Inverted-Bearing Reverse Shoulder Arthroplasty: Long-term Survivorship, Complications, Clinical and Radiological Outcomes.

BACKGROUND: Inverted-bearing reverse shoulder arthroplasty (IB-RSA) is characterized by a polyethylene glenosphere and a metallic humeral liner to minimize PE wear and debris secondary to impingement between the humerus and glenoid neck. IB-RSA long-term survivorship, complication and revision rates, as well as clinical and radiographic outcomes have not been reported yet. METHODS: This is a monocentric retrospective study on a consecutive series of 151 patients who underwent primary IB-RSA from January 2009 to September 2015 and were evaluated clinically and radiologically at minimum 8 years follow-up. All complications and reoperations were recorded. Survivorship analysis with any revision surgery as endpoint was done using Kaplan-Meier survival curves. RESULTS: Seventy-eight patients (follow-up rate 51.7%) were reviewed at a mean follow-up of 10.1 ± 1.9 years. At 10 years the revision-free survival was 98.7% (95% CI: 94.8-99.7). Sixteen complications (10.6%) were observed: 2 axillary nerve injuries, 2 infections, 2 glenoid loosenings (which stabilized within one year), 2 cases of otherwise unexplained painful stiffness, 4 acromial fractures, 1 post-traumatic scapular pillar fracture and 3 post-traumatic humeral periprosthetic fractures. Two patients were revised due to infection. No cases of late glenoid loosening and humeral loosening were observed. The revision rate was 1.3%. All the clinical scores and range of motion significantly improved at the last follow-up compared with preoperative status: final Constant score was 66.1 ± 17.4, SSV 79.1 ± 20.9, ASES 82.2 ± 17.7. Scapular notching was observed in 51.4% of patients: only 1 case of grade 3 notching was observed in an early glenoid subsidence case. CONCLUSIONS: Primary IB-RSA appears to be a safe and effective procedure and does not present specific implant-associated complications at long-term follow-up. Radiographic analysis showed that inverting the biomaterials leads to a distinct kind of notching with mainly mechanical features.

Antisenescence effect of REAC biomodulation to counteract the evolution of myelodysplastic syndrome.

About 30 percent of patients diagnosed with myelodysplastic syndromes (MDS) progress to acute myeloid leukemia (AML). The senescence of bone marrow?derived mesenchymal stem cells (BMSCs) seems to be one of the determining factors in inducing this drift. Research is continuously looking for new methodologies and technologies that can use bioelectric signals to act on senescence and cell differentiation towards the phenotype of interest. The Radio Electric Asymmetric Conveyer (REAC) technology, aimed at reorganizing the endogenous bioelectric activity, has already shown to be able to determine direct cell reprogramming effects and counteract the senescence mechanisms in stem cells. Aim of the present study was to prove if the anti-senescence results previously obtained in different kind of stem cells with the REAC Tissue optimization - regenerative (TO-RGN) treatment, could also be observed in BMSCs, evaluating cell viability, telomerase activity, p19ARF, P21, P53, and hTERT gene expression. The results show that the REAC TO-RGN treatment may be a useful tool to counteract the BMSCs senescence which can be the basis of AML drift. Nevertheless, further clinical studies on humans are needed to confirm this hypothesis.

Conservative management vs. surgical repair in degenerative rotator cuff tears: a systematic review and meta-analysis.

OBJECTIVE: To analyze the available evidence comparing the clinical and functional outcomes of physiotherapy vs. surgical repair in the management of degenerative rotator cuff tears (RCTs), and to perform a meta-analysis to clarify the possible superiority of one approach vs. the other. MATERIALS AND METHODS: A literature search was carried out on the PubMed, Scopus and Web of Science databases on May 30th, 2020, to identify all the randomized trials comparing surgery to conservative management of degenerative rotator cuff tears. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, overall clinical findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 7 studies, including 326 patients and dealing with conservative treatment vs. surgical repair for rotator cuff tears, were included in this study. Although surgery provided superior results both in terms of VAS (p=0.017) and Constant score (p<0.0001) compared to conservative management at 1 year follow-up, this superiority did not reach the "minimal clinical important difference". Otherwise, a few data are available about long-term outcomes, thus there is insufficient evidence about the role of surgery to prevent the progression of tendon wear. CONCLUSIONS: A proper rehabilitation program is able to provide similar results compared to surgery at a short term follow-up in degenerative RCTs. Further long term data are necessary to understand if tendon repair might have a protective role towards worsening of degeneration thus providing better clinical outcome than conservative management.

