Parental Expressed Emotion and Behavioural Outcomes in Autistic Children and Adolescents: A Systematic Review

Growing interest in the links between parent-child relationships and child behavioural presentations in families of autistic children has led to an increased use of the Five Minute Speech Sample (FMSS) measure of parental expressed emotion (EE) in autism research. This review focuses on studies exploring the relationships between parental EE and behavioural outcomes in autistic children. Electronic searches of six databases and grey literature wielded eight studies that met eligibility criteria. Study designs were a mixture of cross-sectional and longitudinal and quality of studies was variable. Parental criticism was largely positively related to, and showed some predictive value for, child behaviour problems. Warmth was mostly negatively related to, and showed some predictive value for, child behaviour problems. Preliminary evidence from one study showed paternal warmth to be significantly related to child behaviours, whilst child behaviours were also significantly related to paternal warmth, suggesting a bidirectional relationship. Analysis of additional EE components produced variable results, however parental stress and depressive symptoms were consistently related to child behaviour, and preliminary evidence suggests a possible role of maternal education level and family cohesion. Outcomes were variable across FMSS coding systems and greater consistency in their application is needed in future research. The current findings suggest that parental EE has an important relationship with child behaviour and future intervention efforts may benefit from aiming to reduced EE in order to improve child outcomes.

Prospective Phase II Trial of Primary Lung Tumor Stereotactic Body Radiation Therapy (SBRT) Followed By Concurrent Mediastinal Chemoradiation and Adjuvant Immunotherapy for Locally-Advanced Non-Small Cell Lung Cancer (LA NSCLC)

PURPOSE/OBJECTIVE(S)

To report the efficacy and toxicity outcomes of a prospective phase II trial of primary tumor SBRT followed by conventional chemoradiation to the lymph nodes and adjuvant immunotherapy in patients (pts) with unresectable LA NSCLC.

MATERIALS/METHODS

Eligible pts included stage II-III LA NSCLC with peripheral primary tumors ≤ 7cm or centrally based tumors that had at least 2 cm separation from involved nodal disease. Pts received SBRT to the primary tumor (50-54 Gy in 3-5 fractions) followed by standard radiation to 60 Gy in 30 fractions to the involved lymph nodes with concurrent platinum doublet chemotherapy. The trial was amended to allow pts without disease progression after chemoradiation to receive adjuvant durvalumab per the PACIFIC trial. The primary endpoint was 1 year progression free survival (PFS), evaluated as a binary variable. Frequencies and proportions were used for reporting this primary endpoint, in addition to adverse events and patterns of failure. Median PFS and OS were estimated using Kaplan Meier methods.

RESULTS

Safety and efficacy is reported on the first 50 pts enrolled in the trial with a median follow-up of 24 months (mos) (range, 1-54 mos). Pts were primarily stage IIIA (60%) or stage IIIB (34%), with 6% of pts stage IIB. Overall grade 3 or higher toxicity related to SBRT and/or mediastinal radiation was 8% with two pts (4%) developing grade 3 pneumonitis and one pt having a grade 5 lung infection possibly related to radiation. Overall grade 2 pneumonitis related to SBRT or mediastinal radiation was 20%. Only one pt (2%) developed grade 3 esophagitis. No late cardiac events have been observed. The one-year PFS for all pts was 62% with a median PFS of 26.3 mos and median overall survival of 40.8 mos. Of the 50 pts enrolled, 37 received at least one dose of adjuvant durvalumab. The one-year PFS for pts who received at least one dose of durvalumab was 70.3% with a median PFS not yet reached in this group (median follow-up 24 mos). Patterns of failure were mostly distant with 26% of pts experiencing distant failure, 6% regional, and 2% distant and regional. There was only one local failure (2%) after SBRT in all 50 pts.

CONCLUSION

SBRT to the primary tumor followed by conventional chemoradiation to the involved lymph nodes and adjuvant immunotherapy was well tolerated and showed improved 1-year PFS compared to prior conventional chemoradiation trials for locally advanced NSCLC. The results of this trial will be further evaluated in a randomized phase III study, NRG LU-008. Pts will receive either conventional chemoradiation vs. SBRT to the primary tumor followed by chemoradiation to the involved lymph nodes followed by consolidative immunotherapy to evaluate the possibility of utilization of SBRT as a new standard of care for LA NSCLC.

The socioeconomic gradient in mortality from ovarian, cervical, and endometrial cancer in Australian women, 2001-2018: A population-based study

BACKGROUND

Socio-economic (SE) status is closely linked to health status and the mechanisms of this association are complex. One important adverse effect of SE disadvantage is vulnerability to cancer and cancer is a major cause of morbidity and mortality in Australia.

