bluuebunny/crossref_metadata_2025 huggingface dataset:
Optically thin outbursts of rotating neutron stars cannot be spherical
Authors: Wielgus Maciek
Published: July 2019

We investigate 3D relativistic trajectories of test particles in the spacetime of a slowly rotating compact star, under the combined influence of gravity and a strong, near-Eddington radiation field. While in the static case a spherically symmetric shell of matter suspended above the stellar surface can be formed at the location of radial equilibrium of effective forces, the same is not true for a rotating star. In the latter case the symmetry is broken by the interplay between motion in the non-static spacetime and the influence of strong radiation drag forces, pushing particles towards the equatorial plane. As a result an expanding spherical shell of matter ejected from the neutron star surface collapses on a short time-scale into a single stable equatorial ring supported by radiation. These findings have implications for the geometry of optically thin outflows during luminous neutron star bursts.
Gas inflow and star formation near supermassive black holes: the role of nuclear activity
Authors: Frazer Christopher C , Heitsch Fabian
Published: July 2019

Numerical models of gas inflow towards a supermassive black hole (SMBH) show that star formation may occur in such an environment through the growth of a gravitationally unstable gas disc. We consider the effect of nuclear activity on such a scenario. We present the first three-dimensional grid-based radiative hydrodynamic simulations of direct collisions between infalling gas streams and a 4 × 106 M⊙ SMBH, using ray-tracing to incorporate radiation consistent with an active galactic nucleus (AGN). We assume inflow masses of ≈105 M⊙ and explore radiation fields of 10 per cent and 100 per cent of the Eddington luminosity (Ledd). We follow our models to the point of central gas disc formation preceding star formation and use the Toomre Q parameter (QT) to test for gravitational instability. We find that radiation pressure from UV photons inhibits inflow. Yet, for weak radiation fields, a central disc forms on time-scales similar to that of models without feedback. Average densities of >108 cm−3 limit photoheating to the disc surface allowing for QT ≈ 1. For strong radiation fields, the disc forms more gradually resulting in lower surface densities and larger QT values. Mass accretion rates in our models are consistent with 1–60 per cent of the Eddington limit, thus we conclude that it is unlikely that radiative feedback from AGN activity would inhibit circumnuclear star formation arising from a massive inflow event.
Structural basis of σ appropriation
Authors: Shi Jing , Wen Aijia , Zhao Minxing , You Linlin , Zhang Yu , Feng Yu
Published: July 2019

Bacteriophage T4 middle promoters are activated through a process called σ appropriation, which requires the concerted effort of two T4-encoded transcription factors: AsiA and MotA. Despite extensive biochemical and genetic analyses, puzzle remains, in part, because of a lack of precise structural information for σ appropriation complex. Here, we report a single-particle cryo-electron microscopy (cryo-EM) structure of an intact σ appropriation complex, comprising AsiA, MotA, Escherichia coli RNA polymerase (RNAP), σ70 and a T4 middle promoter. As expected, AsiA binds to and remodels σ region 4 to prevent its contact with host promoters. Unexpectedly, AsiA undergoes a large conformational change, takes over the job of σ region 4 and provides an anchor point for the upstream double-stranded DNA. Because σ region 4 is conserved among bacteria, other transcription factors may use the same strategy to alter the landscape of transcription immediately. Together, the structure provides a foundation for understanding σ appropriation and transcription activation.
Do Local Tobacco-21 Laws Reduce Smoking Among 18 to 20 Year-Olds?
Authors: Friedman Abigail S , Wu Rachel J
Published: July 2019

Introduction

States and municipalities are increasingly restricting tobacco sales to those under age 21, in an effort to reduce youth and young adult smoking. However, the effectiveness of such policies remains unclear, particularly when implemented locally.

Methods

Analyses use 2011–2016 data from the Behavioral Risk Factor Surveillance System’s Selected Metropolitan/Micropolitan Area Risk Trends dataset. Difference-in-differences and triple-difference regressions estimate the relationship between local tobacco-21 policies and smoking among 18- to 20-year-olds living in MMSAs (metropolitan/micropolitan statistical areas and metropolitan divisions).

Results

Current smoking rates fell from 16.5% in 2011 to 8.9% in 2016 among 18- 20-year-olds in these data. Regressions indicate that a tobacco-21 policy covering one’s entire MMSA yields an approximately 3.1 percentage point reduction in 18- to 20-year-olds’ likelihoods of smoking (confidence interval [CI] = –0.0548 to –0.0063). Accounting for partial policy exposure—tobacco-21 laws implemented in some but not all jurisdictions within an MMSA—this estimate implies that the average exposed 18- to 20-year-old experienced a 1.2 percentage point drop in their likelihood of being a smoker at interview relative to unexposed respondents of the same age, all else equal.

Conclusions

Local tobacco-21 policies yield a substantive reduction in smoking among 18- to 20-year-olds living in MMSAs. This finding provides empirical support for efforts to raise the tobacco purchasing age to 21 as a means to reduce young adult smoking. Moreover, it suggests that state laws preempting local tobacco-21 policies may impede public health.

