Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone ...grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice.
A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice.
All surgeons completed a fellowship, with an equal number of sports medicine fellowship–trained (46%) and shoulder and elbow fellowship–trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss.
Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality––with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.
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Background: In order to describe the impact of future targeted therapies on treatment outcomes of patients (pts) with relapsed and/or refractory (RR) acute myeloid leukemia ...(AML), a better understanding of the clinical management pathway in these pts is needed. We therefore evaluated the treatment patterns and associated outcomes in a real-world cohort of pts with RR-AML using a population-based cancer registry and patient medical records. Methods: Pts newly diagnosed wih AML between January 2013 and December 2016, aged ≥ 18 years were identified from the provincial-wide Alberta Cancer Registry (ACR). Data for pts who met the criteria for RR-AML were assessed by hematologists and were extracted from medical records. RR-AML pts were then categorized as: receiving intensive therapy (IT); receiving non-intensive therapy (NIT); or treated with best-supportive care (BSC) following a diagnosis of RR-AML. Results: 572 AML pts were identified from the ACR, of which 199 met criteria for RR-AML and were included in the analysis (124 males, 75 females; median age at diagnosis of RR-AML 66.8 years; median follow-up 4.7 months). In this RR-AML cohort, 26 (13%) pts received ≥ 2 lines of prior therapy. Unadjusted median overall survival (mOS) was 5.3 months, with a 12-month overall survival rate of 29.6% (95% CI 29.0–30.3%) from the time of RR. Following RR, 46 (23%) pts received IT, 65 (33%) pts were treated with NIT, and 88 (44%) pts received BSC, with unadjusted mOS of 13.8, 9.4, and 2.1 months, respectively ( P < 0.001). When stratified by European LeukemiaNet risk classification at diagnosis, unadjusted mOS was 12.4, 4.7, and 4.0 months for favorable risk, intermediate risk, and adverse risk groups, respectively ( P < 0.01). Conclusions: This retrospective, real-world study in Alberta Canada confirms the poor prognosis reported to date in the RR-AML population. Notably, a large proportion of pts received BSC which was associated with dismal survival outcomes. These data also highlight that effective and tolerable alternatives to current treatment options are urgently needed.
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Background: Patients with cancer are vulnerable to chronic opioid use. Although opioid use may be appropriate, preliminary data suggest that a significant proportion may be using ...opioids inappropriately. This study aims to evaluate the association between the history of the providers’ opioid-prescribing patterns and post-surgical opioid use in cancer patients undergoing curative-intent surgery. Methods: This population-based study included all patients diagnosed with common solid tumors who received curative-intent surgery and were non-opioid users prior to surgery between 2009 and 2015 in Alberta, Canada. Based on previously published methods, a new persistent opioid user was defined as opioid-naïve prior to surgery and who subsequently filled at least one opioid prescription between 60 and 180 days after surgery. The opioid-prescribing patterns of a patient’s most responsible provider (MRP) were measured as the mean daily dosage (oral morphine equivalent, OME) that was prescribed to all other patients by that provider prior to the surgical date. Multivariable logistic regression was performed to identify associations between the MRP’s prescribing patterns and the patient’s opioid use after surgery. Results: 14,780 patients met the inclusion criteria and were associated with 2,880 MRPs, among which 2,364 (16%) patients became new persistent opioid users after surgery. Multivariate analysis demonstrated that patients with MRPs who routinely prescribed higher doses of opioids (≥60 vs. 0-59 mg OME: OR = 2.33, P < 0.0001) for their patients were associated with a greater risk of new persistent opioid use after surgery. In addition, those with a higher Charlson comorbidity index (P = 0.006), visited more prescribers (P < 0.0001), had a specific tumor type (breast, colorectal, lung, prostate, melanoma or kidney vs. others, P < 0.0001), received adjuvant chemotherapy (OR = 1.37, P < 0.0001), and received adjuvant radiation (OR = 1.3, P = 0.0004) were also associated with greater risk of new persistent opioid use after surgery. Conclusions: Our results suggest that prescribers with a history of prescribing higher opioid doses are an important predictor of chronic opioid use among cancer patients undergoing curative-intent surgery. Awareness of physician prescribing practices and their unintended consequences may inform strategies to minimize persistent post-operative opioid use in cancer patients.
