Trends and Regional Variation in Hip, Knee and Shoulder Replacement

Analyzes patterns in underuse or overuse of joint replacements among Medicare beneficiaries by geographic regions and race/ethnicity. Explores underlying factors and highlights the need for physician and patient education and shared decision making

Using inertial measurement units to quantify shoulder elevation after reverse total shoulder arthroplasty: a pilot study comparing goniometric measures captured clinically to inertial measures captured ‘in-the-wild’

Background: Reverse total shoulder arthroplasty (rTSA) is utilized for a variety of indications, but most commonly for patients with rotator cuff arthropathy. This procedure reduces pain, improves satisfaction, and increases clinically measured range of motion (ROM). However, traditional clinical ROM measurements captured via goniometer may not accurately represent ‘real-world’ utilization of ROM. In contrast, inertial measurement units (IMUs) are useful for establishing ROM outside the clinical setting. We sought to measure ‘real-world’ ROM after rTSA using IMUs. Methods: A previously validated IMU-based method for continuously capturing shoulder elevation was used to assess 10 individuals receiving rTSA (1M, 82 ± 5 years) and compared to a previously captured 10 healthy individuals (4M, 69 ± 20 years) without shoulder dysfunction. Control subject data were previously collected over 1 week of continuous use. Patients undergoing rTSA donned sensors for 1 week pre-rTSA, 6 weeks at 3 months post-rTSA following clearance to perform active-independent ROM, and 1 week at 1 year and 2 years post-rTSA. Shoulder elevation was computed continuously each day. Daily continuous elevation was broken into 5° angle ‘bins’ (eg, 0-5°, 5-10°, etc.) and converted to percentage of the total day. IMU-based outcome measures were ROM binned percent (as described previously) and maximum/average elevation each week. Clinical goniometric ROM and patient-reported outcome measures were also captured. Results: No differences existed between patient and healthy control demographics. While patients showed improvement in American Shoulder and Elbow Surgeon (ASES) score, pain score, and goniometric ROM, IMU-based average and maximum elevation were equal between control subjects and patients both pre- and post-rTSA. The percent of time spent above 90° was equal between cohorts pre-rTSA, rose significantly at 3 months post-rTSA, and returned to preoperative levels thereafter. Discussion: Although pain, satisfaction, and ROM measured clinically may improve following rTSA, real-world utilization of improved ROM was not seen herein. Improvements during the acute rehabilitation phase may be transient, indicating longer or more specific rehabilitation protocols are necessary to see chronic improvements in post-rTSA movement patterns

Modulating GLUT1 Expression in Retinal Pigment Epithelium Decreases Glucose Levels in the Retina: Impact on Photoreceptors and Müller Glial Cells

The retina is one of the most metabolically active tissues in the body and utilizes glucose to produce energy and intermediates required for daily renewal of photoreceptor cell outer segments. Glucose transporter 1 (GLUT1) facilitates glucose transport across outer blood retinal barrier (BRB) formed by the retinal pigment epithelium (RPE) and the inner BRB formed by the endothelium. We used conditional knockout mice to study the impact of reducing glucose transport across the RPE on photoreceptor and Müller glial cells. Transgenic mice expressing Cre recombinase under control of the Bestrophin1 (Best1) promoter were bred with Glut1 flox/flox mice to generate Tg-Best1-Cre:Glut1 flox/flox mice (RPE∆Glut1). The RPE∆Glut1 mice displayed a mosaic pattern of Cre expression within the RPE that allowed us to analyze mice with ~50% (RPE∆Glut1 m ) recombination and mice with \u3e70% (RPE∆Glut1 h ) recombination separately. Deletion of GLUT1 from the RPE did not affect its carrier or barrier functions, indicating that the RPE utilizes other substrates to support its metabolic needs thereby sparing glucose for the outer retina. RPE∆Glut1 m mice had normal retinal morphology, function, and no cell death; however, where GLUT1 was absent from a span of RPE greater than 100 µm, there was shortening of the photoreceptor cell outer segments. RPE∆Glut1 h mice showed outer segment shortening, cell death of photoreceptors, and activation of Müller glial cells. The severe phenotype seen in RPE∆Glut1 h mice indicates that glucose transport via the GLUT1 transporter in the RPE is required to meet the anabolic and catabolic requirements of photoreceptors and maintain Müller glial cells in a quiescent state. © 2019, American Physiological Society. All rights reserved

