Feasibility and Usability of Augmented Reality Technology in the Orthopaedic Operating Room.

PURPOSE OF REVIEW: Augmented reality (AR) has gained popularity in various sectors, including gaming, entertainment, and healthcare. The desire for improved surgical navigation within orthopaedic surgery has led to the evaluation of the feasibility and usability of AR in the operating room (OR). However, the safe and effective use of AR technology in the OR necessitates a proper understanding of its capabilities and limitations. This review aims to describe the fundamental elements of AR, highlight limitations for use within the field of orthopaedic surgery, and discuss potential areas for development. RECENT FINDINGS: To date, studies have demonstrated evidence that AR technology can be used to enhance navigation and performance in orthopaedic procedures. General hardware and software limitations of the technology include the registration process, ergonomics, and battery life. Other limitations are related to the human response factors such as inattentional blindness, which may lead to the inability to see complications within the surgical field. Furthermore, the prolonged use of AR can cause eye strain and headache due to phenomena such as the vergence-convergence conflict. AR technology may prove to be a better alternative to current orthopaedic surgery navigation systems. However, the current limitations should be mitigated to further improve the feasibility and usability of AR in the OR setting. It is important for both non-clinicians and clinicians to work in conjunction to guide the development of future iterations of AR technology and its implementation into the OR workflow.

Breast Cancer Molecular Subtyping in Practice: A Real-World Study of the APIS Breast Cancer Subtyping Assay in a Consecutive Series of Breast Core Biopsies.

The APIS Breast Cancer Subtyping Kit is an mRNA-based assessment of the seven parameters including three biomarkers routinely assessed in all the newly diagnosed breast cancers (BC), oestrogen receptor (ER), progesterone receptor (PR) and HER-2 and an additional four genes that create a novel proliferation signature, MKI67, PCNA, CCNA2 and KIF23. Taken together, the data are used to produce a molecular subtype for every sample. The kit was evaluated against the current standard protocol of immunohistochemistry (IHC) and/or in situ hybridisation (ISH) in breast cancer patients. The data were presented at the weekly breast multidisciplinary team (MDT) meeting. A total of 98 consecutive cases of pre-operative breast cancer core biopsies and two core biopsies of nodal metastases yielding 100 cases were assessed. IHC and APIS results were available for 100 and 99 cases. ER was concordant in 97% cases, PR was concordant in 89% and HER-2 results were concordant with IHC/ISH in 100% of the cases. Ki-67 IHC was discordant in 3% of cases when compared with MK167 alone but discordant in 24% when compared with the four-gene proliferation signature. In conclusion, our study indicates that the APIS Breast Cancer Subtyping Kit is highly concordant when compared to the results produced for ER/PR/HER-2 by IHC and/or ISH. The assay could play a role in the routine assessment of newly diagnosed breast cancer (BC) specimens.

Transcriptional profiling of early differentiation of primary human mesenchymal stem cells into chondrocytes.

Articular cartilage has only very limited regenerative capacities in humans. Tissue engineering techniques for cartilage damage repair are limited in the production of hyaline cartilage. Mesenchymal stem/stromal cells (MSCs) are multipotent stem cells and can be differentiated into mature cartilage cells, chondrocytes, which could be used for repairing damaged cartilage. Chondrogenesis is a highly complex, relatively inefficient process lasting over 3 weeks in vitro. Methods: In order to better understand chondrogenic differentiation, especially the commitment phase, we have performed transcriptional profiling of MSC differentiation into chondrocytes from early timepoints starting 15 minutes after induction to 16 hours and fully differentiated chondrocytes at 21 days in triplicates.

Racial and Ethnic Disparities in the Management of Diabetic Feet.

PURPOSE OF REVIEW: Diabetes mellitus is a chronic medical condition affecting many individuals worldwide and leads to billions of dollars spent within the healthcare system for its treatment and complications. Complications from diabetes include diabetic foot conditions that can have a devasting impact on quality of life. Diabetic foot ulcers and amputations occur in minority individuals at an increased rate compared to Caucasian individuals. This review provides an update examining the racial and ethnic disparities in the management of diabetic foot conditions and the differences in rates of amputation. RECENT FINDINGS: Current research continues to show a disparity as it relates to diabetic foot management. There are novel treatment options for diabetic foot ulcers that are currently being explored. However, there continues to be a lack in racial diversity in new treatment studies conducted in the USA. Individuals from racial and ethnic minority groups have diabetes at higher rates compared to Caucasian individuals, and are also more likely to develop diabetic foot ulcers and receive amputations. Over the last few years, more efforts have been made to improve health disparities. However, there needs to be an improvement in increasing racial diversity when investigating new therapies for diabetic foot ulcers.

Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program.

Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods: We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results: A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions: The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Data availability, reusability, and analytic reproducibility: evaluating the impact of a mandatory open data policy at the journal Cognition.

Access to data is a critical feature of an efficient, progressive and ultimately self-correcting scientific ecosystem. But the extent to which in-principle benefits of data sharing are realized in practice is unclear. Crucially, it is largely unknown whether published findings can be reproduced by repeating reported analyses upon shared data ('analytic reproducibility'). To investigate this, we conducted an observational evaluation of a mandatory open data policy introduced at the journal Cognition. Interrupted time-series analyses indicated a substantial post-policy increase in data available statements (104/417, 25% pre-policy to 136/174, 78% post-policy), although not all data appeared reusable (23/104, 22% pre-policy to 85/136, 62%, post-policy). For 35 of the articles determined to have reusable data, we attempted to reproduce 1324 target values. Ultimately, 64 values could not be reproduced within a 10% margin of error. For 22 articles all target values were reproduced, but 11 of these required author assistance. For 13 articles at least one value could not be reproduced despite author assistance. Importantly, there were no clear indications that original conclusions were seriously impacted. Mandatory open data policies can increase the frequency and quality of data sharing. However, suboptimal data curation, unclear analysis specification and reporting errors can impede analytic reproducibility, undermining the utility of data sharing and the credibility of scientific findings.

Osteoporosis and osteoarthritis, rheumatoid arthritis and spondylarthropathies.

Osteoporosis (OP) commonly occurs in the setting of inflammatory arthritis, whereas there is an inverse relationship with osteoarthritis (OA). We review the recent updates in epidemiology and pathophysiology of OP relating to several arthridities. In ankylosing spondylitis, lateral lumbar spine dual x-ray absorptiometry is better at detecting osteoporosis compared with the AP view and patients receiving treatment with anti- tumor necrosis factor medications had lower levels of bone turnover markers. With regard to rheumatoid arthritis, anticitrullinated peptide positivity without clinical arthritis as well as higher levels of interleukin-6 is associated with decreased bone mineral density and polymorphisms in the vitamin D receptor in RA patients may predispose to OP. With regard to OA, results from the Global Longitudinal Study of Osteoporosis in Women study and several radiological studies suggest that differences in the distribution of bone mass at the femoral neck may account for the inverse relationship of OA and OP, and several studies suggest that OA and OP have opposing cytokine and bone metabolism marker profiles.

A case of metaplastic breast cancer in a man.

Metaplastic breast cancers (MPBCs) represent <1% of breast cancers. Reports of MPBC in men are limited to case reports. We report a case of MPBC with pulmonary metastasis occurring in a 59-year-old man who initially presented with a presumed breast abscess. Histology from the breast lesion revealed a poorly differentiated carcinoma and a computed tomography scan showed an ulcerative right-sided breast mass and an area of scarring in the apex of the left lung. The breast lesion and the lung lesion were resected separately and the histology from the lung showed a poorly differentiated carcinoma with sarcomatous features in keeping with metastasis from a primary breast cancer. Our patient then proceeded to chemotherapy with FEC 100 regimen (5-fluorouracil, epirubicin and cyclophosphamide). MPBC is an aggressive breast cancer that has a propensity to metastasis to the lungs. Prognosis is poor.

Characterisation of a stereotypical cellular and extracellular adult liver progenitor cell niche in rodents and diseased human liver.

BACKGROUND: Stem/progenitor cell niches in tissues regulate stem/progenitor cell differentiation and proliferation through local signalling. OBJECTIVE: To examine the composition and formation of stem progenitor cell niches. METHODS: The composition of the hepatic progenitor cell niche in independent models of liver injury and hepatic progenitor cell activation in rodents and humans was studied. To identify the origin of the progenitor and niche cells, sex-mismatched bone marrow transplants in mice, who had received the choline-ethionine-deficient-diet to induce liver injury and progenitor cell activation, were used. The matrix surrounding the progenitor cells was described by immunohistochemical staining and its functional role controlling progenitor cell behaviour was studied in cell culture experiments using different matrix layers. RESULTS: The progenitor cell response in liver injury is intimately surrounded by myofibroblasts and macrophages, and to a lesser extent by endothelial cells. Hepatic progenitor cells are not of bone marrow origin; however, bone marrow-derived cells associate intimately with these cells and are macrophages. Laminin always surrounds the progenitor cells. In vitro studies showed that laminin aids maintenance of progenitor and biliary cell phenotype and promotes their gene expression (Dlk1, Aquaporin 1, gammaGT) while inhibiting hepatocyte differentiation and gene expression (CEPB/alpha). CONCLUSIONS: During liver damage in rodents and humans a stereotypical cellular and laminin niche forms around hepatic progenitor cells. Laminin helps maintenance of undifferentiated progenitor cells. The niche links the intrahepatic progenitor cells with bone marrow-derived cells and links tissue damage with progenitor cell-mediated tissue repair.