The soluble glycoprotein NMB (GPNMB) produced by macrophages induces cancer stemness and metastasis via CD44 and IL-33.

In cancer, myeloid cells have tumor-supporting roles. We reported that the protein GPNMB (glycoprotein nonmetastatic B) was profoundly upregulated in macrophages interacting with tumor cells. Here, using mouse tumor models, we show that macrophage-derived soluble GPNMB increases tumor growth and metastasis in Gpnmb-mutant mice (DBA/2J). GPNMB triggers in the cancer cells the formation of self-renewing spheroids, which are characterized by the expression of cancer stem cell markers, prolonged cell survival and increased tumor-forming ability. Through the CD44 receptor, GPNMB mechanistically activates tumor cells to express the cytokine IL-33 and its receptor IL-1R1L. We also determined that recombinant IL-33 binding to IL-1R1L is sufficient to induce tumor spheroid formation with features of cancer stem cells. Overall, our results reveal a new paracrine axis, GPNMB and IL-33, which is activated during the cross talk of macrophages with tumor cells and eventually promotes cancer cell survival, the expansion of cancer stem cells and the acquisition of a metastatic phenotype.

Long-term stability of coracoclavicular suture fixation for acute acromioclavicular joint separation.

PURPOSE: The optimal (SBJI) surgical treatment for acute acromioclavicular (AC) joint disruption remains controversial. What is being presented is the long-term functional outcomes of a double cross-looped coracoclavicular (CC) suture technique with the intention of restoring both anteroposterior and superior displacement of the clavicle. METHODS: Between 2007 and 2016, 81 patients underwent surgical reconstruction for acute acromioclavicular joint (AC) disruption in two orthopaedic centers. Two patients died for reasons unrelated to the treatment, and seven missed the final follow-up appointment, leaving 72 patients (67 males; 5 females; age 37 ± 12.4; range 15-64 years) for clinical and radiological assessments. All cases were classified according to the Rockwood classification as type III (n = 34), IV (n = 14) or V (n = 24). The dislocation was repaired with double cross-looped CC fixation using four Ethibond sutures passing underneath the coracoid and through a 4.5 mm drill hole in the clavicle in opposing directions to control both anteroposterior and vertical displacement. Radiological investigation preoperatively and at the last follow-up included anteroposterior and/or Zanca views, axillary or Alexander views, and comparative stress radiography of both AC joints. Patients were evaluated clinically with the Constant-Murley score (CMS) and Acromio Clavicular Joint Instability Score (ACJIS). Loss of reduction, subluxation, CC ligament ossification, post-traumatic arthritis, and peri-implant fractures were also recorded. RESULTS: Seventy-two patients were available for the last clinical and radiological evaluations. At a median follow-up period of 6.3 ± 2.1 years (range 3-12 years), the CMS and ACJIS were 92.1 ± 7.2 (range 60-100 points) and 90.4 ± 8.6 (range 45-100 points), respectively. Complications included 9 (12.5%) patients with slight loss of reduction, 2 (1.7%) with dislocation recurrence, 1 (1.3%) with superficial infection, 1 (1.3%) with a fracture of the lateral end of the clavicle, and 2 (1.7%) with persistent tenderness in the AC joint. The incidence of periarticular ossification was 22.4% and did not affect the final outcome. CONCLUSIONS: This technique represents an effective and low-cost treatment for acute AC joint separations. LEVEL OF EVIDENCE: IV.

Arthroscopic transosseous versus suture anchor repair: clinical outcomes in patients with bilateral rotator cuff tears.

The aim of our study was to define if Arthroscopic Transosseous Rotator Cuff Techniques should have comparable results to those of the suture-anchors technique in a single row configuration. We reported the preliminary results of a consecutive population of 22 patients who underwent a rotator cuff treatment on the left and right sides for average medium-sized thickness tears with minimal fatty infiltration with the two different techniques: transosseous rotator cuff repair technique on one side and single row with suture-anchors on the other side, in different times. Subjective evaluation with DASH questionnaires, Constant Scores and Numerical Rating Scale (NRS) for pain evaluation, have been submitted pre and postoperatively after both operations. A statistical analysis was performed to assess the superiority of one technique and to compare pre and postoperative ROM data and clinical outcomes. A transosseous rotator cuff repair was performed in 7 patients on the dominant arm, while the other 15 patients had dominant arm cuff tear lesions repaired by using suture-anchors technique. At last follow-up a significant improvement, in shoulder pain and function, was referred at both sides. Also, DASH, Constant Scores and NRS for pain evaluation improved with both techniques, but no statistical difference was found between them. Arthroscopic transosseous rotator cuff repair technique shows comparable results to those of the suture-anchors technique in a single row configuration.