AIMS

We aimed to estimate the effect of SE status on mortality rates from ovarian, cervical, and endometrial cancer.

MATERIALS AND METHODS

National mortality data were obtained from the Australian Bureau of Statistics (ABS) for the calendar years from 2001 to 2018, inclusive. Individual deaths were grouped by the ABS Index of Relative Socio-economic Advantage and Disadvantage. Population data were obtained to provided denominators allowing calculation of mortality rates (deaths per 100 000 women aged 30-79 years). Statistical analyses performed included tabulating point-estimates of mortality rates and their changes over time and modelling the trends of rates using maximum likelihood method.

RESULTS

Age-standardised mortality rates for ovarian and cervical cancer fell over the study period but increased for endometrial cancer. There was clear evidence of a SE gradient in the mortality rate for all three cancers. This SE gradient increased over the study period for ovarian and cervical cancer but remained unchanged for endometrial cancer.

CONCLUSIONS

Women at greater SE disadvantage have higher rates of death from the commonest gynaecological cancers and this gradient has not reduced over the last two decades. After the COVID-19 pandemic efforts must be redoubled to ensure that Australians already at risk of ill health do not face even greater risks because of their circumstances.

Transcriptional and Translational Dynamics of Zika and Dengue Virus Infection

Zika virus (ZIKV) and dengue virus (DENV) are members of the Flaviviridae family of RNA viruses and cause severe disease in humans. ZIKV and DENV share over 90% of their genome sequences, however, the clinical features of Zika and dengue infections are very different reflecting tropism and cellular effects. Here, we used simultaneous RNA sequencing and ribosome footprinting to define the transcriptional and translational dynamics of ZIKV and DENV infection in human neuronal progenitor cells (hNPCs). The gene expression data showed induction of aminoacyl tRNA synthetases (ARS) and the translation activating PIM1 kinase, indicating an increase in RNA translation capacity. The data also reveal activation of different cell stress responses, with ZIKV triggering a BACH1/2 redox program, and DENV activating the ATF/CHOP endoplasmic reticulum (ER) stress program. The RNA translation data highlight activation of polyamine metabolism through changes in key enzymes and their regulators. This pathway is needed for eIF5A hypusination and has been implicated in viral translation and replication. Concerning the viral RNA genomes, ribosome occupancy readily identified highly translated open reading frames and a novel upstream ORF (uORF) in the DENV genome. Together, our data highlight both the cellular stress response and the activation of RNA translation and polyamine metabolism during DENV and ZIKV infection.

Mental Health Workers' Attitudes Towards Individuals With a Diagnosis of Borderline Personality Disorder: A Systematic Literature Review

The attitudes of mental health workers toward individuals with mental health conditions can impact the quality of care they provide. Negative attitudes among mental health workers seem particularly common in response to people diagnosed with borderline personality disorder (BPD). The current review aimed to identify and review the literature regarding mental health workers' attitudes toward individuals diagnosed with BPD, specifically focusing on studies comparing workers' attitudes toward BPD with attitudes toward other mental health diagnoses. The findings suggest that mental health workers have more negative attitudes toward individuals labeled as having BPD than toward individuals with other diagnoses, such as depression. This is likely due to factors associated with the label itself, in addition to workers' perceptions of BPD symptoms and previous experiences of delivering treatment. The implications of these findings are considered, with a particular focus on how mental health services can effectively address negative attitudes toward BPD.

A Comprehensive Review of PCSK9 Inhibitors

Cardiovascular disease (CVD) is the leading cause of death in the United States and worldwide. A major risk factor for this condition is increased serum low-density lipoprotein cholesterol (LDL-C) levels for which statins have been successful in reducing serum LDL-C to healthy concentrations. However, patients who are statin intolerant or those who do not achieve their treatment goals while on high-intensity statin therapy, such as those with familial hypercholesterolemia, remain at risk. With the discovery of PCSK9 inhibitors, the ability to provide more aggressive treatment for patients with homozygous and heterozygous familial hypercholesterolemia has increased. Ezetimibe reduces LDL-C by 15%-20% when combined with statin.^2,3 Protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been found to achieve profound reductions in LDL-C (54%-74%) when added to statins. They have shown dramatic effects at lowering major adverse cardiovascular events (MACE) in high-risk patients⁴ with LDL-C levels ≥70 mg/dL and can be used in populations that are statin intolerant or not at goal levels with maximally tolerated statin therapy. PCSK9 inhibitors also produce minimal side effects. Myopathy, a common side effect for patients on statins, has been rare in patients on PCSK9 inhibitors. Randomized trials have shown that reduction in LDL-C has translated to clinical benefits even in patients who have not achieved their LDL-C target.