Enormous genomic resources have been developed for plants in the monocot order Poales; however, it is not clear how representative the Poales are for the monocots as a whole. The Asparagales are a ...monophyletic order sister to the lineage carrying the Poales and possess economically important plants such as asparagus, garlic, and onion. To assess the genomic differences between the Asparagales and Poales, we generated 11,008 unique ESTs from a normalized cDNA library of onion. Sequence analyses of these ESTs revealed microsatellite markers, single nucleotide polymorphisms, and homologs of transposable elements. Mean nucleotide similarity between rice and the Asparagales was 78% across coding regions. Expressed sequence and genomic comparisons revealed strong differences between the Asparagales and Poales for codon usage and mean GC content, GC distribution, and relative GC content at each codon position, indicating that genomic characteristics are not uniform across the monocots. The Asparagales were more similar to eudicots than to the Poales for these genomic characteristics.
The coronavirus disease 2019 (COVID-19) pandemic is a reminder that global infectious disease outbreaks are not new and they have the potential to cause catastrophic morbidity and mortality, disrupt ...health care delivery, demand critical decision making in the absence of scientific certainty, interrupt trainee education, inflict economic damage, and cause a spike in demand for health care services that exceeds societal capacity. In this article, we look back at how the sleep medicine community adapted to challenges imposed by the COVID-19 pandemic. To mitigate viral transmission perhaps the single most effective and efficient adaptation was the rapid adoption of telemedicine. Many additional strategies were taken up virtually overnight, including more home sleep apnea testing, reconsideration of potential risks of positive airway pressure therapy, a reduction or cessation of laboratory services, and deployment of workers to provide frontline care to infected patients. During some periods, critical shortages in essential personal protective equipment, respiratory assist devices, and even oxygen added to logistical challenges, which were exacerbated by persistent financial threats and insufficient staffing. Through ongoing innovation, resiliency, and adaptability, breakthroughs were made in assigning staff responsibilities and designing workflows, using clinical spaces, obtaining legislative support, and achieving professional society collaboration and guidance so that the missions of providing health care, teaching, and academic pursuits could continue. Here we summarize what we have learned through these critical months and highlight key adaptations that deserve to be embraced as we move forward.
Khosla S, Beam E, Berneking M, et al. The COVID-19 pandemic and sleep medicine: a look back and a look ahead.
. 2022;18(8):2045-2050.
Background
With the increasing use of medications that alter the risk of gastrointestinal bleeding (GIB), comprising aspirin, proton pump inhibitors (PPIs), and Helicobacter pylori eradication ...therapies, the trends of GIB are evolving.
Objective
The aim of this study is to determine and predict the trends of GIB and to evaluate the effects of population prescriptions of these medications on GIB incidences.
Methods
We retrieved patients hospitalized for GIB in all public hospitals in Hong Kong between 2009 and 2019. Monthly age‐ and sex‐standardized GIB data were fitted and predicted, based on population prescriptions of aspirin, nonsteroidal anti‐inflammatory drugs (NSAIDs), anticoagulants, other antiplatelet drugs, PPIs, and H. pylori therapies, using autoregressive integrated moving average model for time series analysis.
Results
The incidence of upper GIB (UGIB) showed a clear declining trend while lower GIB (LGIB) decreased slightly. Older population (>80 years) had the greatest decline in UGIB but was associated with an increase in LGIB. Prescriptions of PPIs and aspirin increased significantly with time. PPIs prescriptions were negatively associated with UGIB incidence (coefficient log(PPIs) −4.58; 95% confidence interval CI: −5.69, −3.47). H. pylori eradication in the previous month showed a nonsignificant trend on UGIB (coefficient −0.14; 95% CI: −0.30, 0.02). In contrast, aspirin increased the incidences of UGIB (coefficient 0.06; 95% CI: 0.04, 0.07) and LGIB (coefficient 0.04; 95% CI: 0.03, 0.05). NSAIDs, anticoagulants, and other antiplatelet drugs were not significantly associated with the trend of either UGIB or LGIB. UGIB is predicted to decline continuously but LGIB is projected to rise, particularly with increasing use of aspirin.