Implications

Although states and municipalities are increasingly restricting tobacco sales to under 21-year-olds, such policies’ effectiveness remains unclear, particularly when implemented locally. Using quasi-experimental methods, this article provides what may be the first evidence that sub-state tobacco-21 laws reduce smoking among 18- to 20-year-olds. Specifically, considering metropolitan and micropolitan areas from 2011 to 2016, the average 18- to 20-year-old who was exposed to these policies exhibited a 1.2 percentage point drop in their likelihood of being a current established smoker, relative to those who were unexposed. These findings validate local tobacco-21 laws as a means to reduce young adult smoking.
Ethicization of constitutional public order in the European multicultural State
Authors: Cavaggion Giovanni
Published: July 2019

The concept of ‘public order’, despite being common to almost every European legal system, is extremely difficult to grasp, as it suffers from a high degree of indeterminateness that makes it impossible to develop a universal definition. In constitutional law, public order traditionally serves as a limit to fundamental rights. The article argues that globalization and the advent of the multicultural State kickstarted a deep transformation in the meaning and scope of constitutional public order, with a growing tendency among European legislators and judiciaries to define it by resorting to extralegal concepts such as majoritarian ‘values’ and ‘ways of life’ to justify the ban of ‘unwanted’ minoritarian cultural practices (cases analysed include: face-veil; burqini; kirpan; swimming lessons). The article argues that constitutional public order should be re-anchored to a strictly legal dimension, preventing it from drifting towards the moral sphere (ethicization), which would enable a revival of assimilationist integration models.
Development of a Brief Patient-Administered Screening Tool for Prescription Opioid Dependence for Primary Care Settings
Authors: Nielsen Suzanne , Picco Louisa , Campbell Gabrielle , Lintzeris Nicholas , Larance Briony , Farrell Michael , Degenhardt Louisa , Bruno Raimondo
Published: July 2019

Objective

To develop a short, patient-administered screening tool that will allow for earlier assessment of prescription opioid dependence (often referred to as addiction) in primary care settings.

Design and Setting

Cross-sectional analysis (N = 1,134) from the two-year time point of the Pain and Opioids IN Treatment (POINT) cohort was used in the scale development.

Subjects

Participants who completed two-year interviews in the POINT study, a prospective cohort study that followed people with chronic noncancer pain over a five-year period, and who were prescribed strong opioids for a minimum of six weeks at baseline.

Methods

An advisory committee provided advice on wording and content for screening in primary care settings. Univariate logistic regression identified individual items that were significantly associated with meeting ICD-11 criteria for prescription opioid dependence. Exploratory and confirmatory factor analysis (EFA and CFA) were conducted, and items were reduced to identify a small item set that were discriminative and shared a simple underlying structure.

Results

Sixty-four variables associated with ICD-11 criteria for prescription opioid dependence were initially identified. Four rounds of EFA were performed, resulting in five items remaining. CFA identified two possible four-item combinations, with the final combination chosen based on greater item endorsement and the results of goodness-of-fit indices.

Conclusions

Addressing prescription opioid dependence is an important part of the global public health challenge surrounding rising opioid-related harm. This study addresses an important initial requisite step to develop a brief screening tool. Further studies are required to validate the tool in clinical settings.
Acceptability and Effects of Commercially Available Activity Trackers for Chronic Pain Management Among Older African American Adults
Authors: Janevic Mary R , Shute Varick , Murphy Susan L , Piette John D
Published: July 2019

Background

Wearable activity trackers may facilitate walking for chronic pain management.

Objective

We assessed the acceptability of a commercially available tracker and three alternative modes of reporting daily steps among older adults in a low-income, urban community. We examined whether using the tracker (Fitbit ZipTM) was associated with improvements in functioning and activity.

Design

Randomized controlled pilot and feasibility trial.

Subjects

Fifty-one African American adults in Detroit, Michigan, aged 60 to 85 years, with chronic musculoskeletal pain (28 in the intervention group, 23 controls).

Methods

Participants completed telephone surveys at baseline and eight weeks. Intervention participants wore trackers for six weeks, alternately reporting daily step counts via text messages, automated telephone calls, and syncing (two weeks each). We used multimethods to assess satisfaction with trackers and reporting modalities. Adherence was indicated by the proportion of expected days on which valid step counts were reported. We assessed changes in pain interference, physical function, social participation, walking frequency, and walking duration.

Results

More than 90% of participants rated trackers as easy to use, but some had technical or dexterity-related difficulties. Text reporting yielded 79% reporting adherence vs 69% each for automated calls and syncing. Intervention participants did not show greater improvement in functioning or walking than controls.

Conclusions

With appropriate support, wearable activity trackers and mHealth reporting for chronic pain self-care are feasible for use by vulnerable older adults. Future research should test whether the effects of trackers on pain-related outcomes can be enhanced by incorporating behavior change strategies and training in evidence-based cognitive-behavioral techniques.
Effect of Combined Diclofenac and B Vitamins (Thiamine, Pyridoxine, and Cyanocobalamin) for Low Back Pain Management: Systematic Review and Meta-analysis
Authors: Calderon-Ospina Carlos-Alberto , Nava-Mesa Mauricio Orlando , Arbeláez Ariza Carlos Emilio
Published: July 2019

Background

Cumulative evidence suggests an analgesic effect of thiamine, pyridoxine, and cyanocobalamin (TPC) in monotherapy, and also when combined with nonsteroidal anti-inflammatory drugs (NSAIDs), particularly diclofenac, in a synergistic manner. The aim of this review was to determine the effects of diclofenac combined with TPC compared with diclofenac monotherapy for low back pain (LBP) management.

