Prevalence and risk factors of scapular stress fracture after reverse shoulder arthroplasty: a multicentric retrospective study.

PURPOSE: Scapular stress fracture (sSF) is a difficult complication to treat after reverse total shoulder arthroplasty (RSA). The aim of this study was to identify the prevalence and possible risk factors in a large population. METHODS: A total of 2165 RSAs that were implanted between January 2006 and October 2017 in five hospitals were evaluated. Within this cohort, sSF was radiologically confirmed. Age, gender, surgical indication and hospital of treatment were determined for the entire cohort. A matched 3:1 case-control study was then performed to investigate several clinical and surgical variables. RESULTS: sSF occurred in 3.1% (63 patients), with a median time interval of five months post-operative [IQR = 9, range: (1-79)]. Within the entire cohort, females (OR = 2.99) and rotator cuff arthropathy (RCA) (OR = 2.79) were more prone to this complication. Age had little influence (OR = 1.03). After exclusion, fifty-five eligible cases were matched to 165 controls based on hospital, gender, age and surgical indication. After univariable analysis, significance was obtained for osteopenia (P = 0.037), osteoporosis (P = 0.032), surgical approach (P = 0.002) and peri-operative acromioclavicular (AC) joint surgery (P = 0.035). Multivariate analysis demonstrated that osteopenia (OR = 3.94), osteoporosis (OR = 2.85) and a deltopectoral approach (OR = 3.70) were independent risk factors. CONCLUSION: According to our findings, older women with poor bone quality and a history of RCA suffered more frequently from sSF. Anterolateral approach during surgery was a surgical protective factor, possibly due to the mobilization of the acromioclavicular joint. Although this study indicates who is at risk for sSF, further investigation for prevention of sSF in these patients is necessary.

Roles of Education and IQ in Cognitive Reserve in Parkinson's Disease-Mild Cognitive Impairment.

BACKGROUND/AIMS: The role of cognitive reserve in Parkinson's disease (PD)-mild cognitive impairment (MCI) is incompletely understood. METHODS: The relationships between PD-MCI, years of education, and estimated premorbid IQ were examined in 119 consecutive non-demented PD patients using logistic regression models. RESULTS: Higher education and IQ were associated with reduced odds of PD-MCI in univariate analysis. In multivariable analysis, a higher IQ was associated with a significantly decreased odds of PD-MCI, but education was not. CONCLUSION: The association of higher IQ and decreased odds of PD-MCI supports a role for cognitive reserve in PD, but further studies are needed to clarify the interaction of IQ and education and the impact of other contributors such as employment and hobbies.

(Ex-)smoking asthma patients in general and specialized Belgian practice.

INTRODUCTION: Smokers are often excluded from asthma studies. In the present study, data are presented on the prevalence, characteristics and management approach of this patient population in the Belgian practice both at the level of general practitioners (GPs) and specialists. MATERIALS AND METHODS: One hundred and nineteen smoking, non-smoking and ex-smoking patients (25-65 yrs) with asthma, COPD or both, were recruited by 33 GPs and 33 specialists. Data were obtained retrospectively from medical records. However, only a small number of files were complete. RESULTS: The majority of COPD patients were (ex-)smokers: 94% in the specialist group, 78% in the GP group. Cardiovascular comorbidity appeared in both groups in the same frequency order: COPD>(ex-)smoking patients with asthma (AS)>non-smoking patients with asthma (ANS), with a significant difference between AS and ANS in the specialist population. Chronic cough during more than 3 months in two consecutive years was reported in 97% of COPD patients, in 71% of the AS patients and in only 25% of the ANS patients. The type of cough differed between AS and ANS in the GP group, with a higher prevalence of productive cough in the former. Treatment patterns observed were as expected according to diagnosis except for a disproportionate use of Tiotropium in AS in the GP group. CONCLUSION: AS were somewhere in between COPD patients and ANS for a large number of the characteristics studied, suggesting that they are an intermediate phenotype between COPD and asthma.

Comparison of macrophage phenotype between decidua basalis and decidua parietalis by flow cytometry.