Arthroscopic anatomic repair of Bankart lesion in rugby players.

Recent studies have reported equivalent outcomes of arthroscopic and open shoulder stabilization. However, surgical strategy for shoulder instability is a challenging and controversial problem for surgeons that have to treat collision sport athletes. In fact, only few studies support the arthroscopic surgery for this group of patients. The aim of this study is to evaluate the outcome of arthroscopic stabilization in a homogenous population of professional young athletes practicing in high-level collision sport. We treated 22 consecutive professional rugby players, with a mean age of 23.6 years, affected by traumatic anterior shoulder instability. All patients underwent arthroscopic Bankart repair with bone suture-anchors. Exclusion criteria were: failed previous shoulder surgery, atraumatic, multidirectional or posterior instability, bone defects greater than 20% of the anterior-inferior glenoid, engaging Hill-Sachs, rotator cuff tears, capsular-ligament avulsion on the humeral side (HAGL). Patients were evaluated according to Constant score, Rowe score and Visual Analogue Scale (VAS) for discomfort and handicap. The mean follow-up was 40.7 months (range, 6 to 87 months). All patients except one were able to return at the same previous sports level at 5 to 6 months postoperatively. Re-dislocation occurred in 3 players for high impact trauma during competition or training. Our results confirm that, also in the collision sport patients, anatomic arthroscopic Bankart repair is a good option for the treatment of traumatic anterior instability without associated lesions. .

Shoulder adhesive capsulitis and hypercholesterolemia: role of APO A1 lipoprotein polymorphism on etiology and severity.

PURPOSE: Relationship between shoulder adhesive capsulitis (AC) and hypercholesterolemia is known. The connecting link might be represented by the correlation between HDL and transforming growth factor beta (TGF-ß): normally, HDLs stimulate TGF-ß expression; the latter is employed in the development of fibrous tissue. We assess whether the presence of the Apo-A1-G75A-polymorphism, which is correlated to an enhanced HDL function, could be a risk factor for the genesis and severity of AC. METHODS: Peripheral blood samples of 27 patients [7M; 20F, mean age 54.81 (41-65)] with AC and hypercholesterolemia were submitted to polymerase chain reaction in order to evaluate the Apo-A1-G75A-polymorphism. Genome database was used as control. Two categories were obtained according to AC severity: type I (active forward flexion ≥ 100°) and type II (< 100°). Data were submitted to statistics. RESULTS: The prevalence of Apo-A1-G75A-polymorphism in the studied group and in the control group was 22.2% (10AG; 1AA; 16GG) and 19% (OR 1.22, IC 0.59-2.53, p > 0.05), respectively. Patients with type I and II capsulitis were 11 [flexion 148.0° (range 100°-165°)] and 16 [flexion 82.5° (range 50°-95°)], respectively. The prevalence of Apo-A1-G75A in type I was 18.1% (2AG; 9GG) and in type II was 56.3% (8GA; 1AA; 7GG), respectively (RR 1.87, IC 1.005-3.482, p < 0.05). CONCLUSIONS: Apo-A1-G75A-polymorphism is not necessary for the genesis, but it is a risk factor for severity of AC. LEVEL OF EVIDENCE: III.

Age-Related Changes of Elastic Fibers in Shoulder Capsule of Patients with Glenohumeral Instability: A Pilot Study.