Methods

We searched for randomized clinical trials on the MEDLINE, EMBASE, LILACS, and Cochrane databases of records of clinical trials, among other sources. We evaluated the risk of bias regarding randomization, allocation concealment, blinding, incomplete outcome data, selective reporting, and other biases. A random-effects meta-analysis to examine patients with acute LBP (N = 1,108 adults) was performed, along with a subsequent sensitivity analysis.

Results

Five studies in patients with LBP were included in the qualitative synthesis. Four of these studies in acute LBP were included in the first meta-analysis. A sensitivity test based on risk of bias (three moderate- to high-quality studies) found that the combination therapy of diclofenac plus TPC was associated with a significant reduction in the duration of treatment (around 50%) compared with diclofenac monotherapy (odds ratio = 2.23, 95% confidence interval = 1.59 to 3.13, P < 0.00001). We found no differences in the safety profile and patient satisfaction.

Conclusions

This meta-analysis demonstrated that combination therapy of diclofenac with TPC might have an analgesic superiority compared with diclofenac monotherapy in acute LBP. However, there is not enough evidence to recommend this therapy in other types of pain due to the scarcity of high-quality studies.
Co-occurrence of Chronic Musculoskeletal Pain and Cardiovascular Diseases: A Systematic Review with Meta-analysis
Authors: Oliveira Crystian B , Maher Chris G , Franco Marcia R , Kamper Steven J , Williams Christopher M , Silva Fernanda G , Pinto Rafael Z
Published: July 2019

Objective

To determine the magnitude of the association between cardiovascular disease and chronic musculoskeletal pain.

Design

Systematic review with meta-analysis.

Methods

A comprehensive search was performed in five electronic databases. Population-based studies reporting the prevalence of cardiovascular diseases in adults stratified by chronic musculoskeletal pain status were considered eligible. Two independent reviewers performed the screening of the records following the inclusion criteria, extracted data, and evaluated the risk of bias of the included studies using an assessment tool of risk of bias for observational studies. In addition, we assessed the overall quality of evidence using an adaptation of the GRADE approach for prognosis.

Results

Twenty studies were included in this review. There was high-quality evidence that people with chronic musculoskeletal pain are 1.91 times more likely to report having a cardiovascular disease compared with those without chronic musculoskeletal pain (risk ratio = 1.91, 95% confidence interval = 1.64–2.21).

Conclusions

Our findings demonstrated associations between chronic musculoskeletal pain and any cardiovascular diseases. Future studies are still warranted to better understand the association between chronic musculoskeletal pain and the specific types of cardiovascular diseases.
Synaptic vesicle mimics affect the aggregation of wild-type and A53T α-synuclein variants differently albeit similar membrane affinity
Authors: Rocha Sandra , Kumar Ranjeet , Horvath Istvan , Wittung-Stafshede Pernilla
Published: July 2019

α-Synuclein misfolding results in the accumulation of amyloid fibrils in Parkinson’s disease. Missense protein mutations (e.g. A53T) have been linked to early onset disease. Although α-synuclein interacts with synaptic vesicles in the brain, it is not clear what role they play in the protein aggregation process. Here, we compare the effect of small unilamellar vesicles (lipid composition similar to synaptic vesicles) on wild-type (WT) and A53T α-synuclein aggregation. Using biophysical techniques, we reveal that binding affinity to the vesicles is similar for the two proteins, and both interact with the helix long axis parallel to the membrane surface. Still, the vesicles affect the aggregation of the variants differently: effects on secondary processes such as fragmentation dominate for WT, whereas for A53T, fibril elongation is mostly affected. We speculate that vesicle interactions with aggregate intermediate species, in addition to monomer binding, vary between WT and A53T, resulting in different consequences for amyloid formation.
Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area
Authors: Palsson Thorvaldur S , Gibson William , Darlow Ben , Bunzli Samantha , Lehman Gregory , Rabey Martin , Moloney Niamh , Vaegter Henrik B , Bagg Matthew K , Travers Mervyn
Published: July 2019

The sacroiliac joint (SIJ) is often considered to be involved when people present for care with low back pain where SIJ is located. However, determining why the pain has arisen can be challenging, especially in the absence of a specific cause such as pregnancy, disease, or trauma, when the SIJ might be identified as a source of symptoms with the help of manual clinical tests. Nonspecific SIJ-related pain is commonly suggested to be causally associated with movement problems in the SIJ(s)—a diagnosis traditionally derived from manual assessment of movements of the SIJ complex. Management choices often consist of patient education, manual treatment, and exercise. Although some elements of management are consistent with guidelines, this Perspective article argues that the assumptions on which these diagnoses and treatments are based are problematic, particularly if they reinforce unhelpful, pathoanatomical beliefs. This article reviews the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. In particular, it questions the continued use of assessing movement dysfunction despite mounting evidence undermining the biological plausibility and subsequent treatment paradigms based on such diagnoses. Clinicians are encouraged to align their assessment methods and explanatory models with contemporary science to reduce the risk of their diagnoses and choice of intervention negatively affecting clinical outcomes.
Updated management for patients with cardiovascular disease and diabetes
Authors: Dugan Joy , Butts Amy , Collins Billy St. John , Saini Parmjeet S. , Bradley Sarah
Published: July 2019