Emergence of Hemagglutinin Mutations during the Course of Influenza Infection

Influenza remains a significant cause of disease mortality. The ongoing threat of influenza infection is partly attributable to the emergence of new mutations in the influenza genome. Among the influenza viral gene products, the hemagglutinin (HA) glycoprotein plays a critical role in influenza pathogenesis, is the target for vaccines and accumulates new mutations that may alter the efficacy of immunization. To study the emergence of HA mutations during the course of infection, we employed a deep-targeted sequencing method. We used samples from 17 patients with active H1N1 or H3N2 influenza infections. These patients were not treated with antivirals. In addition, we had samples from five patients who were analyzed longitudinally. Thus, we determined the quantitative changes in the fractional representation of HA mutations during the course of infection. Across individuals in the study, a series of novel HA mutations directly altered the HA coding sequence were identified. Serial viral sampling revealed HA mutations that either were stable, expanded or were reduced in representation during the course of the infection. Overall, we demonstrated the emergence of unique mutations specific to an infected individual and temporal genetic variation during infection

A Post-Launch Summary of the Science of NASA's Psyche Mission

Astronomical observations indicate that asteroid (16) Psyche is a large, high-density (likely >3,400 kg·m−3), metal-rich (30–55 vol. %) asteroid. Psyche may be remnant core material or it could be a primordial, undifferentiated metal-rich object. We discuss the science objectives of the upcoming Psyche mission, which will employ three instruments (the Magnetometer, Multispectral Imager, and Gamma-Ray and Neutron Spectrometer) and will use Doppler tracking of the spacecraft to explore the asteroid. This mission will shed light on the nature and origins of metal-rich objects in the solar system and beyond, including the cores of the terrestrial planets

Metastatic Tumor Evolution and Organoid Modeling Implicate TGFBR2 as a Cancer Driver in Diffuse Gastric Cancer

Background: Gastric cancer is the second-leading cause of global cancer deaths, with metastatic disease representing the primary cause of mortality. To identify candidate drivers involved in oncogenesis and tumor evolution, we conduct an extensive genome sequencing analysis of metastatic progression in a diffuse gastric cancer. This involves a comparison between a primary tumor from a hereditary diffuse gastric cancer syndrome proband and its recurrence as an ovarian metastasis. Results: Both the primary tumor and ovarian metastasis have common biallelic loss-of-function of both the CDH1 and TP53 tumor suppressors, indicating a common genetic origin. While the primary tumor exhibits amplification of the Fibroblast growth factor receptor 2 (FGFR2) gene, the metastasis notably lacks FGFR2 amplification but rather possesses unique biallelic alterations of Transforming growth factor-beta receptor 2 (TGFBR2), indicating the divergent in vivo evolution of a TGFBR2-mutant metastatic clonal population in this patient. As TGFBR2 mutations have not previously been functionally validated in gastric cancer, we modeled the metastatic potential of TGFBR2 loss in a murine three-dimensional primary gastric organoid culture. The Tgfbr2 shRNA knockdown within Cdh1-/-; Tp53-/- organoids generates invasion in vitro and robust metastatic tumorigenicity in vivo, confirming Tgfbr2 metastasis suppressor activity. Conclusions: We document the metastatic differentiation and genetic heterogeneity of diffuse gastric cancer and reveal the potential metastatic role of TGFBR2 loss-of-function. In support of this study, we apply a murine primary organoid culture method capable of recapitulating in vivo metastatic gastric cancer. Overall, we describe an integrated approach to identify and functionally validate putative cancer drivers involved in metastasi

The 10th Biennial Hatter Cardiovascular Institute workshop: cellular protection—evaluating new directions in the setting of myocardial infarction, ischaemic stroke, and cardio-oncology

Due to its poor capacity for regeneration, the heart is particularly sensitive to the loss of contractile cardiomyocytes. The onslaught of damage caused by ischaemia and reperfusion, occurring during an acute myocardial infarction and the subsequent reperfusion therapy, can wipe out upwards of a billion cardiomyocytes. A similar program of cell death can cause the irreversible loss of neurons in ischaemic stroke. Similar pathways of lethal cell injury can contribute to other pathologies such as left ventricular dysfunction and heart failure caused by cancer therapy. Consequently, strategies designed to protect the heart from lethal cell injury have the potential to be applicable across all three pathologies. The investigators meeting at the 10th Hatter Cardiovascular Institute workshop examined the parallels between ST-segment elevation myocardial infarction (STEMI), ischaemic stroke, and other pathologies that cause the loss of cardiomyocytes including cancer therapeutic cardiotoxicity. They examined the prospects for protection by remote ischaemic conditioning (RIC) in each scenario, and evaluated impasses and novel opportunities for cellular protection, with the future landscape for RIC in the clinical setting to be determined by the outcome of the large ERIC-PPCI/CONDI2 study. It was agreed that the way forward must include measures to improve experimental methodologies, such that they better reflect the clinical scenario and to judiciously select combinations of therapies targeting specific pathways of cellular death and injury

Efficacy of transoral fundoplication vs omeprazole for treatment of regurgitation in a randomized controlled trial.

