The Prevalence and Clinical Implications of Comorbid Back Pain in Shoulder Instability: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

Background:Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty. Purpose/Hypothesis:The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures. Study Design:Cross-sectional study; Level of evidence, 3. Methods:As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain. Results:The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years). Patients with comorbid back pain (158 patients; 15.8%) were significantly older (28.1 vs 23.4 years; P < .001) and were more likely to be female (25.3% vs 17.4%; P = .02) but did not differ in terms of either preoperative imaging or intraoperative findings. Patients with self-reported back pain had significantly worse preoperative pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index) (P < .001), more frequent depression (22.2% vs 8.3%; P < .001), poorer mental health status (worse scores for the RAND 36-Item Health Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment Screener) (P < .01), and worse preoperative expectations (P < .01). Conclusion:Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient's preoperative state but also postoperative pain control and/or postoperative outcomes

Clear Liquor Scrubbing with Anhydrite Production

The objective of this project to develop an advanced flue gas desulfurization (FGD) process that has decreased capital and operating costs, higher SO{sub 2} removal efficiency, and better by-product solids quality than existing, commercially available technology. A clear liquor process (which uses a scrubbing liquid with no solids) will be used to accomplish this objective rather than a slurry liquor process (which contains solids). This clear liquor scrubbing (CLS) project is focused on three research areas: (1) Development of a clear liquor scrubbing process that uses a clear solution to remove SO{sub 2} from flue gas and can be operated under inhibited-oxidation conditions; (2) Development of an anhydrite process that converts precipitated calcium sulfite to anhydrous calcium sulfate (anhydrite); and (3) Development of an alkali/humidification process to remove HCl from flue gas upstream of the FGD system. The anhydrite process also can be retrofit into existing FGD systems to produce a valuable by-product as an alternative to gypsum. This fits well into another of FETC's PRDA objectives of developing an advanced byproduct recovery subsystem capable of transforming SO{sub 2} into a useable byproduct or high-volume valuable commodities of interest. This paper describes the proposed processes, outlines the test approach, and preliminary Phase I test results

Energy Penalty Analysis of Possible Cooling Water Intake Structure Requirements on Existing Coal-Fired Power Plants.

Section 316(b) of the Clean Water Act requires that cooling water intake structures must reflect the best technology available for minimizing adverse environmental impact. Many existing power plants in the United States utilize once-through cooling systems to condense steam. Once-through systems withdraw large volumes (often hundreds of millions of gallons per day) of water from surface water bodies. As the water is withdrawn, fish and other aquatic organisms can be trapped against the screens or other parts of the intake structure (impingement) or if small enough, can pass through the intake structure and be transported through the cooling system to the condenser (entrainment). Both of these processes can injure or kill the organisms. EPA adopted 316(b) regulations for new facilities (Phase I) on December 18, 2001. Under the final rule, most new facilities could be expected to install recirculating cooling systems, primarily wet cooling towers. The EPA Administrator signed proposed 316(b) regulations for existing facilities (Phase II) on February 28, 2002. The lead option in this proposal would allow most existing facilities to achieve compliance without requiring them to convert once-through cooling systems to recirculating systems. However, one of the alternate options being proposed would require recirculating cooling in selected plants. EPA is considering various options to determine best technology available. Among the options under consideration are wet-cooling towers and dry-cooling towers. Both types of towers are considered to be part of recirculating cooling systems, in which the cooling water is continuously recycled from the condenser, where it absorbs heat by cooling and condensing steam, to the tower, where it rejects heat to the atmosphere before returning to the condenser. Some water is lost to evaporation (wet tower only) and other water is removed from the recirculating system as a blow down stream to control the building up of suspended and dissolved solids. Makeup water is withdrawn, usually from surface water bodies, to replace the lost water. The volume of makeup water is many times smaller than the volume needed to operate a once-through system. Although neither the final new facility rule nor the proposed existing facility rule require dry cooling towers as the national best technology available, the environmental community and several States have supported the use of dry-cooling technology as the appropriate technology for addressing adverse environmental impacts. It is possible that the requirements included in the new facility rule and the ongoing push for dry cooling systems by some stakeholders may have a role in shaping the rule for existing facilities. The temperature of the cooling water entering the condenser affects the performance of the turbine--the cooler the temperature, the better the performance. This is because the cooling water temperature affects the level of vacuum at the discharge of the steam turbine. As cooling water temperatures decrease, a higher vacuum can be produced and additional energy can be extracted. On an annual average, once-through cooling water has a lower temperature than recirculated water from a cooling tower. By switching a once-through cooling system to a cooling tower, less energy can be generated by the power plant from the same amount of fuel. This reduction in energy output is known as the energy penalty. If a switch away from once-through cooling is broadly implemented through a final 316(b) rule or other regulatory initiatives, the energy penalty could result in adverse effects on energy supplies. Therefore, in accordance with the recommendations of the Report of the National Energy Policy Development Group (better known as the May 2001 National Energy Policy), the U.S. Department of Energy (DOE), through its Office of Fossil Energy, National Energy Technology Laboratory (NETL), and Argonne National Laboratory (ANL), has studied the energy penalty resulting from converting plants with once-through cooling to wet towers or indirect-dry towers. Five locations--Delaware River Basin (Philadelphia), Michigan/Great Lakes (Detroit), Ohio River Valley (Indianapolis), South (Atlanta), and Southwest (Yuma)--were modeled using an ASPEN simulator model. The model evaluated the performance and energy penalty for hypothetical 400-MW coal-fired plants that were retrofitted from using once-through cooling systems to wet- and dry-recirculating systems. The modeling was initially done to simulate the hottest time of the year using temperature input values that are exceeded only 1 percent of the time between June through September at each modeled location. These are the same temperature inputs commonly used by cooling tower designers to ensure that towers perform properly under most climatic conditions