O49 The use of augmented reality for surgical guidance: an assessment of the human error

Introduction

Microsoft HoloLens® is an augmented-reality headset which is increasingly used for surgical guidance. This headset allows the overlay of patient-specific virtual models obtained from medical images onto the patient’s body surface using automatic marker-based alignment. This can guide surgeons during certain surgical tasks, e.g. determining biopsy needle entry points. This study aims to measure the human error in the localisation of virtual models with the headset and discuss its surgical implications.

Method

59 adults were recruited between the ages of 20–59 years. A 12 cm2 digital marker was displayed on a monitor in 9 different positions, one at a time. This was repeated 3 times, resulting in 27 markers shown to each participant. Once a marker was detected by the headset’s camera, a virtual hexagon was rendered on the headset’s transparent lenses. Participants were tasked to click on the hexagon’s vertices using a mouse. The clicks’ coordinates were recorded by the system and compared to the predicted coordinates. This allowed for the calculation of the vertex localisation error.

Result

The mean vertex localisation error was found to be 5.19 mm (±3.56) with a range from 0.08 to 29.77 mm. There was a significant difference between marker positions as determined by a one-way ANOVA (P < 0.001).

Conclusion

This study suggests that the error in the localisation of virtual models depends on the position of the markers relative to the user wearing the headset. Further research is required to explore whether training can reduce the human error with this headset.

Take-home Message

The range of the human error in localising virtual models via the Microsoft HoloLens® headset is large and may be dependent on the position of the marker relative to the user of the headset. Further research is needed to investigate whether training with the headset can improve human performance.

Individuals with high bone mass have increased progression of radiographic and clinical features of knee osteoarthritis

OBJECTIVE

High bone mass (HBM) is associated with an increased prevalence of radiographic knee OA (kOA), characterized by osteophytosis. We aimed to determine if progression of radiographic kOA, and its sub-phenotypes, is increased in HBM and whether observed changes are clinically relevant.

DESIGN

A cohort with and without HBM (L1 and/or total hip bone mineral density Z-score≥+3.2) had knee radiographs collected at baseline and 8-year follow-up. Sub-phenotypes were graded using the OARSI atlas. Medial/lateral tibial/femoral osteophyte and medial/lateral joint space narrowing (JSN) grades were summed and Δosteophytes, ΔJSN derived. Pain, function and stiffness were quantified using the WOMAC questionnaire. Associations between HBM status and sub-phenotype progression were determined using multivariable linear/poisson regression, adjusting for age, sex, height, baseline sub-phenotype grade, menopause, education and total body fat mass (TBFM). Generalized estimating equations accounted for individual-level clustering.

RESULTS

169 individuals had repeated radiographs, providing 330 knee images; 63% had HBM, 73% were female, mean (SD) age was 58 (12) years. Whilst HBM was not clearly associated with overall Kellgren-Lawrence measured progression (RR = 1.55 [0.56.4.32]), HBM was positively associated with both Δosteophytes and ΔJSN individually (adjusted mean differences between individuals with and without HBM 0.45 [0.01.0.89] and 0.15 [0.01.0.29], respectively). HBM individuals had higher WOMAC knee pain scores (β = 7.42 [1.17.13.66]), largely explained by adjustment for osteophyte score (58% attenuated) rather than JSN (30% attenuated) or TBFM (16% attenuated). The same pattern was observed for symptomatic stiffness and functional limitation.

CONCLUSIONS

HBM is associated with osteophyte progression, which appears to contribute to increased reported pain, stiffness and functional loss.

Subregional statistical shape modelling identifies lesser trochanter size as a possible risk factor for radiographic hip osteoarthritis, a cross-sectional analysis from the Osteoporotic Fractures in Men Study

OBJECTIVE

Statistical shape modelling (SSM) of hip dual-energy X-ray absorptiometry (DXA) scans has identified relationships between hip shape and radiographic hip OA (rHOA). We aimed to further elucidate shape characteristics related to rHOA by focusing on subregions identified from whole-hip shape models.

METHOD

SSM was applied to hip DXAs obtained in the Osteoporotic Fractures in Men Study. Whole-hip shape modes (HSMs) associated with rHOA were combined to form a composite at-risk-shape. Subsequently, subregional HSMs (cam-type and lesser trochanter modes) were built, and associations with rHOA were examined by logistic regression. Subregional HSMs were further characterised, by examining associations with 3D-HSMs derived from concurrent hip CT scans.

