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Objectives: To evaluate the diagnostic role of ultrasound in brachial plexopathies., Methods: We included 59 healthy subjects (HS) and 42 patients consecutively referred with clinical suspicion of brachial plexopathy from October 2015 to May 2016. Patients underwent routine electrodiagnostic testing (EDx) as reference standard and a blinded standardised ultrasound examination of the brachial plexus as index test with cross-sectional area (CSA) as the ultrasound parameter of choice., Results: Seventeen patients were diagnosed by EDx with brachial plexopathy, ten with mononeuropathies, and ten had normal EDx. Five had a cervical radiculopathy. In 11 (64%) out of the 17 patients with EDx diagnosed plexopathy, we found at least one abnormal level on ultrasound. Six (60%) out of ten normal EDx patients had a normal ultrasound examination at all levels. Ultrasound identified the same abnormal level(s) as EDx in eight (73%) of the 11 patients who had both abnormal EDx and ultrasound results. Mean CSA was higher in the plexopathy group compared to HS at the level of the C6 root (p = .022), the middle trunk (p = .027), and the medial cord (p = .003)., Conclusion: Ultrasound examination showed abnormalities in patients with brachial plexopathies in good agreement with EDx., Significance: Ultrasound may be an important supplement to electrodiagnostics in evaluating brachial plexopathies., (Copyright © 2019. Published by Elsevier B.V.)

A dolichoectatic intracranial vessel with multiple fusiform aneurysms on the same vessel segment is rare, and usually managed with a bypass with aneurysm trapping. This video demonstrates trapping and a double-barrel superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass to treat two fusiform aneurysms in a left dolichoectatic superior MCA trunk. A 46-year-old man with AIDS presented with aphasia and hemiparesis. IRB approval and patient consent were obtained. Both STA branches (frontal and parietal) were harvested. After widely splitting the sylvian fissure from its proximal portion to the angular gyrus, the two fusiform aneurysms on the superior MCA trunk were identified in the insular recess and the circular sulcus. The outflow artery from each aneurysm was identified and prepared for the bypass. The STA was transected, and both limbs were brought down into the fissure. After trapping the distal aneurysm, an end-to-end anastomosis of the parietal STA branch to the M2 MCA was performed. Thereafter, a second bypass was performed in an end-to-side fashion to an M2 branch from the base of the first aneurysm. The second aneurysm was then trapped. Indocyanine green angiography confirmed the patency of both bypasses. Complete aneurysm occlusion and bypass patency were also confirmed with postoperative angiography. The patient recovered from his pre-operative neurological deficits. This case demonstrates the efficacy of double-barrel STA-MCA bypass in combination with aneurysm trapping in a patient with a complex dolichoectatic superior MCA trunk aneurysm. It also highlights the advantage of using end-to-end anastomosis for deep recipients with limited access., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Introduction: Newborn screening is important for early diagnosis and effective treatment of inborn errors of metabolism (IEM). In response to a 2008 coroners' report of a 14-year-old boy who died of an undiagnosed IEM, the OPathPaed service model was proposed. In the present study, we investigated the feasibility of the OPathPaed model for delivering expanded newborn screening in Hong Kong. In addition, health care professionals were surveyed on their knowledge and opinions of newborn screening for IEM., Methods: The present prospective study involving three regional hospitals was conducted in phases, from 1 October 2012 to 31 August 2014. The 10 steps of the OPathPaed model were evaluated: parental education, consent, sampling, sample dispatch, dried blood spot preparation and testing, reporting, recall and counselling, confirmation test, treatment and monitoring, and cost-benefit analysis. A fully automated online extraction system for dried blood spot analysis was also evaluated. A questionnaire was distributed to 430 health care professionals by convenience sampling., Results: In total, 2440 neonates were recruited for newborn screening; no true-positive cases were found. Completed questionnaires were received from 210 respondents. Health care professionals supported implementation of an expanded newborn screening for IEM. In addition, there is a substantial need of more education for health care professionals. The majority of respondents supported implementing the expanded newborn screening for IEM immediately or within 3 years., Conclusion: The feasibility of OPathPaed model has been confirmed. It is significant and timely that when this pilot study was completed, a government-led initiative to study the feasibility of newborn screening for IEM in the public health care system on a larger scale was announced in the Hong Kong Special Administrative Region Chief Executive Policy Address of 2015.