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality for patients with diabetes. The latest guidelines from the American Diabetes Association include new information on hypertension, lipid management, heart failure, and coronary heart disease. This year, for the first time, the cardiovascular disease and risk management section was endorsed by the American College of Cardiology. Primary and secondary prevention of ASCVD is a critical element of the primary care visit for patients with diabetes. This article provides key highlights that are important for busy clinicians.
Substance Use Disorder Education in Medical Schools: A Scoping Review
Authors: Muzyk Andrew , Smothers Zachary P.W. , Akrobetu Dennis , Ruiz Veve Jennifer , MacEachern Mark , Tetrault Jeanette M. , Gruppen Larry
Published: July 2019

Purpose

As medical schools adapt their curricula to prepare future physicians for the opioid crisis and for treating patients with substance use disorders (SUDs), educators should refer to courses described in the literature. This scoping review aimed to (1) provide a comprehensive evaluation and summation of peer-reviewed literature reporting on SUD education in medical schools globally and (2) appraise the research quality and educational outcomes reported in SUD education studies in medical schools.

Method

The authors searched 6 databases (3 Ovid MEDLINE databases, Embase, ERIC, and Web of Science) from inception through May 25, 2018. Original English-language research studies focusing on medical students and describing SUD education in medical schools were included. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess included studies.

Results

Of 3,178 articles identified, 43 met inclusion criteria. Studies were conducted in 9 countries. Most reported on educational interventions for tobacco (n = 20; 47%); others reported on interventions for SUDs broadly (n = 15; 35%), alcohol (n = 8; 19%), and opioids (n = 1; 2%). The mean MERSQI score was 12.27 (standard deviation 2.30). Four studies (9%) reported on educational outcomes at the level of behaviors or patient or health care outcomes. The majority (n = 39; 91%) reported significant benefits.

Conclusions

Educational interventions relating to SUDs were effective in improving medical students’ knowledge, skills, and attitudes. Educators should develop courses that achieve higher-level educational outcomes, increase education on opioid use disorders, and focus on the greatest public health concerns.
Trends in Tenure Status in Academic Family Medicine, 1977–2017: Implications for Recruitment, Retention, and the Academic Mission
Authors: Xierali Imam M. , Nivet Marc A. , Syed Zubair A. , Shakil Amer , Schneider F. David
Published: July 2019

Purpose

Tenure status has important implications for medical school faculty recruitment and retention and may affect educational quality, academic freedom, and collegiality. However, tenure trends in academic family medicine are unknown. This study aimed to describe trends in tenure status of family medicine faculty overall and by gender and status of minorities underrepresented in medicine (URM) in Liaison Committee on Medical Education–accredited medical schools.

Method

Association of American Medical Colleges Faculty Roster data were used to describe trends in tenure status of full-time family medicine faculty, 1977 to 2017. Bivariate and trend analyses were conducted to assess associations and describe patterns between tenure status and gender, race, and ethnicity. Interdepartmental variations in tenure trends over the years were also examined.

Results

Among family medicine faculty, the proportions of faculty tenured or on a tenure track dropped more than threefold from 1977 (46.6%; n = 507/1,089) to 2017 (12.7%; n = 729/5,752). Lower proportions of women and URM faculty were tenured or on a tenure track than male and non-URM faculty, respectively. But the gaps among them were converging. Compared with other clinical departments, family medicine had the highest proportion of faculty (74.6%; n = 4,291/5,752) not on a tenure track in 2017.

Conclusions

Proportion of tenure positions significantly decreased among family medicine faculty in U.S. medical schools. While gaps between male and female faculty and among certain racial/ethnic groups remained for family medicine tenure status, they have decreased over time, mainly because of a substantial increase in nontenured positions.
Developing and Implementing Curricular Objectives for Sexual Health in Undergraduate Medical Education: A Practical Approach
Authors: Stumbar Sarah E. , Brown David R. , Lupi Carla S.
Published: July 2019

Problem

In 2014, medical students at the Florida International University Herbert Wertheim College of Medicine (FIU HWCOM) first drew attention to perceived gaps in the sexual health curriculum. The authors used Kern and colleagues’ model for curriculum development to review and update the existing curriculum.

Approach

To develop longitudinal sexual health curricular objectives for undergraduate medical education (UME), the authors reviewed existing specialty- and organization-specific objectives. Then, an iterative process guided by clear criteria was used to develop feasible objectives, which were refined through stakeholder feedback. As these objectives were being finalized in 2017, UME sexual health competencies were first published; the authors mapped their objectives to these, as possible. The medical school’s course activities and assessments were mapped to the authors’ sexual health objectives to identify curricular gaps and unplanned redundancies.