RESULTS

4,098 participants were identified with hip DXAs and radiographs. Composite shapes from whole-hip HSMs revealed that lesser trochanter size and cam-type femoral head are related to rHOA. From sub-regional models, lesser trochanter mode (LTM)1 [OR 0.74; 95%CI 0.63.0.87] and cam-type mode (CTM)3 [OR 1.27; 1.13.1.42] were associated with rHOA, associations being similar to those for whole hip HSMs. 515 MrOS participants had hip DXAs and 3D-HSMs derived from hip CT scans. LTM1 was associated with 3D-HSMs that also represented a larger lesser trochanter [3D-HSM7 (beta (β)-0.23;-0.33,-0.14) and 3D-HSM9 (β0.36; 0.27.0.45)], and CTM3 with 3D-HSMs describing cam morphology [3D-HSM3 (β-0.16;-0.25,-0.07) and 3D-HSM6 (β 0.19; 0.10.0.28)].

CONCLUSION

Subregional SSM of hip DXA scans suggested larger lesser trochanter and cam morphology underlie associations between overall hip shape and rHOA. 3D hip modelling suggests our subregional SSMs represent true anatomical variations in hip shape, warranting further investigation.

Synergistic effects of common schizophrenia risk variants

The mechanisms by which common risk variants of small effect interact to contribute to complex genetic disorders are unclear. Here, we apply a genetic approach, using isogenic human induced pluripotent stem cells, to evaluate the effects of schizophrenia (SZ)-associated common variants predicted to function as SZ expression quantitative trait loci (eQTLs). By integrating CRISPR-mediated gene editing, activation and repression technologies to study one putative SZ eQTL (FURIN rs4702) and four top-ranked SZ eQTL genes (FURIN, SNAP91, TSNARE1 and CLCN3), our platform resolves pre- and postsynaptic neuronal deficits, recapitulates genotype-dependent gene expression differences and identifies convergence downstream of SZ eQTL gene perturbations. Our observations highlight the cell-type-specific effects of common variants and demonstrate a synergistic effect between SZ eQTL genes that converges on synaptic function. We propose that the links between rare and common variants implicated in psychiatric disease risk constitute a potentially generalizable phenomenon occurring more widely in complex genetic disorders.

Examining the relationship between astrocyte dysfunction and neurodegeneration in ALS using hiPSCs

Amyotrophic lateral sclerosis (ALS) is a complex and fatal neurodegenerative disease for which the causes of disease onset and progression remain unclear. Recent advances in human induced pluripotent stem cell (hiPSC)-based models permit the study of the genetic factors associated with ALS in patient-derived neural cell types, including motor neurons and glia. While astrocyte dysfunction has traditionally been thought to exacerbate disease progression, astrocytic dysfunction may play a more direct role in disease initiation and progression. Such non-cell autonomous mechanisms expand the potential targets of therapeutic intervention, but only a handful of ALS risk-associated genes have been examined for their impact on astrocyte dysfunction and neurodegeneration. This review summarizes what is currently known about astrocyte function in ALS and suggests ways in which hiPSC-based models can be used to more effectively study the role of astrocytes in neurodegenerative disease.

Preoperative surgical risk stratification in osteosarcoma based on the proximity to the major vessels

Aims

The aim of this study was to determine the risk of local recurrence and survival in patients with osteosarcoma based on the proximity of the tumour to the major vessels.

Patients and Methods

A total of 226 patients with high-grade non-metastatic osteosarcoma in the limbs were investigated. Median age at diagnosis was 15 years (4 to 67) with the ratio of male to female patients being 1.5:1. The most common site of the tumour was the femur (n = 103) followed by tibia (n = 66). The vascular proximity was categorized based on the preoperative MRI after neoadjuvant chemotherapy into four types: type 1 > 5 mm; type 2 ≤ 5 mm, > 0 mm; type 3 attached; type 4 surrounded.

Results

Limb salvage rate based on the proximity type was 92%, 88%, 51%, and 0% for types 1 to 4, respectively, and the overall survival at five years was 82%, 77%, 57%, and 67%, respectively (p < 0.001). Local recurrence rate in patients with limb-salvage surgery was 7%, 8%, and 22% for the types 1 to 3, respectively (p = 0.041), and local recurrence at the perivascular area was observed in 1% and 4% for type 2 and 3, respectively. The mean microscopic margin to the major vessels was 6.9 mm, 3.0 mm, and 1.4 mm for types 1 to 3, respectively. In type 3, local recurrence-free survival with limb salvage was significantly poorer compared with amputation (p = 0.025), while the latter offered no overall survival benefit. In this group of patients, factors such as good response to chemotherapy or limited vascular attachment to less than half circumference or longitudinal 10 mm reduced the risk of local recurrence.