Background: Renal angiomyolipoma is rare, but many of these patients may have an acute debut with severe bleeding. These patients need urgent treatment with interventional embolization as an attractive option., Purpose: To investigate the technical and clinical effect of this treatment and to evaluate long-term clinical outcomes with clinical control and radiological imaging., Material and Methods: Eight patients with angiomyolipoma were treated with embolization. Five patients were treated acutely. Five patients were followed-up for mean 4.5 years with clinical and radiological examinations., Results: The renal angiomyolipoma decreased significantly from mean 7.2 cm to 2.9 cm after embolization (p = 0.04). Cortical infarctions of about one-third of the circumference of the embolized kidneys could be detected on follow-up examinations, but all patients had normal total kidney function. The bleeding was primarily stopped in all patients, however, in one patient bleeding from a lumbar artery was supplementary embolized within 24 h. In another case the interventional procedure ended up in embolization of the whole kidney as it was impossible to embolize all the feeding arteries selectively. One patient had a nephrectomy one month after embolization because of infection and re-bleeding and one patient after 2.5 years because of tumor size >4 cm. The technical success was 7/8 (88%) and clinical success was 6/8 patients (75%)., Conclusion: Selective embolization of renal angiomyolipoma is a minimally invasive and safe procedure with few complications. It is a nephron sparing alternative to renal resection. The reduction in tumor size after embolization is significant and long-lasting.

Background: Avascular necrosis (AVN) of the femoral head (FH) is believed to be caused by a multitude of etiologic factors and is associated with significant morbidity in younger populations. Eventually, the disease progresses and results in FH collapse. Thus, a focus on early disease management aimed at joint preservation by preventing or delaying progression is key. The use of stem cells (SC) for the treatment of AVN of the FH has been proposed. We undertook a systematic review of the medical literature examining the use of SC for the treatment of early stage (precollapse) AVN of the FH, in both pre-clinical and clinical studies., Methods: Data collected included: Pre-clinical studies - model of AVN, variety and dosage of SC, histologic and imaging analyses. Clinical studies - study design, classification and etiology of AVN, SC dosage and treatment protocol, incidence of disease progression, patient reported outcomes, volume of necrotic lesion and hip survivorship., Results: In pre-clinical studies, the use of SC uniformly demonstrated improvements in osteogenesis and angiogenesis, yet source of implanted SC was variable. In clinical studies, groups treated with SC showed significant improvements in patient reported outcomes; however hip survivorship was not affected. Discrepancies regarding dose of SC, AVN etiology and disease severity were present., Conclusions: Routine use of this treatment method will first require further research into dose and quality optimization as well as confirmed improvements in hip survivorship.

Background: A number of factors have been identified as influencing total knee arthroplasty outcomes, including patient factors such as gender and medical comorbidity, technical factors such as alignment of the prosthesis, and provider factors such as hospital and surgeon procedure volumes. Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of total joint arthroplasty to higher volume centers, and adoption of volume standards. To contribute to the discussions concerning the optimization of provider factors and proposals to regionalize total knee arthroplasty practices, we undertook a systematic review to investigate the association between surgeon volume and primary total knee arthroplasty outcomes., Methods: We performed a systematic review examining the association between surgeon volume and primary knee arthroplasty outcomes. To be included in the review, the study population had to include patients undergoing primary total knee arthroplasty. Studies had to report on the association between surgeon volume and primary total knee arthroplasty outcomes, including perioperative mortality and morbidity, patient-reported outcomes, or total knee arthroplasty implant survivorship. There were no restrictions placed on study design or language., Results: Studies were variable in defining surgeon volume ('low': <3 to <52 total knee arthroplasty per year; 'high': >5 to >70 total knee arthroplasty per year). Mortality rate, survivorship and thromboembolic events were not found to be associated with surgeon volume. We found a significant association between low surgeon volume and higher rate of infection (0.26% - 2.8% higher), procedure time (165 min versus 135 min), longer length of stay (0.4 - 2.13 days longer), transfusion rate (13% versus 4%), and worse patient reported outcomes., Conclusions: Findings suggest a trend towards better outcomes for higher volume surgeons, but results must be interpreted with caution.