Outcomes

This process resulted in 12 sexual health curricular objectives that are adaptable by other institutions. In mapping the FIU HWCOM curriculum to these objectives, specific gaps and assessment weaknesses emerged. With stakeholder support obtained through a strong curricular management structure, the work of modifying content to address gaps has begun.

Next Steps

New assessments specific to these sexual health objectives are needed, especially within the clinical curriculum. Assessment of these objectives may be strengthened through the development of new sexual-health-related entrustable professional activities (EPAs) nested within the broader Core EPAs for Entering Residency being piloted. When data on learning outcomes are available, the process of targeting curricular improvement will begin.
Using Longitudinal Milestones Data and Learning Analytics to Facilitate the Professional Development of Residents: Early Lessons From Three Specialties
Authors: Holmboe Eric S. , Yamazaki Kenji , Nasca Thomas J. , Hamstra Stanley J.
Published: July 2019

Purpose

To investigate the effectiveness of using national, longitudinal milestones data to provide formative assessments to identify residents at risk of not achieving recommended competency milestone goals by residency completion. The investigators hypothesized that specific, lower milestone ratings at earlier time points in residency would be predictive of not achieving recommended Level (L) 4 milestones by graduation.

Method

In 2018, the investigators conducted a longitudinal cohort study of emergency medicine (EM), family medicine (FM), and internal medicine (IM) residents who completed their residency programs from 2015 to 2018. They calculated predictive values and odds ratios, adjusting for nesting within programs, for specific milestone rating thresholds at 6-month intervals for all subcompetencies within each specialty. They used final milestones ratings (May–June 2018) as the outcome variables, setting L4 as the ideal educational outcome.

Results

The investigators included 1,386 (98.9%) EM residents, 3,276 (98.0%) FM residents, and 7,399 (98.0%) IM residents in their analysis. The percentage of residents not reaching L4 by graduation ranged from 11% to 31% in EM, 16% to 53% in FM, and 5% to 15% in IM. Using a milestone rating of L2.5 or lower at the end of post-graduate year 2, the predictive probability of not attaining the L4 milestone graduation goal ranged from 32% to 56% in EM, 32% to 67% in FM, and 15% to 36% in IM.

Conclusions

Longitudinal milestones ratings may provide educationally useful, predictive information to help individual residents address potential competency gaps, but the predictive power of the milestones ratings varies by specialty and subcompetency within these 3 adult care specialties.
Laparoscopic Hysterectomy Route, Resource Use, and Outcomes
Authors: Desai Vrunda B. , Wright Jason D. , Lin Haiqun , Gross Cary P. , Sallah Ya Haddy , Schwartz Peter E. , Xu Xiao
Published: July 2019

OBJECTIVE:

To examine changes in utilization of different types of laparoscopic hysterectomy, as well as their associated resource use and surgical outcomes, after the U.S. Food and Drug Administration (FDA) safety statement in April 2014 regarding power morcellation.

METHODS:

We retrospectively analyzed data from the 2012–2016 American College of Surgeons National Surgical Quality Improvement Program and identified 145,746 women undergoing hysterectomy for benign indications. We measured use of laparoscopic supracervical hysterectomy compared to total laparoscopic hysterectomy (including laparoscopic-assisted vaginal hysterectomy) in these patients, as well as operative time, surgical setting (inpatient vs outpatient), length of stay, and 30-day surgical outcomes (wound complication, medical complication, reoperation, and readmission). We used an interrupted time series analysis to examine the association between FDA warning and changes in utilization and outcomes of laparoscopic hysterectomy.

RESULTS:

After adjusting for patient characteristics and background trends in practice, use of laparoscopic supracervical hysterectomy was significantly lower in the postwarning than prewarning period (odds ratio [OR]=0.49, 95% CI 0.45–0.53), whereas use of total laparoscopic hysterectomy was not affected (OR 1.01, 95% CI 0.96–1.06). Overall, after an initial reduction, use of laparoscopic hysterectomy (laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy combined) increased over time in the postwarning period (adjusted OR of utilization for each calendar quarter elapsed=1.03, 95% CI 1.02–1.03). After the FDA warning, operative time for laparoscopic supracervical hysterectomy increased by 11.45 minutes (95% CI 6.22–16.69), whereas the decreasing trend in the likelihood of inpatient stay for total laparoscopic hysterectomy was attenuated (OR for each calendar quarter elapsed=0.92 in prewarning period, 95% CI 0.91–0.93; and 0.97 in postwarning period, 95% CI 0.97–0.98). There was no significant change in 30-day surgical outcomes after the FDA warning.

CONCLUSION:

Rates of laparoscopic supracervical hysterectomy fell in association with power morcellation safety warnings, whereas rates of other laparoscopic hysterectomies continued to rise. There was no change in patient outcomes among laparoscopic hysterectomies.
Bridge Plating of Proximal Tibial Metaphyseal Fracture by Limited Open Technique
Authors: Pulley Benjamin R. , Gardner Michael J.
Published: July 2019

In this video, we demonstrate application of a bridge plate by limited open technique for fixation of a proximal tibial metaphyseal fracture. Although intramedullary nailing remains our preferred surgical technique for treatment of most extra-articular fractures of the proximal tibia, we find bridge plating by limited open technique to be an important alternative option for select fracture patterns not amenable to intramedullary nailing.