Conclusion

The proximity of osteosarcoma to major blood vessels is a poor prognostic factor for local control and survival. Amputation offers better local control for tumours attached to the blood vessels but does not improve survival. Limb salvage surgery offers similar local control if the tumour attachment to blood vessels is limited. Cite this article: Bone Joint J 2019;101-B:1024–1031.

Distinguishing bone and soft tissue infections mimicking sarcomas requires multimodal multidisciplinary team assessment

INTRODUCTION

The aims of this study were to report the presenting characteristics and identify how best to distinguish bone and soft-tissue infections that mimic sarcomas.

MATERIALS AND METHODS

A total of 238 (211 osteomyelitis and 27 soft-tissue infections) patients referred to a tertiary sarcoma multidisciplinary team with suspected sarcoma who were ultimately diagnosed with a bone or soft tissue infection were included. Data from a prospectively collated database was analysed retrospectively.

RESULTS

Of all possible bone and soft-tissue sarcoma referrals, a diagnosis of infection was made in 2.1% and 0.7%, respectively. Median age was 18 years in the osteomyelitis group and 46 years in the soft-tissue infection group. In the osteomyelitis group, the most common presenting features were pain (85.8%) and swelling (32.7%). In the soft-tissue infection group, the most common clinical features were swelling (96.3%) and pain (70.4%). Those in the soft-tissue group were more likely to have raised inflammatory markers. Radiological investigations were unable to discern between tumour or infection in 59.7% of osteomyelitis and 81.5% of soft-tissue infection cases. No organism was identified in 64.9% of those who had a percutaneous biopsy culture.

CONCLUSIONS

This study has highlighted that infection is frequently clinically indistinguishable from sarcoma and remains a principle non-neoplastic differential diagnosis. When patients are investigated for suspected sarcoma, infections can be missed due to falsely negative radiological investigations and percutaneous biopsy. As no single clinical, biochemical or radiological feature or investigation can be relied upon for diagnosis, clinicians should have a low threshold for tissue biopsy and discussion in a sarcoma multidisciplinary team meeting.

Prognostic factors for local recurrence in extremity-located giant cell tumours of bone with pathological fracture

AIMS

The aim of this paper was to investigate the prognostic factors for local recurrence in patients with pathological fracture through giant cell tumours of bone (GCTB).

PATIENTS AND METHODS

A total of 107 patients presenting with fractures through GCTB treated at our institution (Royal Orthopaedic Hospital, Birmingham, United Kingdom) between 1995 and 2016 were retrospectively studied. Of these patients, 57 were female (53%) and 50 were male (47%).The mean age at diagnosis was 33 years (14 to 86). A univariate analysis was performed, followed by multivariate analysis to identify risk factors based on the treatment and clinical characteristics.

RESULTS

The initial surgical treatment was curettage with or without adjuvants in 55 patients (51%), en bloc resection with or without reconstruction in 45 patients (42%), and neoadjuvant denosumab, followed by resection (n = 3, 3%) or curettage (n = 4, 4%). The choice of treatment depended on tumour location, Campanacci tumour staging, intra-articular involvement, and fracture displacement. Neoadjuvant denosumab was used only in fractures through Campanacci stage 3 tumours. Local recurrence occurred in 28 patients (25%). Surgery more than six weeks after the fracture did not affect the risk of recurrence in any of the groups. In Campanacci stage 3 tumours not treated with denosumab, en bloc resection had lower local recurrences (13%), compared with curettage (39%). In tumours classified as Campanacci 2, intralesional curettage and en bloc resections had similar recurrence rates (21% and 24%, respectively). After univariate analysis, the type of surgical intervention, location, and the use of denosumab were independent factors predicting local recurrence. Further surgery was required 33% more often after intralesional curettage in comparison with resections (mean 1.59, 0 to 5 vs 1.06, 0 to 3 operations). All patients treated with denosumab followed by intralesional curettage developed local recurrence.

CONCLUSION

In patients with pathological fractures through GCTB not treated with denosumab, en bloc resection offers lower risks of local recurrence in tumours classified as Campanacci stage 3. Curettage or resections are both similar options in terms of the risk of local recurrence for tumours classified as Campanacci stage 2. The benefits of denosumab followed by intralesional curettage in these patients still remains unclear.