The two regions of the maternal decidua, decidua basalis and decidua parietalis, differ in the extent of trophoblast invasion and consequently in cytokines and other biological mediators, extracellular matrix and cellular components. Our aim was to compare the phenotypic features of macrophages from the two decidual regions across a broad gestational age range. We isolated macrophages by enzymatic digestion from healthy decidua samples obtained after elective abortions, at 9-18-week and at 19-23-weeks, or after term deliveries (caesarean sections at term and spontaneous term vaginal deliveries). Macrophages were analysed by flow cytometry applying the same instrument settings to all the samples to allow semi-quantitative comparison of the expression of a particular marker between different samples. We found higher expressions of CD80, CD86 and HLA-DR, suggestive of a more activated phenotype of decidual macrophages, at early/mid pregnancy than at term. Marginal differences were found between term decidual macrophages obtained after spontaneous vaginal deliveries or caesarean sections which imply that the parturient process is not associated with decidual macrophage activation. The expressions of CD105, DC-SIGN and MMR were the strongest in decidua basalis of mid pregnancy and indicate the importance of decidual macrophages in tissue homeostasis at the uteroplacental interface.

Kinetic analysis reveals potency of CD4+ CD25bright+ regulatory T-cells in kidney transplant patients.

Donor-specific hyporesponsiveness as occurs after allogeneic kidney transplantation may be mediated by repression of effector cells by a specific subset of T-cells: the CD4(+) CD25(bright+) FoxP3(+) regulatory T-cells (Tregs). Here, we examined the suppressive capacity of Tregs isolated from the leukafereses product of 6 kidney transplant recipients, by reconstituting Tregs to responder T-cells at several time-points after initiation of proliferation. We show that Tregs derived from kidney transplant patients potently restrain proliferation to donor-antigens and 3rd party-antigens in classic reconstitution assays (i.e. addition of Tregs at the start of the co-incubation). However, when Tregs were added 5 days after initiation of proliferation, they were still capable of suppressing proliferation to donor-antigens (by 38%) but no longer to 3rd party-antigens. Thus, we conclude that the potency of Tregs to suppress reactivity to specific antigens should be determined by reconstitution to ongoing reactions.

Differential distribution of CD4(+)CD25(bright) and CD8(+)CD28(-) T-cells in decidua and maternal blood during human pregnancy.

During pregnancy several maternal and fetal mechanisms are established to prevent a destructive immune response against the allogeneic fetus. Despite these mechanisms, fetus specific T-cells persist throughout gestation but little is known about the regulation of these T-cells. Recently, CD4(+)CD25(+) regulatory T-cells have been identified in human decidua. Human decidua forms the maternal part of the fetal-maternal interface and is subdivided in two distinct regions: the decidua (d.) basalis and the decidua (d.) parietalis. The aim of this study was to determine the distribution of specific T-cell subsets in d. basalis and d. parietalis in early and term pregnancy, with a special emphasis on the presence of CD4(+)CD25(bright) (regulatory) T-cells and CD8(+)CD28(-) (suppressor) T-cells. In addition, we compared phenotypic characteristics of decidua derived T-cell subsets with maternal peripheral blood (mPBL) T-cells and T-cells from non-pregnant controls. We identified significantly higher percentages of CD4(+)CD25(bright) and CD8(+)CD28(-) T-cells in decidua compared to peripheral blood suggesting an important role for these T-cell subsets locally at the fetal-maternal interface. The major differences in T-cell subset distribution and the presence of additional phenotypic differences between T-cells in d. basalis, d. parietalis and mPBL may reflect specific immunomodulatory functions of these T-cell subsets at these different sites during pregnancy.

The vascular depression hypothesis: the influence of age on the relationship between cerebrovascular risk factors and depressive symptoms in community dwelling elders.

