, Israel; 5The Ruth and Bruce Rappaport Faculty of Medicine,Technion, Haifa, Israel*These authors contributed equally to this workCorrespondence: Julia Berman Email juliab@tlvmc.gov.ilObjective: To assess the clinical response to ixekizumab following secukinumab failure in patients with psoriatic arthritis.Methods: A retrospective multi-center observational study included psoriatic arthritis (PsA) patients with a history of treatment with secukinumab, further treated with ixekizumab. Primary endpoint was primary response to treatment (drug survival > 6 months); secondary endpoints were changes in disease activity indices from initiation of ixekizumab to 6 and 12 months later and overall drug survival.Results: Of 23 PsA patients, 86% (n = 20) received more than two TNF inhibitors (TNFi). Median secukinumab treatment time was 15 months (IQR 10– 21.5 months). Subsequently, 19 patients (83%) had a primary response to ixekizumab. Overall treatment duration during follow-up period for primary responders was 14 months (IQR 10– 20.5). Reasons for ixekizumab cessation were worsening psoriasis (27%), peripheral arthritis (27%), both (47%), worsening of axial disease (13%), and adverse events (6%). Articular disease indices including Disease Activity Index for Psoriatic Arthritis (DAPSA), tender joints count (TJC) and Simplified Disease Activity Index (SDAI) were significantly lower at 6 and 12 months (DAPSA 1.5– 2 levels reduction; p = 0.018 and 1– 1.5 levels reduction; p = 0.031, respectively; TJC − 2.16 [− 4.0, − 0.3]; p = 0.025 and − 1.69 [− 3.09, − 0.28]; p = 0.022, respectively; SDAI − 10.13 [− 16.4, − 3.8], p = 0.003 and − 12.2 [− 17.1, − 7.2], p = 0.0002, respectively). PASI75 at 6 and 12 months was achieved by 63% and 57%, respectively, and PASI100 at 6 and 12 months by 31% and 21%, respectively.Conclusion: Patients with resistant PsA, including inadequate response to secukinumab, demonstrated a good response to ixekizumab, albeit limited on time. Within class switch from secukinumab to ixekizumab may be a plausible therapeutic option in PsA patients following secukinumab failure.Keywords: secukinumab, ixekizumab, arthritis, psoriatic, duration of therapy, antibodies, monoclonal, humanized, psoriasis

Shared research infrastructure that is globally distributed and widely accessible has been a hallmark of the networking community. We present a vision for a future mid-scale distributed research infrastructure aimed at enabling new types of discoveries. The “lessons learned” from constructing and operating the Global Environment for Network Innovations (GENI) infrastructure are the basis for our attempt to project future concepts and solutions. Our aim is to engage the community to contribute new ideas and to inform funding agencies about future research directions.

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

Ureteral-iliac artery fistula (UIAF) is a rare life threatening cause of hematuria. The increasing frequency is attributed to increasing use of ureteral stents. A 68-year-old female presented with gross hematuria. She had prior low anterior resection for rectal cancer and a retained ureteral stent. CT abdomen and pelvis showed a large recurrent pelvic mass and a retained stent. The patient underwent cystoscopy which showed a normal bladder. Upon removal of the stent, brisk bleeding was noted coming from the ureteral orifice. Antegrade pyelogram was done which revealed a UIAF. Angiography was done and a covered stent was placed. Multiple treatment options are available. All must consider management of the arterial and ureteral side. The arterial side may be addressed by primary open repair, embolization with extra-anatomic vascular reconstruction, or endovascular stenting. The ureter can be managed with nephroureterectomy, ureteral reconstruction, placement of a nephrostomy tube, or ureteral stenting. Being minimally invasive, we believe that endovascular stenting should be the preferred therapeutic option as it also corrects the source of bleeding while preserving distal blood flow.