Unexpected similarities between C9ORF72 and sporadic forms of ALS/FTD suggest a common disease mechanism

Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) represent two ends of a disease spectrum with shared clinical, genetic and pathological features. These include near ubiquitous pathological inclusions of the RNA-binding protein (RBP) TDP-43, and often the presence of a GGGGCC expansion in the C9ORF72 (C9) gene. Previously, we reported that the sequestration of hnRNP H altered the splicing of target transcripts in C9ALS patients (Conlon et al., 2016). Here, we show that this signature also occurs in half of 50 postmortem sporadic, non-C9 ALS/FTD brains. Furthermore, and equally surprisingly, these ‘like-C9’ brains also contained correspondingly high amounts of insoluble TDP-43, as well as several other disease-related RBPs, and this correlates with widespread global splicing defects. Finally, we show that the like-C9 sporadic patients, like actual C9ALS patients, were much more likely to have developed FTD. We propose that these unexpected links between C9 and sporadic ALS/FTD define a common mechanism in this disease spectrum.

Naming Notes: Transitions from Free Text to Structured Entry

To practice medicine in the near future, health care providers in the USA need an information infrastructure they do not yet have. We offer a contribution from social science research to discussions of current medical records practices and how health care activity systems may be transformed by the advent of electronic health records. The goal of the paper is to set forth a framework that connects over-arching questions concerning medical informatics systems development with the practical, cultural and conceptual issues involved in transitions from handwritten and other free text documentation to structured entry of medical records to build patient profiles. The research is broadly framed by an interest in how reciprocal modifications of the design and use of an electronic health record are negotiated in an iterative prototyping project. It is conducted as part of a complex multi-disciplinary research and development effort to create an electronic health record prototype for use in the integrated health care delivery environment of the Southern California Kaiser Permanente Medical Care Program.

Shoulder Arthroplasty Imaging: What's New

Background

Shoulder arthroplasty, in its different forms (hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty) has transformed the clinical outcomes of shoulder disorders. Improvement of general clinical outcome is the result of stronger adequacy of the treatment to the diagnosis, enhanced surgical techniques, specific implanted materials, and more accurate follow up. Imaging is an important tool in each step of these processes.

Method

This article is a review article declining recent imaging processes for shoulder arthroplasty.

Results

Shoulder imaging is important for shoulder arthroplasty pre-operative planning but also for post-operative monitoring of the prosthesis and this article has a focus on the validity of plain radiographs for detecting radiolucent line and on new Computed Tomography scan method established to eliminate the prosthesis metallic artefacts that obscure the component fixation visualisation.

Conclusion

Number of shoulder arthroplasties implanted have grown up rapidly for the past decade, leading to an increase in the number of complications. In parallel, new imaging system have been established to monitor these complications, especially component loosening.

Short, Medium and Long Term Complications After Total Anatomical Shoulder Arthroplasty

Total shoulder arthroplasty (TSA) is an effective approach for the treatment of a variety of clinical conditions affecting the shoulder, including osteoarthritis, inflammatory arthritis and osteonecrosis, and the number of TSA implanted has grown exponentially over the past decade. This review gives an update of the major complications, mainly infections, instability and loosening, encountered after TSA, based on a corpus of recent publications and a dynamic approach: The review focuses on the causes of glenoid loosening, which account for 80% of the complication, and underlines the importance of glenoid positioning in the recovery of early shouder function and in the long term survival rate of TSA.

Application of CRISPR/Cas9 to the study of brain development and neuropsychiatric disease

CRISPR/Cas9 technology has transformed our ability to manipulate the genome and epigenome, from efficient genomic editing to targeted localization of effectors to specific loci. Through the manipulation of DNA- and histone-modifying enzyme activities, activation or repression of gene expression, and targeting of transcriptional regulators, the role of gene-regulatory and epigenetic pathways in basic biology and disease processes can be directly queried. Here, we discuss emerging CRISPR-based methodologies, with specific consideration of neurobiological applications of human induced pluripotent stem cell (hiPSC)-based models.

Surgical Innovation in Sarcoma Surgery

The field of orthopaedic oncology relies on innovative techniques to resect and reconstruct a bone or soft tissue tumour. This article reviews some of the most recent and important innovations in the field, including biological and implant reconstructions, together with computer-assisted surgery. It also looks at innovations in other fields of oncology to assess the impact and change that has been required by surgeons; topics including surgical margins, preoperative radiotherapy and future advances are discussed.

Surveillance of intramedullary cartilage tumours in long bones

AIMS

The purpose of this study was to determine if clinical and radiological surveillance of cartilage tumours with low biological activity is appropriate.

PATIENTS AND METHODS

A total of 98 patients with an intramedullary cartilage neoplasm in a long bone met our inclusion criteria and were included in the study. These patients had undergone a total of 384 scans. Patients with radiological follow-up of more than three years (46 patients) were divided into two groups: an active group (11 patients) and a latent group (35 patients).

RESULTS

Active lesions had a total growth in all three planes that was > 6 mm, whilst latent lesions had < 6 mm of growth. Most latent lesions were heavily calcified: active lesions were calcified less than 50% (p = 0.025).

