Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation

Introduction

Most emergency physicians routinely obtain shoulder radiographs before and after shoulder dislocations. However, currently there is limited literature demonstrating how frequently new fractures are identified on post-reduction radiographs. The primary objective of this study was to determine the frequency of new, clinically significant fractures identified on post-reduction radiographs with a secondary outcome assessing total new fractures identified.

Methods

We conducted a retrospective chart review using appropriate International Classification of Diseases, 9^th Revision (ICD-9) codes to identify all potential shoulder dislocations that were reduced in a single, urban, academic emergency department (ED) over a five-year period. We excluded cases that required operative reduction, had associated proximal humeral head or shaft fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted separately by two study investigators with disagreements settled by consensus among three investigators. Images from indeterminate cases were reviewed by a radiology attending physician with musculoskeletal expertise. The primary outcome was the percentage of new, clinically significant fractures defined as those altering acute ED management. Secondary outcomes included percentage of new fractures of any type.

Results

We identified 185 total patients meeting our study criteria. There were no new, clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI [3.3%–10.7%]) total new fractures identified, all of which were without clinical significance for acute ED management.

Conclusion

Post-reduction radiographs do not appear to identify any new, clinically significant fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED setting for shoulder dislocations.

Effects of Succinic Acid and Other Microbial Fermentation Products on HIV Expression in Macrophages

Bacterial vaginosis (BV), a common condition in women, is associated with increased shedding of HIV in the female genital tract. While the Lactobacillus species that comprise a healthy vaginal microbiota produce lactic acid, the bacteria common in BV produce high concentrations of short chain fatty acids (SCFAs) and succinic acid. Macrophages are abundant in the lower genital tract mucosa and are thought to play an important role in HIV infection. In this study, we investigated whether SCFAs and succinic acid impacted HIV expression in monocyte-derived macrophages. Monocytes differentiated with either granulocyte-macrophage colony-stimulating factor (GM-CSF) or macrophage colony-stimulating factor (M-CSF) were infected with either HIVBal or an HIV-luciferase reporter virus and treated with SCFAs, succinic acid, or lactic acid. Butyric acid suppressed HIV expression while succinic acid significantly increased expression in macrophages differentiated with either GM-CSF or M-CSF. Acetic, propionic, and lactic acids had no effect on HIV expression. Only succinic acid resulted in a significant increase in interleukin-8 production by infected macrophages. Our results suggest that succinic acid present in increased concentrations in the genital tract of women with BV plays a pro-inflammatory role and increases HIV expression. This could be one factor contributing to increased virus shedding seen in women with BV.

The role of bacterial vaginosis and trichomonas in HIV transmission across the female genital tract

Bacterial vaginosis (BV) and Trichomonas vaginalis (TV) infections are both very common and are associated with increased risk of sexual transmission of HIV. There are several mechanisms by which BV and TV could affect susceptibility including inducing pro-inflammatory cytokines and disrupting mucosal barrier function. This review highlights recent advances in our understanding of how these genital conditions lead to an increased risk of HIV infection in women.