Video available at:
http://links.lww.com/JOT/A801
Unstable Intertrochanteric Hip Repair With Short Cephalomedullary Nail
Authors: A. Egol Kenneth , Wasterlain Amy , Driesman Adam , Mandel Jessica , Konda Sanjit
Published: July 2019

Introduction:

Approximately half of all hip fractures are intertrochanteric femur fractures. This video demonstrates the technique of repair of an unstable intertrochanteric hip fracture using a cephalomedullary device.

Methods:

The patient is an 88-year-old woman presenting with an intertrochanteric hip fracture secondary to a low-energy injury. The patient was indicated for surgery due to the unstable nature of the fracture.

Results:

This video demonstrates the cephalomedullary nailing technique for the repair of an unstable intertrochanteric hip fracture after a low-energy injury. Anatomical reduction and stable fixation were obtained with this technique.

Conclusions:

The case demonstrates a cephalomedullary technique of intertrochanteric fracture fixation using a cephalomedullary nail. The technique has significant advantages including minimal intraoperative blood loss, shorter operative times, potential for more biological healing with a load-sharing device, and low infection rate.

Video available at:
http://links.lww.com/JOT/A798
Repair of Bado II Monteggia Fracture: Case Presentation and Surgical Technique
Authors: Egol Kenneth A. , Bianco Isabella , Milone Michael , Konda Sanjit
Published: July 2019

Introduction:

Monteggia fractures are rare, although complex elbow injuries. Bado II Monteggia fractures are characterized by posterior dislocation of the radial head and concurrent fracture of the proximal or middle third of the ulna. This video demonstrates the open reduction and internal fixation of a complex Bado II Monteggia fracture dislocation.

Methods:

The patient is a 65-year-old woman with a Bado II Monteggia fracture after a low-energy fall from standing height. Given the extent of comminution and the instability of the elbow, the patient was indicated for surgical fixation.

Results:

This video demonstrates a locking plate technique for repair of a comminuted fracture of the proximal ulna. Anatomical reduction of ulnohumeral and radiocapitellar joints and stable fixation with bone grafting of the fracture are achieved with a medial 2.0/2.4-mm plate and a dorsal precontoured variable-angle locking plate. Demonstration of radial head arthroplasty is provided as an alternative for utilization in cases with a radial head fracture.

Conclusions:

Anatomical reduction and fixation of complex Monteggia fracture dislocations can be achieved with adherence to standard aspects of bony reconstruction. In this video we present the case of a Bado II Monteggia fracture surgically repaired with a locking plate construct.

Video available at:
http://links.lww.com/JOT/A791
Fibular Lengthening Osteotomy With Revision Syndesmotic Repair for Ankle Fracture Malunion
Authors: Ju Derek G. , Debbi Eytan M. , Neustein Adam Z. , Moon Charles N.
Published: July 2019

Ankle malunions with a shortened fibula and syndesmosis widening can pose challenges to the patient and treating physician. Indications for revision-operative intervention include persistent pain and disability. Shortened fibula malunions can be addressed using a lengthening fibular osteotomy and revision fixation. Chronic syndesmotic injuries can be addressed with syndesmotic debridement, open reduction, and suture button fixation. In this video, we present our surgical technique and rationale for the management of a shortened fibular malunion with persistent syndesmotic widening.

Video available at:
http://links.lww.com/JOT/A806
Posterior Approach for a Cemented Hemiarthroplasty
Authors: Petersen Kyle A. , Siesel Craig , Broering Chad , Miller Eric T.
Published: July 2019

Purpose:

Femoral neck fractures are common injuries with over 1 million occurring yearly. This video demonstrates a case of a displaced femoral neck fracture treated with a cemented hemiarthroplasty through a posterior approach.

Methods:

Multiple approaches to the hip for arthroplasty have been described, each with advantages and disadvantages. Careful technique is critical to success.

Results:

This presents a case of a displaced femoral neck fracture treated with a cemented hemiarthroplasty through a posterior approach.

Conclusions:

Displaced femoral neck fractures are common fractures. The posterior approach for cemented hemiarthroplasty is a safe, reproducible technique.

Video available at:
http://links.lww.com/JOT/A796
The VE-PTP Inhibitor AKB-9778 Improves Antitumor Activity and Diminishes the Toxicity of Interleukin 2 (IL-2) Administration
Authors: Li Guanqiao , Sachdev Ulka , Peters Kevin , Liang Xiaoyan , Lotze Michael T.
Published: July 2019