Patient satisfaction is an important outcome measurement in TKA/THA surgery. Patient satisfaction can be evaluated from 2 perspectives, determinants of satisfaction and components of satisfaction.(5) In total joint arthroplasty, improvements in satisfaction can be achieved by examining these perspectives. Patient satisfaction is one of the many PROMs used in orthopedic surgery and is an integral part of the growing sentiment to evaluate surgery from the patient's perspective as well as from the surgeon's. The importance of measuring outcomes from the patient perspective is integral to today's patient-centered models of care.

Negative co-stimulatory signaling mediated via cell surface programmed death (PD)-1 expression modulates T and B cell activation and is involved in maintaining peripheral tolerance. In this study, we examined the effects of a fully human PD-1-abrogating antibody on the in vitro expansion and function of human vaccine-induced CD8+ T cells (CTLs) specific for the melanoma-associated antigens glycoprotein 100 (gp100) and melanoma antigen recognized by T cells (MART)-1. PD-1 blockade during peptide stimulation augmented the absolute numbers of CD3+, CD4+, CD8+ and gp100/MART-1 MHC:peptide tetramer+ CTLs. This correlated with increased frequencies of IFN-gamma-secreting antigen-specific cells and augmented lysis of gp100+/MART-1+ melanoma targets. PD-1 blockade also increased the fraction of antigen-specific CTLs that recognized melanoma targets by degranulation, suggesting increased recognition efficiency for cognate peptide. The increased frequencies and absolute numbers of antigen-specific CTLs by PD-1 blockade resulted from augmented proliferation, not decreased apoptosis. Kinetic analysis of cytokine secretion demonstrated that PD-1 blockade increased both type-1 and type-2 cytokine accumulation in culture without any apparent skewing of the cytokine repertoire. These findings have implications for developing new cancer immunotherapy strategies.

We have determined the mass spectra of three polypeptides which have been designed as an effective reagent to be used in the diagnosis of a Chinese strain of Hepatitis E Virus (HEV). The spectra were determined by electrospray ionization-Fourier transform ion cyclotron resonance mass spectrometer. These are peptide 30, peptide 33 and peptide 42, where the guanidine amino group of arginine in each polypeptide was protected. The molecular weights were respectively measured as 3575, 4094 and 5390 Dalton, against the molecular weights of bovine serum albumin (66430 Da) and bovine insulin (5732.77 Da).

The growth and differentiation of L6 myoblasts are subject to control by two proteins secreted by cells of the Buffalo rat liver line. The first of these, rat insulinlike growth factor-II (formerly designated multiplication stimulating activity) is a potent stimulator of myoblast proliferation and differentiation, as well as associated processes such as amino acid uptake and incorporation into protein, RNA synthesis, and thymidine incorporation into DNA. In addition, this hormone causes a significant decrease in the rate of protein degradation. All of these actions seem to be attributable to a single molecular species, although their time courses and sensitivity to the hormone differ substantially. The second protein, the differentiation inhibitor (DI), is a nonmitogenic inhibitor of all tested aspects of myoblast differentiation, including fusion and the elevation of creatine kinase. Indirect immunofluorescence experiments demonstrated that DI also blocks accumulation of myosin heavy chain and myomesin. Upon removal of DI after 72 h incubation, all of these effects were reversed and normal myotubes containing the usual complement of muscle-specific proteins were formed. Thus, this system makes it possible to achieve specific stimulation or inhibition of muscle cell differentiation by addition of purified proteins to cloned cells in serum-free medium.