The aim of this paper was to evaluate the factors that predict regression of untreated CIN 2 and 3. A total of 93 patients with colposcopic persistent CIN 2 and 3 lesions after biopsy were followed for 6 months. Human papillomavirus (HPV) types were determined by polymerase chain reaction at enrolment. We analysed the biologic and demographic predictors of natural regression using univariate and multivariate methods. The overall regression rate was 52% (48 out of 93), including 58% (22 out of 38) of CIN 2 and 47% (26 out of 55) of CIN 3 lesions (P=0.31 for difference). Human papillomavirus was detected in 84% (78 out of 93) of patients. In univariate analysis, 80% (12 out of 15) of lesions without HPV regressed compared to 46% (36 out of 78) of lesions with HPV infection (P=0.016). Women without HPV and those who had a resolution of HPV had a four-fold higher chance of regression than those with persistent HPV (relative odds=3.5, 95% CI=1.4-8.6). Women with five or fewer lifetime sexual partners had higher rates of regression than women with more than five partners (P=0.003). In multivariate analysis, HPV status and number of sexual partners remained as significant independent predictors of regression. In conclusion, HPV status and number of lifetime sexual partners were strongly predictive of regression of untreated CIN 2 and 3.

To evaluate the effect of daily beta-carotene (30 mg) versus placebo over a 2-year period on cervical intraepithelial neoplasia (CIN) 2 and 3 lesions. Human papillomavirus (HPV) typing was done to determine whether lesion regression was related to HPV. Micronutrient levels were measured to determine whether levels were predictive of regression. Variables that influence the risk of HPV infection and CIN, such as cigarette smoking and sexual behavior, were evaluated. Women were randomized to beta-carotene or placebo, with cytology and colposcopy every 3 months. Cervical biopsies were performed before treatment and after 6 and 24 months to evaluate response. Persistence of or progression to CIN 3 resulted in removal from the study, whereas treatment continued for 2 years on all others. The presence and type of HPV was determined by PCR. Response was defined as an improvement in CIN by 2 grades. Mantel-Haenszel chi(2) test was used to analyze response to treatment. Fisher's exact test was used to determine the effect of HPV and CIN grade on response Wilcoxon's rank-sum tests were used to compare micronutrient levels between groups. Twenty-one of 124 enrolled women were not randomized because they either moved, became pregnant, voluntarily withdrew, or the pathological review of their initial cervical biopsies did not confirm CIN 2 or 3. Of the remaining 103 women, 33 experienced lesion regression, 45 had persistent or progressive disease, and 25 women did not complete the study and were considered nonresponders in the final analysis. The overall regression rate (32%) was similar between treatment arms and when stratified for CIN grade. Data on 99 women with HPV typing showed that 77% were HPV-positive and 23% HPV-negative at enrollment. HPV-positive lesions were subdivided into indeterminate-, low-, and high-risk categories; the response rate was highest for women with no HPV detected (61%), lower for indeterminate/low-risk (30%), and lowest for high-risk (18%; P =.001). CIN regression was negatively correlated with retinol levels. In conclusion, beta-carotene does not enhance the regression of high-grade CIN, especially in HPV-positive subjects.

The shed portion of the 55 and 75 kDa membrane receptors for tumor necrosis factor (TNF) and lymphotoxin (LT) have been described in the serum of patients with cancer. This study was designed to determine whether serum levels of the 55 and 75 kDa soluble TNF/LT receptors (sTNFr) had clinical significance in patients with gynecologic malignancies. Serum samples from 79 patients with ovarian, endometrial, or cervical cancer were assayed for CA 125 levels by RIA and the 55 and 75 kDa sTNFr levels by ELISA. Receptor and CA 125 levels were also analyzed with respect to disease status and response to treatment in banked serum samples from 14 patients with epithelial ovarian cancer who had been followed clinically for 1-3 years. Patients resulted were compared to serum samples tested from normal donors. We found that serum levels of both sTNFr's were elevated in the 79 patients with various gynecologic malignancies [55 kDa of 3.07 +/- 3.79 ng/ml (P < 0.02) and 75 kDa of 2.93 +/- 1.27 ng/ml (P < 0.001)] compared to 16 normal controls (55 kDa of 0.65 +/- 0.22 ng/ml and 75 kDa of 1.62 +/- 0.37 ng/ml). Serum levels of 55 and 75 kDa TNF/LT receptors were a more sensitive indicator of active cancer and had greater predictive value for detecting tumor in patients with ovarian cancer than CA 125. The sTNFr's were also more sensitive than CA 125 in detecting persistent or recurrent tumor and measuring response to therapy. These preliminary results suggest that measurement of serum levels of 55 and 75 kDa sTNFr's, even though not tumor specific, may be a uniquely new method for identifying and monitoring patients with gynecologic malignancy.