BACKGROUND: Recurrent shoulder dislocations occur much more frequently in adolescents than in the older population but a clear explanation of this incidence does not exist. The aim of the present study was to define the age-related distribution of the elastic fibers (EFs) in the shoulder capsule's extracellular matrix as a factor influencing shoulder instability. MATERIALS AND METHODS: Biopsy specimens were obtained from the shoulder capsule of patients divided preoperatively into three groups: Group 1 consisted of 10 male patients undergoing surgery for unidirectional traumatic anterior instability (TUBS); Group 2 consisted of 10 male patients undergoing surgery for multidirectional instability (MDI); Group 3 represents the control, including 10 patients with no history of instability. In addition to the group as a whole, specific subgroups were analyzed separately on the basis of the age of subjects: > 22 or < to 22 years. All the samples were analyzed by histochemical (Weigert's resorcinol fuchsin and Verhoeff's iron hematoxylin), immunohistochemical (monoclonal antielastin antibody), and histomorphometric methods. RESULTS: Both the elastin density and the percentage of area covered by EFs were significantly higher in younger subjects (<22 years old). Furthermore, the elastin density and the percentage of area covered by EFs were significantly higher in specimens of group of patients affected by multidirectional shoulder instability in comparison to the other two groups. CONCLUSION: Data of the present study confirmed the presence of an age-related distribution of EFs in the human shoulder capsule. The greater amount of EFs observed in younger subjects and in unstable shoulders could play an important role in predisposing the joint to first dislocation and recurrence.

Rotator cuff degeneration of the healthy shoulder in patients with unilateral arm amputation is not worsened by overuse.

PURPOSE: In order to evaluate whether overuse has a significant role in rotator cuff tear (RCT) aetiology, we evaluated both shoulders of patients with old unilateral arm amputation expecting a higher rate of RC degeneration in the healthy side. METHODS: Nineteen males and six females (mean age: 57.3 ± 10.1) with an old (>20 years) unilateral arm amputation were submitted to an MRI of both shoulders. Tendon status and muscle tropism were evaluated according to Sugaya and Fuchs classifications, respectively; the acromion humeral distance was measured. Statistical analysis was performed to verify the prevalence of Sugaya and Fuchs categories in each sides. RESULTS: A significant prevalence of Sugaya type II in the amputated side (p = 0.02) and of type I in the healthy side (p < 0.001) was found. Rotator cuff was healthy in 28 and 52% of amputated and non-amputated side, respectively. The mean acromio-humeral distances of the amputated and healthy side were 0.8 cm (SD: 0.1) and 0.9 cm (SD: 0.1), respectively, (p = 0.02). A significant prevalence of Fuchs type II category in the healthy side (p < 0.001) was found. Fuchs III/IV were observed in 40 and 12% of amputated and healthy side, respectively. CONCLUSIONS: The present study resizes the role of overuse on the aetiology of RCT. Cuff tear prevalence in not amputated shoulders, inevitably submitted to functional overload, was not higher than that of coetaneous subjects with two functional upper limbs. Shoulder non-use is a risk factor for rotator cuff tear. As the prevalence of rotator cuff degeneration/tear is higher in the amputee side, non-use is a more relevant risk factor than overuse. In the daily clinical practice, patients with rotator cuff tear should be encouraged to shoulder movement because rotator cuff tendon status could be worsened by disuse. LEVEL OF EVIDENCE: III.

Dynamic brace is a good option to treat first anterior shoulder dislocation in season.

PURPOSE: We evaluate the ability of in-season competitive athletes to return to competition after an anterior shoulder instability treated conservatively with a new dynamic brace combined with a specific rehabilitation program. METHODS: Twenty soccer players affected by traumatic anterior shoulder dislocation have been enrolled in the "Footballer In Season Fast Rehab" project during 2 consecutive football seasons. We excluded patients affected by rotator cuff tears and the bony defect over 25%. All the players have been treated the day after the first dislocation with a new dynamic brace used until the end of the second month after the first glenohumeral dislocation combined with a specific rehab protocol. Athletes were evaluated for the time necessary to completely resume sport activities, to complete the season, and for the recurrence of dislocation. RESULTS: All the athletes enrolled in this study were able to come back on the ground in approximately 40 days after the dislocation except 2 of them. Only two athletes claimed a slight discomfort at the return to play. One athlete had a traumatic relapse of the instability, 50 days after the dislocation. Another athlete claimed to have had a subluxation during a training session 45 days after the dislocation. 90% of the athletes were able to end the season without any shoulder discomfort. CONCLUSIONS: The dynamic brace combined to the rehabilitation protocol represents the solution that allows a quick start of resumption of training while maintaining a stable pain-free shoulder. LEVEL OF EVIDENCE: Level 4.