CONCLUSION

Clinico-radiological surveillance can identify growing cartilage lesions: MRI is the surveillance modality of choice. A CT scan is recommended, in addition, at presentation to assess the amount of calcification within the lesion. A first follow-up MRI is suggested one year from diagnosis. If the total growth in the cartilage lesion is > 6 mm, surgical treatment should be considered. Otherwise, a second surveillance scan can be performed at three years to determine further management. Cite this article: Bone Joint J 2016;98-B:1542-7.

Development & automation of a novel [(18)F]F prosthetic group, 2-[(18)F]-fluoro-3-pyridinecarboxaldehyde, and its application to an amino(oxy)-functionalised Aβ peptide

2-[(18)F]-Fluoro-3-pyridinecarboxaldehyde ([(18)F]FPCA) is a novel, water-soluble prosthetic group. It's radiochemistry has been developed and fully-automated for application in chemoselective radiolabelling of amino(oxy)-derivatised RI-OR2-TAT peptide, (Aoa-k)-RI-OR2-TAT, using a GE TRACERlab FX-FN. RI-OR2-TAT is a brain-penetrant, retro-inverso peptide that binds to amyloid species associated with Alzheimer's Disease. Radiolabelled (Aoa-k)-RI-OR2-TAT was reproducibly synthesised and the product of the reaction with FPCA has been fully characterised. In-vivo biodistribution of [(18)F]RI-OR2-TAT has been measured in Wistar rats.

Stimuli-responsive cylindrical hydrogels mimic intestinal peristalsis to propel a solid object

The emerging field of soft robotics relies on soft, stimuli-responsive materials to enable load transport, manipulation, and mobility in complex unconstrained environments. These materials often need to replicate biological functionality such as muscle contractions and flexibility. Here we demonstrate a soft actuator prototype based on thermosensitive PNIPAAM hydrogels that can transport and manipulate objects. A hollow cylindrical hydrogel was selectively heated and cooled with Peltier devices to yield a traveling wave of shrinking and swelling akin to intestinal peristalsis. A 4 mm diameter bead was placed inside the cylinder and propelled 19.5 mm, equal to distance traveled by the peristaltic wave. We derived conditions that enable peristaltic transport as a function of transporter-cargo design parameters. We conclude that hydrogel-based peristaltic manipulators covering 2 orders of magnitude in stiffness (1-10(2) kPa) could transport cargo spanning 4 orders of magnitude in size (μm-m).

Non-O1, non-O139 Vibrio cholerae bacteraemia in an Australian population

This retrospective case series identifies the largest cohort of non-O1, non-O139 Vibrio cholerae bacteraemia in an Australian population from 2000 to 2013. We examine the risk factors, epidemiology, clinical presentations and mortality of non-O1, non-O139 V. cholerae bacteraemia in Victoria and compare them with published cases in the literature. This case series highlights the pathogenic potential of non-O1, non-O139 V. cholerae and identifies possible associations with host (underlying chronic liver disease and malignancy) and environmental factors (contaminated water supply and raw seafood). Clinicians should be aware of the morbidity and mortality associated with invasive non-O1, non-O139 V. cholerae infections, particularly in immunocompromised patients.

A validation of the Oswestry Spinal Risk Index

PURPOSE

The purpose of this study was to validate the Oswestry Spinal Risk Index (OSRI) in an external population. The OSRI predicts survival in patients with metastatic spinal cord compression (MSCC).

METHODS

We analysed the data of 100 patients undergoing surgical intervention for MSCC at a tertiary spinal unit and recorded the primary tumour pathology and Karnofsky performance status to calculate the OSRI. Logistic regression models and survival plots were applied to the data in accordance with the original paper.

RESULTS

Lower OSRI scores predicted longer survival. The OSRI score predicted survival accurately in 74% of cases (p = 0.004).

CONCLUSIONS

Our study has found that the OSRI is a significant predictor of survival at levels similar to those of the original authors and is a useful and simple tool in aiding complex decision making in patients presenting with MSCC.

Impact on patient care of discordance in radiology readings between external overnight radiology services and staff radiology readings at a level 1 trauma center

BACKGROUND

Overnight radiology services (ORSs) provide computed tomography (CT) scan readings that are automatically reviewed by staff radiologists (SRs) and the trauma service. Discordant readings and their clinical significance were investigated.

METHODS

ORS-read CT scans over 3 years were reviewed. A discordant reading was clinically significant if it resulted in a substantive change in patient care. All clinically significant findings were reviewed by a blinded radiologist.