The current study examined the moderating effect of age on the relationship between cerebrovascular risk factors (CVRF's) and depressive symptoms. Consistent with the broader vascular depression model, it was hypothesized that CVRF's would demonstrate a stronger link to depressive symptoms in the older age groups than among the younger age groups. Data from 2916 adults from the Resources, Stress, and Older Persons Panel Study were utilized. Path analysis was used to estimate direct and indirect effects (via health related symptoms and limitations) of CVRF's on depressive symptoms. Path analyses were estimated separately on four age groups: 50-64 years old, 65-74 years old, 75-84 years old, and 85 years and older. CVRF's and other comorbid medical conditions were highly predictive of health related symptoms and limitations across the four age groups. Health related symptoms and limitations were strongly linked to depressive symptoms and mediated the influence of medical illnesses (both vascular and nonvascular) on depressive symptoms. However, CVRF's exerted a unique effect on depressive symptoms in the oldest-old group (i.e., 85+). Among those over the age of 85, a greater number of CVRF's was associated with more severe depressive symptoms independent of health related symptoms/limitations and other comorbid medical conditions. Health related symptoms and limitations mediated the relationship between CVRF's and depression in individuals under 85. That is, the influence of vascular burden on depression is predominately indirect via health related limitations. But among those over the age of 85, vascular disease had a unique contribution on depression, even after controlling for other comorbid medical illness and health related limitations. This finding supports the vascular depression hypothesis and is consistent with prior work suggesting vascular disease may exert its greatest effect on depression in the context of increasing frailty.

Reduction of immunosuppressive load in renal transplant recipients with a low donor-specific cytotoxic T-lymphocyte precursor frequency is safe.

BACKGROUND: Tapering of immunosuppressive medication is indicated to prevent long-term side effects. Recently, we have shown that renal transplant recipients can safely be converted from calcineurin inhibitors to MMF or AZA when their donor-specific cytotoxic T-lymphocyte precursor frequencies (CTLpf) are below 10/10(6) PBMC. We wondered whether a low CTLpf also had predictive value when immunosuppressive medication was reduced in patients only on MMF or AZA and steroid medication. METHODS: Renal transplant recipients with stable renal function at least 2 years after transplantation and with low (<10/10(6) PBMC) CTLpf were included. Their MMF or AZA dose was reduced to 75% and to 50% of the original dose at 4 months and 8 months after inclusion. Endpoint of the study was 12 months after inclusion or developing acute rejection. RESULTS: Forty-five patients have reached the 1-year follow up endpoint. Their median time after transplantation was 4.2 years (range 2.0-15.5 years). Acute rejection was seen in one patient only (who had discontinued all his medication). CONCLUSION: In patients with low CTLpf long after kidney transplantation, a 50% reduction of immunosuppression is safe and further decreasing their immunosuppressive load is the obvious next step.

Down-regulated donor-specific T-cell reactivity during successful tapering of immunosuppression after kidney transplantation.

Stable cadaveric renal transplant patients were routinely converted from cyclosporin A (CsA) to either azathioprine (AZA) or mycophenolate mofetil (MMF) 1 year after transplantation to reduce the side effects of long-term immunosuppressive therapy. Thereafter, the AZA and MMF dose was gradually tapered to 50% at 2 years after transplantation. We questioned whether a reduction of immunosuppressive treatment results in a rise of donor-specific T-cell reactivity. Before transplantation (no immunosuppression), 1 year (high dose immunosuppression) and 2 years (low dose immunosuppression) after transplantation, the T-cell reactivity of peripheral blood mononuclear cells (PBMC) against donor and third-party spleen cells was tested in mixed lymphocyte cultures (MLC) and against tetanus toxoid (TET) to test the general immune response. We also measured the frequency of donor and third-party reactive helper (HTLpf) and cytotoxic (CTLpf) T-lymphocyte precursors in a limiting dilution assay. Donor-specific responses, calculated by relative responses (RR = donor/third-party reactivity), were determined. Comparing responses after transplantation during high dose immunosuppression with responses before transplantation (no immmunosuppression), the donor-specific MLC-RR (P = 0.04), HTLp-RR (P = 0.04) and CTLp-RR (P = 0.09) decreased, while the TET-reactivity did not change. Comparing the responses during low dose with high dose immunosuppression, no donor- specific differences were found in the MLC-RR, HTLp-RR and CTLp-RR, although TET-reactivity increased considerably (P = 0.0005). We observed a reduction in donor-specific T-cell reactivity in stable patients after renal transplantation during in vivo high dose immunosuppression. Tapering of the immunosuppressive load had no rebound effect on the donor-specific reactivity, while it allowed recovery of the response to nominal antigens.