Administration of interleukin (IL)-2 has led to a durable response in patients with advanced renal cancer and melanoma but is restricted for clinical application because of adverse effects, including the vascular leak syndrome (VLS). VLS is associated with increased circulating levels of the Tie2 antagonist ligand, angiopoietin 2, and decreased Tie2 receptor phosphorylation and downstream signaling in endothelial cells (ECs). Given that vascular endothelial protein tyrosine phosphatase (VE-PTP) is a specific membrane phosphatase in ECs that dephosphorylates Tie2, the effects of targeting VE-PTP by a selective inhibitor AKB-9778 (AKB) in terms of VLS and antitumor efficacy were examined in this study. The authors found, by targeting VE-PTP, that the antitumor effects induced by IL-2 were augmented [tumor-free 44% (IL-2 alone) vs. 87.5% (IL-2+AKB)], associated with enhanced immune cell infiltrate (90% increase for CD8 T cells and natural killer cells). In addition, the side effects of IL-2 therapy were lessened, as demonstrated by diminished lung weight (less vascular leakage) as well as reduced cytokine levels (serum HMGB1 from 137.04±2.69 to 43.86±3.65 pg/mL; interferon-γ from 590.52±90.52 to 31.37±1.14 pg/mL). The authors further sought to determine the potential mechanism of the action of AKB-9778. The findings suggest that AKB-9778 may function through reducing serum angiopoietin 2 level and regulating EC viability. These findings provide insights into the targeting VE-PTP to improve tolerance and efficacy of IL-2 therapy and highlight the clinical potential of AKB-9778 for treating patients with VLS and cancer.
The role of ipilimumab after anti-PD-1 treatment: two case reports and a literature review
Authors: Ros-Montañá Javier , Saoudi-Gonzalez Nadia , Ortiz-Velez Carolina , Muñoz-Couselo Eva
Published: July 2019

Metastatic melanoma has been historically associated with a poor prognosis; however, the therapeutic landscape has experimented and impressive change in the last years due to rapid advances in the immunotherapy field. The first immunotherapy treatment for metastatic melanoma was ipilimumab (anti-CTLA-4), which showed a significant improvement of overall survival compared to chemotherapy. However, in 2015 anti-PD-1 pembrolizumab shown an improved overall survival, progression-free survival and response rate compared to ipilimumab with either a better toxicity profile. Moreover, other immunotherapy combinations and target therapies, such as BRAF and MEK inhibitors combinations, have shown better outcomes than ipilimumab. Thus, ipilimumab seems to have no role in frontline metastatic melanoma treatment and even their role in second line is being less frequent due to clinical efficacy of those other treatments. Actually, the role of ipilimumab in second line after anti-PD-1 progression is not clear although there is clinical evidence for its use. Here, we report two cases of treatment response with ipilimumab in second line setting after receiving anti-PD-1 combination. So that, ipilimumab may have a role after progression to an anti-PD-1 treatment.
Nerve Preservation and Allografting for Sensory Innervation Following Immediate Implant Breast Reconstruction
Authors: Peled Anne Warren , Peled Ziv M.
Published: July 2019

While newer breast reconstruction approaches utilizing nipple-sparing mastectomy (NSM) techniques and immediate reconstruction can provide excellent aesthetic outcomes, absent postoperative sensation remains a major limitation. Here, we present a novel technique for implant reconstruction combining the latest advances in breast oncologic, reconstructive, and peripheral nerve surgery to improve sensory outcomes. Sixteen women (31 breasts) underwent NSM and prepectoral, direct-to-implant reconstruction. During NSM, careful dissection was performed along the lateral aspect of the breast to preserve any visible intercostal nerves. When nerves could be preserved without compromising oncologic safety, they were left intact within the subcutaneous tissue of the lateral mastectomy skin flap. Nipple/areolar complex (NAC) neurotization was also performed utilizing allograft coapted from transected T4 or T5 lateral intercostal nerves to subareolar nerves identified at the completion of the mastectomy. Of the 12 women (23 breasts) with at least 3 months’ follow-up, NAC 2-point discrimination was preserved in 20 breasts (87%), was worse in 2 breasts (9%), and had actually improved in 1 breast (4%). All patients had intact sensation to light touch throughout the majority of, if not their entire, reconstructed breasts. None of the women developed dysesthesias or neuromas. Nerve grafting in conjunction with careful nerve preservation at the time of NSM and implant-based breast reconstruction is safe and effective with a 90% rate of preserved sensation. With longer follow-up, continued return of sensation or possibly improved sensation from baseline can be reasonably anticipated.
Vascularized Iliac Bone Graft for Complex Closure During Spinal Deformity Surgery
Authors: Reece Edward M. , Raghuram Anjali C. , Bartlett Erica L. , Lazaro Tyler T. , North Robert Y. , Bohl Michael A. , Ropper Alexander E.
Published: July 2019

Spinal pseudarthrosis is failure of bony union across a segment where arthrodesis has been attempted. A variety of treatment approaches have been proposed to promote bony union, including use of vascularized bone graft. We report a successful application of vascularized pedicled iliac crest bone graft (ICBG) to treat recurrent lumbar and sacral pseudarthrosis. The vascularized ICBG offers the advantages of biocompatibility, mechanical stability, and minimal antigenicity. Vascularized bone transfers to the spine undergo fusion without resorption, even in the presence of compressive and rotatory forces. With its ease of access within the operative field and limited donor site morbidity, vascularized ICBG is an ideal orthobiologic that expedites time to bony union.
Trends and Distribution Analysis of Occupational Exposure From Medical Practices in China (2010–2016)
Authors: Deng Jun , Fan Shengnan , Wang Tuo , Hao Shuxia , Liu Xiaohui , Guo Wen , Sun Quanfu
Published: July 2019