Background The aim of this randomized, crossover study was to determine if transoral fundoplication (TF) could further improve clinical outcomes in partial responders to high-dose (HD) proton-pump inhibitor (PPI) therapy and to evaluate durability of TF. Methods In seven United States centers, patients with hiatal hernia ≤2 cm and abnormal esophageal acid exposure (EAE) were randomized to TF (n = 40) or HD PPIs (n = 23) group. At 6-month follow-up, PPI patients underwent crossover. We assessed clinical outcomes 6-month post TF in crossover patients (COP), as compared to 6-month of HD PPI therapy, and 12-month outcomes in patients initially randomized to TF. The primary outcome was symptom control evaluated by Reflux Disease Questionnaire and Reflux Symptom Index. Secondary outcomes included healing of esophagitis, normalization of EAE and PPI use after TF. We analyzed 21 COP and 39 TF patients. McNemar’s test or Fisher exact test was used to compare proportions. Results Of 63 randomized patients, 3 were lost to follow-up, leaving 39 TF and 21 COP for analyses. In the COP, TF further improved control of regurgitation and of atypical symptoms achieved after six months of HD PPIs. Of 20 patients with GERD symptoms after six months of high-dose PPI therapy, 65% (13/20) reported global elimination of troublesome regurgitation and atypical symptoms post TF off PPIs; 67% (6/9) reported no troublesome regurgitation. Esophagitis further healed in 75% (6/8) of patients. Seventy-one percent of COP patients were off PPIs six months following TF. Normalization of EAE decreased from 52% after HD PPIs (on PPIs) to 33% after TF (off PPIs), p =0.388. In the original TF group, 12-month post TF, 77% of patients achieved complete symptom control, 82% ceased PPI therapy, 100% healed esophagitis and 45% normalized EAE. Conclusions The results of this study indicate that in patients with incomplete symptom control on high-dose PPI therapy TF may provide further elimination of symptoms and esophagitis healing. In the original TF group, the clinical outcomes of TF remained stable between 6- and 12-month follow-up. Trial registration Clinicaltrials.gov: NCT01647958

Drones y el orden legal internacional. Tecnología, estrategia y largas cadenas de acción

The main thesis of this article is that the increasing recourse to the use of unmanned aerial systems in asymmetric warfare and the beginning routinization of U.S. drone operations represent part of an evolutionary change in the spatial ordering of global politics -- Using a heuristic framework based on actor-network theory, it is argued that practices of panoptic observation and selective airstrikes, being in need of legal justification, contribute to a reterritorialization of asymmetric conflicts -- Under a new normative spatial regime, a legal condition of state immaturity is constructed, which establishes a zone of conditional sovereignty subject to transnational aerial policing -- At the same time, this process is neither a deterministic result of the new technology nor a deliberate effect of policies to which drones are merely neutral instruments -- Rather, military technology and political decisions both form part of a long chain of action which has evolved under the specific circumstances of recent military interventionsEste artículo propone que la creciente utilización de sistemas aéreos no tripulados y la rutinización de sus operaciones en guerras asimétricas representan parte de un cambio evolutivo en el ordenamiento espacial de la política global -- Utilizando un marco heurístico basado en la teoría del actor-red, se argumenta que las prácticas de observación panóptica y ataques aéreos selectivos, carentes aún de justificación legal, contribuyen a una reterritorialización de los conflictos asimétricos -- En virtud de un nuevo régimen normativo espacial, se construye una condición legal de inmadurez estatal que facilita el establecimiento de una zona de soberanía condicionada, sometida a la vigilancia aérea transnacional -- Al mismo tiempo, esté proceso no es resultado predeterminado de la nueva tecnología, ni efecto deliberado de decisiones políticas para las que los drones son solo instrumentos neutros -- Antes que ello, la tecnología militar y las decisiones políticas forman parte importante de una larga cadena de acción que se ha desarrollado en las circunstancias específicas de intervenciones militares más reciente

Expanding modes of reflection in design futuring

Design futuring approaches, such as speculative design, design fiction and others, seek to (re)envision futures and explore alternatives. As design futuring becomes established in HCI design research, there is an opportunity to expand and develop these approaches. To that end, by reflecting on our own research and examining related work, we contribute five modes of reflection. These modes concern formgiving, temporality, researcher positionality, real-world engagement, and knowledge production. We illustrate the value of each mode through careful analysis of selected design exemplars and provide questions to interrogate the practice of design futuring. Each reflective mode offers productive resources for design practitioners and researchers to articulate their work, generate new directions for their work, and analyze their own and others’ work.