Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty ...that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacteriumacnes , benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection.
After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin?
Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been estimated that more than 90% of all primary shoulder arthroplasties and shoulder reoperations are reported to the register. The age of the study population ranged between 16 and 98 years; the mean age at the primary surgery was 70 ± 10 years for the entire cohort, with a mean age of 67 ± 10 years and 72 ± 9 years for men and women, respectively. The mean observation period was 989 ± 669 days. From 2013 to 2019, there was a clear change in prophylaxis; in particular, the use of the combination of benzylpenicillin and cloxacillin increased dramatically and the use of cloxacillin alone decreased. Clindamycin prophylaxis increased moderately. The primary study endpoint was reported reoperation for infection. In the register, this is defined as repeat procedures of any kind, including biopsy, lavage of the joint, or revision, defined as secondary surgery in which a component was exchanged, removed, or added. To compare the reoperation rate in relation to the different antibiotics used, which changed over time, we controlled for age, gender, previous surgery, cement fixation, and arthroplasty type using a Cox proportional hazards model.
When adjusting for age, gender, previous surgery, cement fixation, and arthroplasty type, cloxacillin prophylaxis was associated with an increased relative risk of reoperation for infection compared with the combination of cloxacillin and benzylpenicillin (hazard ratio HR 2.40 95% confidence interval (CI) 1.35 to 4.25; p = 0.003) and compared with clindamycin alone (HR 1.78 95% CI 1.11 to 2.85; p = 0.02). No difference was found between the cloxacillin and benzylpenicillin combination and clindamycin (HR 0.74 95% CI 0.42 to 1.32; p = 0.31).
Our results indicate that prophylaxis against C. acnes may be warranted in shoulder arthroplasty. Because the absolute number of infections was low and infections could have been underreported to the register, our results should be interpreted with caution. There is no available information about the causative microorganisms. The study lays the groundwork for further investigations of antibiotic prophylaxis regimens in shoulder arthroplasty. Because large randomized controlled trials would be impractical to perform, prospective register-based randomized controlled studies might be a viable method.
Level Ⅲ, therapeutic study.
Aortic valve stenosis (AS) is the most common valvular heart disease, and valve replacement is the only definitive treatment. Here we report a large genome-wide association (GWA) study of 2,457 ...Icelandic AS cases and 349,342 controls with a follow-up in up to 4,850 cases and 451,731 controls of European ancestry. We identify two new AS loci, on chromosome 1p21 near PALMD (rs7543130; odds ratio (OR) = 1.20, P = 1.2 × 10
) and on chromosome 2q22 in TEX41 (rs1830321; OR = 1.15, P = 1.8 × 10
). Rs7543130 also associates with bicuspid aortic valve (BAV) (OR = 1.28, P = 6.6 × 10
) and aortic root diameter (P = 1.30 × 10
), and rs1830321 associates with BAV (OR = 1.12, P = 5.3 × 10
) and coronary artery disease (OR = 1.05, P = 9.3 × 10
). The results implicate both cardiac developmental abnormalities and atherosclerosis-like processes in the pathogenesis of AS. We show that several pathways are shared by CAD and AS. Causal analysis suggests that the shared risk factors of Lp(a) and non-high-density lipoprotein cholesterol contribute substantially to the frequent co-occurence of these diseases.
The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based ...Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).
MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking.
The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.
After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.
The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.
The introduction of diagnostic clinical genome and exome sequencing (CGES) is changing the scope of practice for clinical geneticists. Many large institutions are making a significant investment in ...infrastructure and technology, allowing clinicians to access CGES, especially as health-care coverage begins to extend to clinically indicated genomic sequencing-based tests. Translating and realizing the comprehensive clinical benefits of genomic medicine remain a key challenge for the current and future care of patients. With the increasing application of CGES, it is necessary for geneticists and other health-care providers to understand its benefits and limitations in order to interpret the clinical relevance of genomic variants identified in the context of health and disease. New, collaborative working relationships with specialists across diverse disciplines (e.g., clinicians, laboratorians, bioinformaticians) will undoubtedly be key attributes of the future practice of clinical genetics and may serve as an example for other specialties in medicine. These new skills and relationships will also inform the development of the future model of clinical genetics training curricula. To address the evolving role of the clinical geneticist in the rapidly changing climate of genomic medicine, two Clinical Genetics Think Tank meetings were held that brought together physicians, laboratorians, scientists, genetic counselors, trainees, and patients with experience in clinical genetics, genetic diagnostics, and genetics education. This article provides recommendations that will guide the integration of genomics into clinical practice.
Genet Med18 11, 1075–1084.