The isolation and in vitro expansion of hepatic Sca-1 progenitor cells.

The intra-hepatic population of liver progenitor cells expands during liver injury when hepatocyte proliferation is inhibited. These cells can be purified by density gradient centrifugation and cultured. Separated by size only this population contains small cells of hematopoietic, epithelial and endothelial lineages and is thought to contain liver stem cells. The identity of liver stem cells remains unknown although there is some evidence that tissue Sca1(+) CD45(-) cells display progenitor cell characteristics. We identified both intra-hepatic and gall bladder Sca1(+) cells following liver injury and expanded ex vivo Sca1 cells as part of heterogenous cell culture or as a purified population. We found significant difference between the proliferation of Sca-1 cells when plated on laminin or collagen I while proliferation of heterogenous population was not affected by the extracellular matrix indicating the necessity for culture of Sca1(+) cells with laminin matrix or laminin producing cells in long term liver progenitor cell cultures.

Topical negative pressure stimulates endothelial migration and proliferation: a suggested mechanism for improved integration of Integra.

Topical negative pressure is an effective technique to promote wound healing and the integration of skin graft and synthetic dermal equivalents. We describe an in vitro model to investigate the effect of negative pressure on angiogenesis, a pivotal step. Dermal fibroblasts or human microvascular endothelial cells were cultured on Integra and subjected to intermittent or continuous negative pressure. At fixed intervals of over 120 hours, the Integra was fixed and assessed for cell migration (microscopy), cell viability (MTS assay), and cell proliferation (Ki67 immunostaining). Under control conditions, endothelial cells formed a monolayer and failed to ingress, whereas fibroblasts migrated throughout the Integra within 24 hours. Negative pressure switches endothelial cell to a migratory and proliferative phenotype. Ingress is greatest with intermittent rather than continuous negative pressure. It has no effect on dermal fibroblast function. This study identifies an important, potential pro-angiogenic mechanism by which topical negative pressure promotes wound healing.

Polydeoxyribonucleotide improves angiogenesis and wound healing in experimental thermal injury.

OBJECTIVE: Polydeoxyribonucleotide contains a mixture of nucleotides and interacts with adenosine receptors, stimulating vascular endothelial growth factor expression and wound healing. The purpose of this study was to investigate the effect of polydeoxyribonucleotide on experimental burn wounds. DESIGN: Randomized experiment. SETTING: Research laboratory at a university hospital. SUBJECTS: Thermal injury in mice. INTERVENTIONS: Mice were immersed in 80 degrees C water for 10 secs to achieve a deep-dermal second-degree burn. Animals were randomized to receive either polydeoxyribonucleotide (8 mg/kg/day intraperitoneally for 14 days) or its vehicle alone (0.9% NaCl solution at 100 microL/day intraperitoneally). On days 7 and 14 the animals were killed. Blood was collected for tumor necrosis factor-alpha measurement; burn areas were used for histologic and immunohistochemical examination, for the evaluation of vascular endothelial growth factor and nitric oxide synthases by Western blot, and for the determination of wound nitric oxide products. MEASUREMENTS AND MAIN RESULTS: Polydeoxyribonucleotide increased burn wound re-epithelialization and reduced the time to final wound closure. Polydeoxyribonucleotide improved healing of burn wound through increased epithelial proliferation and maturation of the extracellular matrix as confirmed by fibronectin and laminin immunostaining. Polydeoxyribonucleotide also improved neoangiogenesis as suggested by the marked increase in microvessel density and by the robust expression of platelet-endothelial cell adhesion molecule-1. Furthermore, polydeoxyribonucleotide blunted serum tumor necrosis factor-alpha and enhanced inducible nitric oxide synthase and vascular endothelial growth factor expression and the wound content of nitric oxide products. CONCLUSIONS: Our study suggests that polydeoxyribonucleotide may be an effective therapeutic approach to improve clinical outcomes after thermal injury.

In vitro optimisation of topical negative pressure regimens for angiogenesis into synthetic dermal replacements.