Deleterious Effects of Intermittent Recombinant Parathyroid Hormone on Cartilage Formation in a Rabbit Microfracture Model: a Preliminary Study

Intermittent parathyroid hormone administration can enhance fracture healing in an animal model. Despite the success of exogenous parathyroid hormone on fracture healing and spine fusion, few studies have examined the role of parathyroid hormone on cartilage formation. We determined the effects of intermittent parathyroid hormone on cartilage formation in a rabbit microfracture model of cartilage regeneration. Twelve rabbits were divided into three equal groups: (1) microfracture alone, (2) microfracture + parathyroid hormone daily for 7 days, and (3) microfracture + parathyroid hormone for 28 days. Nonoperated contralateral knees were used as controls. The animals were sacrificed at 3 months and gross and histologic analysis was performed. The microfracture alone group demonstrated the most healing on gross and histologic analysis. Treatment with either 1 or 4 weeks of parathyroid hormone inhibited cartilage formation. Although discouraging from a cartilage repair point of view, this study suggests that the role parathyroid hormone administration has in clinical fracture healing must be examined carefully. Although parathyroid hormone is beneficial to promote healing in spine fusion and midshaft fractures, its deleterious effects on cartilage formation suggests that it may have adverse effects on the outcomes of periarticular fractures such as tibial plateau injuries that require cartilage healing for a successful clinical outcome

Increased platelet counts and platelet activation in early symptomatic versus asymptomatic carotid stenosis and relationship with microembolic status: Results from the Platelets And Carotid Stenosis (PACS) Study

Background: Cerebral microembolic signals (MES) may predict increased stroke risk in carotid stenosis. However, the relationship between platelet counts or platelet activation status and MES in symptomatic versus asymptomatic carotid stenosis has not been comprehensively assessed. Setting: University teaching hospitals. Methods: This prospective, pilot observational study assessed platelet counts and platelet activation status, and the relationship between platelet activation and MES in asymptomatic versus early (≤4 weeks after TIA/stroke) and late phase (≥3 months) symptomatic moderate or severe (≥50%) carotid stenosis patients. Full blood count measurements were performed, and whole blood flow cytometry was used to quantify platelet surface activation marker expression (CD62P and CD63) and circulating leucocyte-platelet complexes. Bilateral simultaneous transcranial Doppler ultrasound monitoring of the middle cerebral arteries was performed for 1 hour to classify patients as MES-positive or MES-negative. Results: Data from 31 asymptomatic patients were compared with 46 symptomatic patients in the early phase, and 35 of these patients followed up to the late phase after symptom onset. The median platelet count (211 vs. 200 x 109/L; p=0.03) and the median % lymphocyte-platelet complexes were higher in early symptomatic than asymptomatic patients (2.8 vs. 2.4%, p=0.001). The % lymphocyte-platelet complexes was higher in early symptomatic than asymptomatic patients with ≥70% carotid stenosis (p=0.0005), and in symptomatic patients recruited within 7 days of symptom onset (p=0.028). Complete TCD data were available in 25 asymptomatic and 31 early phase symptomatic, and 27 late phase symptomatic patients. 12% of asymptomatic versus 32% of early phase symptomatic (p=0.02) and 19% of late phase symptomatic patients (p=0.2) were MES-positive. Early symptomatic MES-negative patients had ahigher % lymphocyte-platelet complexes than asymptomatic MES-negative patients (2.8 vs. 2.3%; p=0.0085). Discussion: Recently symptomatic carotid stenosis patients have higher platelet counts (potentially reflecting increased platelet production, mobilisation or reduced clearance) and platelet activation status than asymptomatic patients. MES were more frequently detected in early symptomatic than asymptomatic patients, but the differences between late symptomatic and asymptomatic groups were not significant. Increased lymphocyte-platelet complex formation in recently symptomatic vs. asymptomatic MES-negative patients indicates enhanced platelet activation in this early symptomatic subgroup. Platelet biomarkers, in combination with TCD, have the potential to aid risk-stratification in asymptomatic and symptomatic carotid stenosis patients

Toxic equivalency factors (TEFs) for PCBs, PCDDs, PCDFs for humans and wildlife.