Depression, cognitive impairment and function in Alzheimer's disease.

Depression is very common in patients with dementia but the relationship is very complex. Depression is regarded as a cause of excess disability in persons with dementia and contributes to their functional decline. The assessment of depression in dementia patients, however, has been difficult in that the validity of self-reported depression in patients with dementia has been questioned. This study was done to investigate whether self-reported depression by persons with dementia (using the GDS) is related to their functional abilities as rated by a family caregiver (using the IADL scale) above and beyond demographic variables. This study was conducted at the Detroit Satellite of the Michigan Alzheimer's Disease Research Center. There were 141 participants, 67% were African American and 33% were European American. Statistical analyses included a correlational and multiple regression approach to determine the predictive relationships of cognitive and depressive symptoms above and beyond the influence of demographic variables and cognition. The results of the study further support the notion that depression in dementia is significantly related to functional decline but, more importantly, that self-reported depression in patients with dementia can be valuable information in understanding patients' functioning.

Pretransplant donor-specific helper T cell reactivity as a tool for tailoring the individual need for immunosuppression.

BACKGROUND: A reliable immunological assay for quantification of donor-specific alloreactivity to identify patients at risk for future allograft rejection would be a helpful tool in organ transplantation. Therefore, we questioned whether the T cell reactivity in patients measured before transplantation was predictive for the occurrence of acute rejection during the first year after kidney transplantation. METHODS: The pretransplant T cell reactivity of peripheral blood mononuclear cells to donor and third-party antigens was tested in mixed lymphocyte cultures, and to tetanus toxoid. In addition, we measured the frequency of donor and third-party reactive helper T lymphocyte precursor and cytotoxic T lymphocyte precursors using limiting dilution analysis. RESULTS: Patients who experienced acute rejection had significantly higher donor-specific mixed lymphocyte cultures responses (n=38; median stimulation index): 113 vs. 15, P=0.005) and helper T lymphocyte precursor frequency (n=37; median 194/106 vs. 62/106, P=0.009) measured before transplantation compared to patients without acute rejection. All patients with a low mixed lymphocyte culture response (stimulation index

Effective screening for Alzheimer's disease among older African Americans.

Relatively little data exist concerning the utility of brief cognitive measures to detect dementia among African Americans. The current study evaluated the clinical utility of the Mini-Mental Status Exam (MMSE) and the Fuld Object Memory Evaluation (FOME) in detecting Alzheimer's disease (AD) among both African American and European American older adults. One hundred and forty geriatric patients from a large urban academic medical center were examined. Overall, the FOME appeared to be more effective in detecting AD than was the MMSE (93% sensitivity vs. 75% sensitivity, respectively), although both measures suffered from relatively low specificity (63.5) in the full sample. The FOME demonstrated exceptional clinical utility among African American patients (sensitivity 98.3%; specificity = 64.5; positive predictive power 83.8%; negative predictive power 95.2%). The results of this study support the use of the FOME among older African Americans to detect dementia.

Comparison of magnetic resonance angiography and digital subtraction angiography for visualization of lower extremity arteries.

Objective vascular assessment is frequently required before microvascular reconstruction involving the lower extremities. The purpose of this study was to evaluate the reliability of magnetic resonance angiography (MRA) for preoperative assessment before free flap surgery. Five patients underwent preoperative MRA: one before fibula harvest for oromandibular reconstruction, and four before muscle free flap reconstruction of the lower extremity. In all patients, the tibioperoneal trunk, anterior tibial, posterior tibial, and peroneal arteries were well visualized to the ankle, including pathological occlusions. The radiographic findings were demonstrated at surgery and were confirmed to be accurate. These findings facilitated and guided the surgical procedure. This study strongly suggests the accuracy and surgical relevance of MRA before free flap surgery. MRA is desirable over angiography because of its noninvasive nature. It may also be better than ultrasonography because the latter is highly dependent on the technician (particularly in identifying the peroneal artery). MRA may likely replace angiography as the objective procedure of choice before microvascular surgery.