BACKGROUND: The use of synthetic dermal replacements (SDRs) in the treatment of large wounds, which have associated morbidity and mortality, has attracted great interest. However, because of poor outcome, SDRs have limited use. The addition of topical negative pressure (TNP) has increased their success, but little research has focused on the underlying mechanisms. This paper studies the in vitro effects of TNP on commonly used SDRs to identify the most effective TNP regimen and optimum SDR for encouraging endothelial cell ingress. METHODS: Endothelial cells were co-cultured in vitro on four SDRs with or without TNP. Negative pressure (125mmHg) was applied intermittently, continuously, for 4h per day, or not at all. Endothelial ingress was measured for each condition. RESULTS: In the collagen controls, cell migration was minimal. Integratrade mark gave the greatest endothelial cell migration (p<0.05, n=3). TNP increased endothelial cell migration, intermittent application being the optimum regimen. CONCLUSIONS: Integratrade mark has an open sponge structure which may account for greater angiogenicity than Allodermtrade mark, Permacoltrade mark and Xenodermtrade mark. In vitro intermittent TNP stimulates the greatest angiogenic response. The majority of clinical studies investigating SDR success with TNP have used continuous regimens; this study suggests a change in clinical practice to intermittent application.

A single type of progenitor cell maintains normal epidermis.

According to the current model of adult epidermal homeostasis, skin tissue is maintained by two discrete populations of progenitor cells: self-renewing stem cells; and their progeny, known as transit amplifying cells, which differentiate after several rounds of cell division. By making use of inducible genetic labelling, we have tracked the fate of a representative sample of progenitor cells in mouse tail epidermis at single-cell resolution in vivo at time intervals up to one year. Here we show that clone-size distributions are consistent with a new model of homeostasis involving only one type of progenitor cell. These cells are found to undergo both symmetric and asymmetric division at rates that ensure epidermal homeostasis. The results raise important questions about the potential role of stem cells on tissue maintenance in vivo.

Multi modality treatment of an extensive pleural thymoma.

Thymomas are the most common tumours of the anterior mediastinum, with most cases presenting incidentally. We present a case of extensive pleural thymoma initially thought to be unresectable, which was treated with neoadjuvant chemotherapy and pleuro pneumonectomy. We discuss the multimodality approach to management of this tumour, in particular the use of neoadjuvant chemotherapy prior to surgical resection.

P2X(5) and P2X(7) receptors in human warts and CIN-612 organotypic raft cultures of human papillomavirus infected keratinocytes.

Purinergic receptors, which bind adenosine 5'-triphosphate (ATP), are expressed on human cutaneous keratinocytes and in squamous cell carcinomas. Studies on normal human epidermis and primary keratinocyte cultures have suggested that P2X(5) receptors are likely to be involved in keratinocyte differentiation and P2X(7) receptors are likely to be part of the machinery of end stage terminal differentiation/apoptosis of keratinocytes. P2X(7) receptor agonists can significantly reduce primary keratinocyte cell numbers in culture. Human papillomaviruses are increasingly recognised as important human carcinogens in the development of non-melanoma skin cancers. In our study, immunohistochemical analysis for P2X(5) and P2X(7) receptors was performed on paraffin sections of normal human skin, warts, raft cultures of normal human keratinocytes and raft cultures of CIN 612 cells, a model of keratinocytes infected with human papillomavirus type 31. In warts there was up-regulation of the expression of P2X(5) receptors. A similar pattern was seen in the CIN 612 raft cultures. Both P2X(5) and P2X(7) receptors were found in the nuclei of koilocytes, abnormal keratinocytes characteristic of human papillomavirus infection. P2X(5) and P2X(7) receptors may provide a new focus for therapeutic research into treatments for warts because these receptors can induce cell differentiation and cell death.

P2Y purinergic receptors regulate the growth of human melanomas.

Adenosine 5'-triphosphate is known to function as a potent extracellular messenger producing its effects via a distinct family of cell surface receptors. Different receptor subtypes have been shown to modulate different cellular functions such as proliferation, differentiation and apoptosis. We investigated the functional expression and proliferative action of metabotropic P2Y receptors in human melanoma tissue and cells. Expression of functional P2Y1, P2Y2 and P2Y6 receptor subtypes was established by reverse transcriptase polymerase chain reaction, immunohistochemistry and intracellular calcium measurements using a Fluorometric Imaging Plate Reader. Incubation of A375 melanoma cells with the P2Y1 receptor-selective agonist 2-methylthioadenosine-5-diphosphate caused a decrease in cell number which was dose-dependent, whereas incubation with the P2Y2 receptor agonist uridine triphosphate caused a dose-dependent increase in cell number. The action of extracellular nucleotides on P2Y receptors was shown to mediate the growth of melanomas and the P2Y1 receptor is a putative target for melanoma therapy.