An expert meeting was organized by the World Health Organization (WHO) and held in Stockholm on 15-18 June 1997. The objective of this meeting was to derive consensus toxic equivalency factors (TEFs) for polychlorinated dibenzo-p-dioxins (PCDDs) and dibenzofurans (PCDFs) and dioxinlike polychlorinated biphenyls (PCBs) for both human, fish, and wildlife risk assessment. Based on existing literature data, TEFs were (re)evaluated and either revised (mammals) or established (fish and birds). A few mammalian WHO-TEFs were revised, including 1,2,3,7,8-pentachlorinated DD, octachlorinated DD, octachlorinated DF, and PCB 77. These mammalian TEFs are also considered applicable for humans and wild mammalian species. Furthermore, it was concluded that there was insufficient in vivo evidence to continue the use of TEFs for some di-ortho PCBs, as suggested earlier by Ahlborg et al. [Chemosphere 28:1049-1067 (1994)]. In addition, TEFs for fish and birds were determined. The WHO working group attempted to harmonize TEFs across different taxa to the extent possible. However, total synchronization of TEFs was not feasible, as there were orders of a magnitude difference in TEFs between taxa for some compounds. In this respect, the absent or very low response of fish to mono-ortho PCBs is most noticeable compared to mammals and birds. Uncertainties that could compromise the TEF concept were also reviewed, including nonadditive interactions, differences in shape of the dose-response curve, and species responsiveness. In spite of these uncertainties, it was concluded that the TEF concept is still the most plausible and feasible approach for risk assessment of halogenated aromatic hydrocarbons with dioxinlike properties

Researching Complex Interventions in Health: The State of the Art : Exeter, UK. 14-15 October 2015.

Erratum to this paper available at http://hdl.handle.net/10871/23087

Prostate cancer cells modulate osteoblast mineralisation and osteoclast differentiation through Id-1

Background: Id-1 is overexpressed in and correlated with metastatic potential of prostate cancer. The role of Id-1 in this metastatic process was further analysed. Methods: Conditioned media from prostate cancer cells, expressing various levels of Id-1, were used to stimulate pre-osteoclast differentiation and osteoblast mineralisation. Downstream effectors of Id-1 were identified. Expressions of Id-1 and its downstream effectors in prostate cancers were studied using immunohistochemistry in a prostate cancer patient cohort (N110). Results: We found that conditioned media from LNCaP prostate cancer cells overexpressing Id-1 had a higher ability to drive osteoclast differentiation and a lower ability to stimulate osteoblast mineralisation than control, whereas conditioned media from PC3 prostate cancer cells with Id-1 knockdown were less able to stimulate osteoclast differentiation. Id-1 was found to negatively regulate TNF-Β and this correlation was confirmed in human prostate cancer specimens (P0.03). Furthermore, addition of recombinant TNF-Β to LNCaP Id-1 cell-derived media blocked the effect of Id-1 overexpression on osteoblast mineralisation. Conclusion: In prostate cancer cells, the ability of Id-1 to modulate bone cell differentiation favouring metastatic bone disease is partially mediated by TNF-Β, and Id-1 could be a potential therapeutic target for prostate cancer to bone metastasis. © 2010 Cancer Research UK. All rights reserved.link_to_OA_fulltex

Telling stories about European Union Health Law: The emergence of a new field of law

The ideational narrative power of law has now solidified, and continues to solidify, ‘European Union health law’, into an entity with a distinctive legal identity. EU health law was previously seen as either non-existent, or so broad as to be meaningless, or as existing only in relations between EU law and health (the ‘and’ approach), or as consisting of a body of barely or loosely connected policy domains (the ‘patchwork’ approach). The process of bringing EU health law into being is a process of narration. The ways in which EU health law is narrated (and continues to be narrated) involve three main groups of actors: the legislature, courts and the academy

The Transplanted Appropriate Adult Scheme in China

Borrowed from England and Wales, the Chinese Appropriate Adult Scheme involves a dynamic of selective adaptation. This article analyses two salient features of the appropriate adult scheme within the Chinese context, in comparison with its counterpart in England and Wales: its complementarity of the juvenile's parent, and the passive role that appropriate adults play during pretrial interrogations. Drawing upon empirical evidence, the article argues that the transplanted Chinese appropriate adult scheme has failed to oversee the legality of interrogations, nor does it provide adequate safeguards for juvenile suspects. The concept of vulnerability that lies at the heart of the appropriate adult safeguard in England and Wales appears to be lost in translation. Rather than providing a safeguard for juveniles at their most vulnerable, the appropriate adult is more concerned with indulging the needs of the interrogators in China