Conclusions
UGIB incidences were decreasing and had been surpassed by LGIB. Based on population prescriptions of aspirin and PPIs, divergent trends of upper and lower GIB are expected, especially in elderly.
Key summary
Summarize the established knowledge on this subject
With increasing use of proton pump inhibitors (PPIs) and Helicobacter pylori eradication therapy, the incidences of upper gastrointestinal bleeding (UGIB) are declining.
The increasing use of antiplatelets and anticoagulants, however, increases the risk of both UGIB and lower gastrointestinal bleeding (LGIB).
The dynamic contribution of these factors on the incidences of UGIB and LGIB at population level remains uncertain.
What are the significant and/or new findings of this study?
The incidences of UGIB showed a clear declining trend while LGIB decreased slightly over the past decade in Hong Kong.
LGIB had actually surpassed UGIB as the leading source of GIB, especially among older population.
The increasing PPIs prescription was associated with the falling incidences of UGIB, whereas the rising use of aspirin was associated with both an increase in UGIB and LGIB.
With the increasing use of aspirin and the lack of effective prevention preventive strategies, LGIB would become a major health challenge.
rRNA transcription in Saccharomyces cerevisiae is performed by RNA polymerase I and regulated by changes in growth conditions. During log phase, ∼50% of the ribosomal DNA (rDNA) genes in each cell ...are transcribed and maintained in an open, psoralen‐accessible conformation. During stationary phase, the percentage of open rDNA genes is greatly reduced. In this study we found that the Rpd3 histone deacetylase was required to inactivate (close) individual rDNA genes as cells entered stationary phase. Even though ∼50% of the rDNA genes remained open during stationary phase in rpd3Δ mutants, overall rRNA synthesis was still reduced. Using electron microscopy of Miller chromatin spreads, we found that the number of RNA polymerases transcribing each open gene in the rpd3Δ mutant was significantly reduced when cells grew past log phase. Bulk levels of histone H3 and H4 acetylation were reduced during stationary phase in an RPD3‐dependent manner. However, histone H3 and H4 acetylation was not significantly altered at the rDNA locus in an rpd3Δ mutant. Rpd3 therefore regulates the number of open rDNA repeats.
Chronic hepatitis B patients with diabetes and metabolic syndrome are at increased risk of cirrhosis and hepatocellular carcinoma, but the underlying mechanism is unclear. Our objective was to test ...whether dysregulation of adipokines contributes to liver injury. We also studied whether viral factors affected adipokines, insulin resistance, and hepatic steatosis.
A prospective cohort of 266 chronic hepatitis B patients undergoing liver biopsy was studied. Fasting blood was taken for the analysis of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), adiponectin, leptin, and resistin. Insulin resistance was assessed by the homeostasis model assessment of insulin resistance (HOMA-IR). Factors associated with significant necroinflammation and cirrhosis were identified.
Histological activity index was correlated with serum TNF-alpha (R=0.40, P<0.0001) and IL-6 (R=0.32, P<0.0001) but not with adiponectin, leptin, or resistin. By multivariate analysis, TNF-alpha was associated with significant necroinflammation after adjusting for age and viral factors (odds ratio (OR) 1.041, 95% confidence interval (CI) 1.002-1.082, P=0.04). Serum adiponectin had positive correlation with hepatitis B virus DNA (R=0.17, P=0.007) and was decreased in patients with insulin resistance and hepatic steatosis. On the other hand, viral load, hepatitis B e-antigen status, and genotypes had no association with insulin resistance, hepatic steatosis, and the levels of TNF-alpha and IL-6. A total of 68 (25.6%) patients had cirrhosis. HOMA-IR, but not adipokine dysregulation, was independently associated with cirrhosis (OR 1.09, 95% CI 1.02-1.15, P=0.006).
TNF-alpha and/or IL-6 contribute to hepatic necroinflammation in chronic hepatitis B patients. Adiponectin protects against insulin resistance and hepatic steatosis but does not affect liver injury. Adipokines and viral factors contribute to liver injury independently.
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