The nasolabial flap revisited as an adjunct to floor-of-mouth reconstruction.

Composite free tissue reconstruction for floor-of-mouth defects are thought of as single-stage procedures. However, postoperative wound complications often require additional soft-tissue coverage to salvage the initial reconstruction. Nasolabial flaps interpolated into the oral cavity offer an expedient solution to soft-tissue deficits encountered during complicated floor-of-mouth reconstructions. The records of 39 patients undergoing free tissue reconstruction, from July 1995 to December 1999 at Shands Hospital and the Gainesville VA Medical Center, for floor-of-mouth defects were reviewed. Six patients developed postoperative wound complications that compromised the initial reconstruction. In all patients, inferiorly based nasolabial flaps were used to provide additional soft-tissue coverage and wound closure. Radiation therapy and facial artery ligation did not affect the outcome. Complete wound healing and salvage of the initial reconstruction was achieved in all 6 patients.

Mycophenolic acid trough levels after kidney transplantation in a cyclosporine-free protocol.

Twenty-seven stable kidney transplant recipients treated with cyclosporine and prednisone were converted to mycophenolate mofetil (MMF) and prednisone 1 year after transplantation. After conversion the patients were treated with a standard daily dose of 1 g MMF b.i.d. and 10 mg prednisone for 4 months. Thereafter, two MMF dose reductions were performed with a 4-month interval. Mycophenolic acid (MPA) trough levels were measured at regular intervals. A relation was found between MPA trough levels and MMF dose. The median MPA trough level for patients treated with 1 g MMF b.i.d. was 4.3 microg/ml (0.95-15.5) and 3.0 microg/ml (0.73-7.8) for patients treated with 750 mg b.i.d. (P = 0.0002). The MPA trough levels further decreased from 3.0 to 2.3 microg/ml (0.6-6.63) in patients treated with 500 mg MMF b.i.d. (P = 0.01). Dose reduction of MMF from 1 g to 750 mg b.i.d. could be performed without acute rejections. A further dose reduction to 500 mg b.i.d. elicited 3 rejections. Patients experiencing an acute rejection had a median MPA trough level of 2.3 microg/ml (1.26-3.38) compared to 3.8 microg/ml (1.48-6.52) in patients without an acute rejection (P = 0.25). We conclude that there is a significant relation between MPA trough levels and MMF dose. MPA trough levels were not predictive of rejection in the present study.

Immunologic monitoring of the beneficial effect of one HLA-DR-shared blood transfusion in heart transplant patients.

BACKGROUND: Pre-transplant blood transfusion (BT) results in better graft survival in organ transplant recipients, especially when BT donor and allograft recipient share an HLA-DR antigen. Although the immunologic mechanisms involved are still poorly understood, we wanted to know whether down regulation of donor-reactive T cells play a role. METHODS: In a retrospective study, we analyzed the clinical effects of BT for 45 heart transplant (HTx) patients who had each received 1 BT that shared an HLA-DR-antigen with the recipient, and 55 who had a DR-mismatched BT before heart transplantation. From 30 patients, 15 with DR-shared BT and 15 with DR-mismatched BT, peripheral blood lymphocytes (PBL) were available. From each patient, we analyzed PBL samples taken at the day of transplantation (pre-transplant), and 1 to 2 months, 5 to 7 months, 9 to 14 months, 2 years, and 6 to 7 years after transplantation. Cytotoxic T-lymphocyte precursors (CTLp) and helper T-lymphocyte precursors (HTLp) were measured in a combined limiting dilution assay. RESULTS: Analysis of survival during the first 10 years revealed a significantly (p = 0.016) better survival rate in the group of patients who had received HLA-DR-shared BT compared with the group who had received HLA-DR-mismatched BT. Patients of the DR-shared group experienced significantly (p = 0.042) less acute rejections compared with the patients who received DR-mismatched BT. We found no differences in the development of graft vascular disease. Frequencies of CTLp specific for the organ donor did not change with time after transplantation in the individual patients, nor did we detect any differences between the two BT groups. We found the same for organ donor-specific HTLp frequencies. CONCLUSIONS: These data suggest again that transfusion effect depends on HLA-DR compatibility between the heart transplant recipient and the pre-transplant BT donor. The mechanism that caused better survival rate was not down regulation of the donor-reactive T-cell frequency.