RESULTS

Five hundred thirty-four CT scans were identified: 191 (35.8%) head, 187 (35%) cervical, 66 (12.4%) chest, and 90 (16.9%) abdomen/pelvis scans. One hundred twenty-three scans (23%) were abnormal with a DR of 16%: 5 head, 2 cervical, 7 chest, and 6 abdomen/pelvis scans. Seven (6%) scans had clinically significant findings missed: 3 head and 4 abdomen/pelvis scans. ORSs missed 7, and SRs missed 3 clinically significant findings. A blinded radiologist confirmed the clinically significant findings.

CONCLUSIONS

The discordant rate of readings for abnormal CT scans was 16% with 37% considered to be clinically significant. ORSs missed 100%, and 29% of the clinically significant findings were identified after SR/trauma service rounds. SR/trauma service review of ORS readings is supported.

The transition from children's to adult diabetes services: understanding the 'problem'

AIMS

The importance of getting transition right for young people with diabetes is increasingly recognized and a strong professional consensus has emerged on best practice in this domain. Research evidence to inform the design of transitional healthcare services is weak, however, and prevailing views about 'the problem of transition' are based on a number of assumptions about adolescence, adulthood and chronic disease management which have been accepted uncritically.

METHODS

Drawing on youth studies and the sociology of chronic disease management, in this paper we describe how 'the problem of transition' has been defined in the professional and UK policy literature and examine the assumptions that underpin it.

RESULTS

We argue that the overwhelming emphasis is on how best to support young people in fitting in with the healthcare system. This has produced an orientation which is more concerned with supporting young people in the process of becoming adults rather than giving attention to their contemporaneous experiences and needs. Two years after the introduction of the UK National Service Framework for diabetes, the challenge of transitional services remains.

CONCLUSIONS

We suggest that the time has come to consider alternative formulations of the 'problem'. Rather than asking how best to manage transition, we might ask how best to meet the needs of young people with diabetes at this stage of the life course. This requires an understanding of their experiences, the social networks in which they are embedded and consideration of how self-management might be supported by the healthcare system.

Development of an advanced water treatment system for wastewater reuse

The aim of this research was to develop an optimal reuse system applying various types of advanced oxidation processes such as titanium dioxide (TiO2), ozone (O3) and electro-coagulation/oxidation methods. This system is suitable for improving the treatment efficiency of difficult wastewaters, and for the efficient reuse of wastewater. The connecting systems were divided into various types to investigate the stability and treatment efficiency according to the kinds of waste load. Different treatment sequences were examined taking into consideration the characteristics and economical efficiency. In the case of electro-coagulation/oxidation + ozone system, the mean treatment efficiency in terms of BOD5, CODCr and SS removal was 98.7%. The effluent concentration was 50.2 mg l(-1), 38.3 mg l(-1), 30.4 mg l(-1), respectively. In considering the economical efficiency and commercial use, around an eighth of the treatment expenses and around a fifth of the maintenance expenses could be saved compared with existing water treatment systems. The initial construction expenses could be reduced by a third to a fifth. Therefore, if a proper implementation of this research is carried out in relation to site conditions and the purpose of the water reuse, the water reuse rate will be higher and water resources can be protected.

Levofloxacin-associated hypoglycaemia complicated by pontine myelinolysis and quadriplegia

BACKGROUND

Central pontine myelinolysis (CPM) usually presents in chronic alcoholics and in patients in whom hyponatraemia has been corrected rapidly. However, CPM may occur in other clinical circumstances, including patients with severe hypoglycaemia. We describe the occurrence of CPM and quadriplegia in a patient who experienced fluoroquinolone-associated severe hypoglycaemia.

CASE REPORT

A 63-year-old man with Type 2 diabetes mellitus was admitted to hospital for resection of a large liposarcoma. Renal-dose levofloxacin was utilized as part of an antimicrobial regimen to treat post-operative peritonitis. On days 6-8 of levofloxacin therapy, the patient experienced recurrent hypoglycaemia despite total parenteral nutrition, 10% dextrose containing fluids and cessation of insulin therapy 3 days prior to the first hypoglycaemic episode. Hypoglycaemia resolved within 24 h of stopping levofloxacin. After a final and severe hypoglycaemic event, the patient developed quadriplegia and tonic left deviation of gaze. Magnetic resonance imaging revealed a high-intensity lesion in the central pons consistent with CPM.

CONCLUSIONS

Fluoroquinolones should be considered as a potential cause of hypoglycaemia. Severe hypoglycaemia has the potential to cause white matter lesions in the pons. Putative mechanisms include failure of membrane ion channels, oligodendrocyte apoptosis and oxidative stress of glucose reperfusion. Fluoroquinolone-associated hypoglycaemia and hypoglycaemia-induced quadriplegia are both rare and we believe this is the first case report linking the two events.