Occupational exposure to ionizing radiation from medical practices in China has been collected for a 7 y period between 2010 and 2016 from roughly 220 individual monitoring service providers through the Chinese Registry of Radiation Workers. Statistical dose distributions and characteristic tendencies are presented based on the evaluation in terms of six occupational categories. A reduction can be seen in average annual effective dose for interventional radiology, nuclear medicine, diagnostic radiology, radiotherapy, dental radiology, and others by 52%, 47%, 46%, 34%, 69%, and 31%, respectively, for the 7 y period. More than 94.5% of radiation workers received annual doses less than the public dose limit (1 mSv) in 2016. Workers engaged in nuclear medicine and interventional radiology activities were found to receive relatively more dose than the other fields of practice. Diagnostic radiology makes the dominant contribution of 68% to the collective effective dose of 73,641.3 person mSv received by 211,613 radiation workers in medical practices in 2016. The observation of workers in medical practices receiving well below the recommended occupational dose limit (20 mSv) could be a result of an improvement in radiation protection practices in the medical field in China. However, it is still necessary to control and manage the workplace and radiation workers to avoid unnecessary exposures, in particular for the workers engaged in nuclear medicine and interventional radiology activities.
Comparison of Clinical Outcomes: Bivalirudin With Transfemoral Access Versus Heparin With Transradial Access in Patients With ST segment Elevation Myocardial Infarction
Authors: Mallidi Jaya , Ulahannan John , Chaubey Vinod K. , Atreya Auras R. , Shakoor Muhammad T. , Fisher Daniel , Garb Jane , Lotfi Amir
Published: July 2019

Introduction:

The best combination of access site and anticoagulant used during primary percutaneous coronary intervention (PCI) in patients presenting with ST segment elevation myocardial infarction is not known.

Methods:

We conducted a retrospective cohort study of all patients >18 years of age who underwent primary PCI in 2 large regional ST segment elevation myocardial infarction centers in Massachusetts between 2012 and 2014. The cohort was divided into 3 groups: bival/fem, hep/rad, or off-protocol, based on anticoagulation and access used. We used multiple logistic regression model to compare major cardiovascular events—major adverse cardiovascular events (MACE) and bleeding complications between the 2 on-protocol groups (bival/fem and hep/rad).

Results:

Of the 1074 patients in this study, there were 443 (41%), 501 (47%), and 130 (12%) patients in bival/fem, hep/rad, and off-protocol groups, respectively. There were significantly higher number of cardiogenic shock patients in the bival/fem compared to the hep/rad group (6.5% vs. 3.0%, P < 0.001). There was a trend toward reduced MACE in the hep/rad group compared to bival/fem (2.8 % vs. 5.1%, P = 0.068). When cardiogenic shock patients are excluded, there is no significant difference in mortality rates (bival/fem: 2.7% vs. hep/rad: 1.0%, P = 0.07) or bleeding complications between the groups (hep/rad: 4.5% vs. bival/fem: 2.1%, P = 0.06).

Conclusions:

In patients undergoing primary PCI, there was a trend toward reduced inpatient MACE with the use of heparin and radial access compared with bivalirudin with femoral access. In patients without cardiogenic shock, there is no significant difference in mortality or bleeding rates between the 2 groups.
Further Investigations on the Crosslinking of Tarsal Collagen as a Treatment for Eyelid Laxity: Optimizing the Procedure in Animal Tissue
Authors: Smith Tai M. , Suzuki Shuko , Sabat Nestor , Rayner Cassie L. , Harkin Damien G. , Chirila Traian V.
Published: July 2019

Safe irradiation conditions are established for the exposure of ex vivo ovine tarsus to ultraviolet-A radiation as a potentially effective treatment for eyelid laxity in human patients.

Purpose:

A follow-up experimental study on the exposure of animal tarsal plate to ultraviolet-A radiation aimed at establishing an optimum range for safe irradiation conditions.

Methods:

Sheep tarsus specimens were excised postmortem and then subjected to irradiation with ultraviolet-A rays (wavelength 365 nm) at higher irradiances than those reported in an initial study, using a laboratory radiation source. The mechanical properties (tensile strength and Young’s modulus) of irradiated and nonirradiated samples were evaluated in a mechanical tester. The test and control specimens were examined histologically with an aim to assess the effects of radiation upon the meibomian glands and tarsal collagen networks, and to establish a safe range for the exposure irradiance level.

Results:

As expected, irradiation induced both stiffening and strengthening of the tarsal plate specimens. At an irradiance of 50 mW/cm2 for 3-minute exposure, these effects were at their maximum level, after which a decline in mechanical characteristics were observed. No destruction of the tarsal connective tissue or the meibomian glands were noticed up to an irradiance of 125 mW/cm2 for 3-minute exposure, corresponding to a fluence of 22.5 J/cm2. Histology revealed that the collagen network surrounding the glands were packed more compactly following irradiation. At a fluence of 45 J/cm2, massive destruction of periglandular collagen-rich network and meibocytes were demonstrated histologically.

Conclusions:

The study indicates that irradiation of tarsal collagen leading to tissue stiffening shall be carried out at levels of fluence between 10 and 15 J/cm2, a region that is deemed safe. The exposure time can be adjusted according to the surgeon’s decision.