Environmental press and adaptation to disability in hospitalized live-alone older adults.

PURPOSE: This study examined the ability of personal competency variables at the time of hospital discharge to predict primary instrumental activities of daily living (IADLs) and secondary outcomes (living arrangements) in a sample of 194 urban, live-alone, older adults who had a new onset disability. DESIGN AND METHODS: Consecutively admitted medical rehabilitation patients, 72% women and 85% African American, participated in the study. Using path analysis, three of the four competency variables collected at the time of hospitalization (cognition, medical burden, activities of daily living) predicted IADLs at 3 and 6 months after hospitalization (e.g., cooking, telephone use, money management). IADLs, in turn, predicted living arrangements at 3 and at 6 months after hospitalization. RESULTS: The findings provided strong support for the importance of assessing a broad range of competency variables when investigating adaptation to disability. IMPLICATIONS: The increased understanding of adaptation in live-alone older adults with a new-onset disability is particularly timely given the increase in live-alone older adults and the dire consequences associated with change in living arrangement (i.e., mortality and morbidity) in this group.

Clinical utility of the Normative Studies Research Project test battery among vascular dementia patients.

The purpose of the present study was to examine the clinical utility of the Normative Studies Research Project test battery for detecting dementia with a known vascular component. The study compared 65 patients who had both suffered a stroke and met the DSM-IV criteria for dementia with 86 older medical patients who were cognitively intact. Multivariate analysis of covariance results demonstrated that these two groups had significantly different means on tests within the battery even after controlling for the influence of demographic variables. Logistic regression results demonstrated positive predictive value of 81.36%, negative predictive value of 85. 23%, and an overall correct classification rate of 83.67%.

Donor-specific T-cell reactivity identifies kidney transplant patients in whom immunosuppressive therapy can be safely reduced.

BACKGROUND: To reduce the side effects of long-term immunosuppressive therapy, stable renal transplant patients were routinely converted from cyclosporine to either azathioprine or mycophenolate mofetil. Thereafter, the azathioprine and mycophenolate mofetil dose was reduced to 75% at 4 months and to 50% at 8 months after conversion. We questioned whether the T-cell reactivity before conversion was able to predict which patients could be safely converted and tapered in their immunosuppressive load, while remaining free from acute rejection. METHODS: Before conversion, the T-cell reactivity of peripheral blood mononuclear cells against donor and third-party spleen cells were tested in mixed lymphocyte cultures. We measured the frequency of donor and third-party reactive helper T-lymphocyte (HTLpf) and cytotoxic T-lymphocyte (CTLpf) precursors and their avidity for HLA class I antigens using limiting dilution analysis. Peripheral blood mononuclear cells were also stimulated with tetanus toxoid to test the general immune response. RESULTS: The tetanus toxoid response, reactivity to donor and third-party cells as measured in mixed lymphocyte cultures and HTLpf, and the avidity of cytotoxic T-lymphocyte precursors were not predictive for the development of acute rejection. However, significant differences were found in donor-specific CTLpf before conversion, between patients with and without acute rejection after conversion in immunosuppression. The donor-specific CTLpf was significantly lower in patients without compared to those with acute rejection (P=0.01). Additionally, when no CTLpf was detectable before conversion, acute rejection did not occur after conversion. Acute rejection was only diagnosed in patients with detectable CTLpf before conversion. CONCLUSION: The number of donor-specific cytotoxic T-lymphocytes identifies patients in whom the immunosuppressive load can be safely reduced.