An algorithmic information-theoretic method is presented for object-level summarization of meaningful changes in image sequences. Object extraction and tracking data are represented as an attributed ...tracking graph (ATG). Time courses of object states are compared using an adaptive information distance measure, aided by a closed-form multidimensional quantization. The notion of meaningful summarization is captured by using the gap statistic to estimate the randomness deficiency from algorithmic statistics. The summary is the clustering result and feature subset that maximize the gap statistic. This approach was validated on four bioimaging applications: 1) It was applied to a synthetic data set containing two populations of cells differing in the rate of growth, for which it correctly identified the two populations and the single feature out of 23 that separated them; 2) it was applied to 59 movies of three types of neuroprosthetic devices being inserted in the brain tissue at three speeds each, for which it correctly identified insertion speed as the primary factor affecting tissue strain; 3) when applied to movies of cultured neural progenitor cells, it correctly distinguished neurons from progenitors without requiring the use of a fixative stain; and 4) when analyzing intracellular molecular transport in cultured neurons undergoing axon specification, it automatically confirmed the role of kinesins in axon specification.
Kabuki syndrome is a monogenic disorder caused by loss of function variants in either of two genes encoding histone-modifying enzymes. We performed targeted sequencing in a cohort of 27 probands with ...a clinical diagnosis of Kabuki syndrome. Of these, 12 had causative variants in the two known Kabuki syndrome genes. In 2, we identified presumptive loss of function de novo variants in KMT2A (missense and splice site variants), a gene that encodes another histone modifying enzyme previously exclusively associated with Wiedermann-Steiner syndrome. Although Kabuki syndrome is a disorder of histone modification, we also find alterations in DNA methylation among individuals with a Kabuki syndrome diagnosis relative to matched normal controls, regardless of whether they carry a variant in KMT2A or KMT2D or not. Furthermore, we observed characteristic global abnormalities of DNA methylation that distinguished patients with a loss of function variant in KMT2D or missense or splice site variants in either KMT2D or KMT2A from normal controls. Our results provide new insights into the relationship of genotype to epigenotype and phenotype and indicate cross-talk between histone and DNA methylation machineries exposed by inborn errors of the epigenetic apparatus.
Purpose
The critical shoulder angle (CSA) and the acromion index (AI) are measurements of acromial shape reported as predictors of degenerative rotator cuff tears (RCT) and glenohumeral ...osteoarthritis (GH OA). Whether they are the cause or effect of shoulder pathologies is uncertain since pre-morbid radiographs most often are lacking. The main aim of this study was to investigate if CSA or AI were related to the development of RCT or GH OA after 20 years. A secondary aim was to investigate if the CSA and AI had changed over time.
Methods
In the hospital archive, 273 preoperative plain shoulder radiographs were found of patients scheduled for elective surgery other than cuff repair and arthroplasty. Forty-five images fulfilled the strict criteria published by Suter and Henninger (2015) and were used to measure CSA and AI with two independent assessors. No patient had any sign of OA in the index radiographs or any information in the medical records indicating RCT. After a median of 20 (16–22) years, 30 of these patients were radiologically re-examined with bilateral true frontal views and ultrasound of the rotator cuff. There were 19 men (20 study shoulders) and 11 females (12 study shoulders).
Results
Mean age at follow-up was 56 (32–78) years. There was no correlation between CSA (
r
= 0.02) (n.s) or AI (
r
= − 0.13) (n.s) in the primary radiographs and OA at follow-up. Nor was any correlation found between index CSA (
r
= 0.12) (n.s) or AI (
r
= − 0.13) (n.s) and RCT at follow-up. Mean difference in CSA was − 1.7 (− 10–3) degrees and mean AI difference was − 0.04 (− 0.13–0.09) between the first and the second radiographs, 20 years later. Bilaterally, mean CSA was 32 and AI 0.61 at follow-up.
Conclusion
In this study, no correlation between the CSA, AI and development of OA or RCT could be found. The mean CSA and AI decreased over a 20-year period but the difference was very small. No difference was found between the study shoulders and the contralaterals. These findings question previously reported etiological associations between scapular anatomy and the development of OA or RCT and thereby the use of these calculations as the basis of treatment.
Level of evidence
III.
Inhomogeneities in a synchrotron source can severely affect the conclusions drawn from observations regarding the source properties. However, their presence is not always easy to establish, since ...several other effects can give rise to similar observed characteristics. It is argued that the recently observed broadening of the radio spectra and/or light curves in some of the type Ib/c supernovae is a direct indication of inhomogeneities. As compared to a homogeneous source, this increases the deduced velocity of the forward shock and the observed correlation between total energy and shock velocity could in part be due to a varying covering factor. The X-ray emission from at least some type Ib/c supernovae is unlikely to be synchrotron radiation from an electron distribution accelerated in a non-linear shock. Instead it is shown that the observed correlation during the first few hundred days between the radio, X-ray and bolometric luminosities indicates that the X-ray emission is inverse Compton scattering of the photospheric photons. Inhomogeneities are consistent with equipartition between electrons and magnetic fields in the optically thin synchrotron emitting regions.
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