Reverse shoulder arthroplasty with glenoid bone grafting for anterior glenoid rim fracture associated with glenohumeral dislocation and proximal humerus fracture.

BACKGROUND: Large fractures of the anterior glenoid rim can result in persisting instability and osteoarthritis of the glenohumeral joint When this fracture is associated with a glenohumeral dislocation and proximal humerus fracture could be a concern. The goal of this paper was to evaluate the clinical and radiological outcomes and complications of reverse shoulder arthroplasty (RSA) and glenoid bone graft in cases with a significant anterior glenoid fracture associated with a proximal humerus fracture. HYPOTHESIS: RSA and step bone graft harvested from proximal humeral head could be a viable option in the treatment of this complex injury. DESIGN: Retrospective case series. MATERIAL AND METHODS: Twenty-six patients underwent RSA and glenoid bone graft in a single stage procedure were evaluated at an average 32 months postoperatively. There were 18 women and 8 men with a mean age of 68.5 years (range 63-75 years). Reverse shoulder arthroplasty with a contoured glenoid bone graft placed underneath the baseplate using humeral head autograft was utilized in all cases. Clinical outcomes were evaluated with range of motion, Constant score and self-reported subjective outcome rated as excellent, good, fair or poor. Radiographic evaluation was performed to evaluate for baseplate displacement or loosening, bone graft union, resorption or collapse. RESULTS: At final follow-up, average active elevation was 135° (range 110°-145°), abduction 122° (range 60°-160°), and external rotation 30° (range 0 to 45°). The mean Constant score was 68.2 (range 54-83). The clinical results were rated as excellent by 15 patients, good by 9, and fair by 2. Radiographic evaluation showed the disc of cancellous bone graft healed without any signs of graft resorption or migration in all 26 cases. No reoperation was performed on any patient in this series. DISCUSSION/CONCLUSION: RSA with glenoid bone grafting produces satisfactory short-term outcomes with acceptable complication rates for treatment of patients greater than 60 years old with proximal humerus fractures associated with an anterior glenoid rim fracture. Further studies are necessary to determine the extended viability of this procedure. LEVEL OF EVIDENCE: III.

Infection-related and -unrelated malignancies, HIV and the aging population.

OBJECTIVES: HIV-positive people have increased risk of infection-related malignancies (IRMs) and infection-unrelated malignancies (IURMs). The aim of the study was to determine the impact of aging on future IRM and IURM incidence. METHODS: People enrolled in EuroSIDA and followed from the latest of the first visit or 1 January 2001 until the last visit or death were included in the study. Poisson regression was used to investigate the impact of aging on the incidence of IRMs and IURMs, adjusting for demographic, clinical and laboratory confounders. Linear exponential smoothing models forecasted future incidence. RESULTS: A total of 15 648 people contributed 95 033 person-years of follow-up, of whom 610 developed 643 malignancies [IRMs: 388 (60%); IURMs: 255 (40%)]. After adjustment, a higher IRM incidence was associated with a lower CD4 count [adjusted incidence rate ratio (aIRR) CD4 count < 200 cells/µL: 3.77; 95% confidence interval (CI) 2.59, 5.51; compared with ≥ 500 cells/µL], independent of age, while a CD4 count < 200 cells/µL was associated with IURMs in people aged < 50 years only (aIRR: 2.51; 95% CI 1.40-4.54). Smoking was associated with IURMs (aIRR: 1.75; 95% CI 1.23, 2.49) compared with never smokers in people aged ≥ 50 years only, and not with IRMs. The incidences of both IURMs and IRMs increased with older age. It was projected that the incidence of IRMs would decrease by 29% over a 5-year period from 3.1 (95% CI 1.5-5.9) per 1000 person-years in 2011, whereas the IURM incidence would increase by 44% from 4.1 (95% CI 2.2-7.2) per 1000 person-years over the same period. CONCLUSIONS: Demographic and HIV-related risk factors for IURMs (aging and smoking) and IRMs (immunodeficiency and ongoing viral replication) differ markedly and the contribution from IURMs relative to IRMs will continue to increase as a result of aging of the HIV-infected population, high smoking and lung cancer prevalence and a low prevalence of untreated HIV infection. These findings suggest the need for targeted preventive measures and evaluation of the cost-benefit of screening for IURMs in HIV-infected populations.

Intramedullary clavicle fixation with single large fragmentary screw.

BACKGROUND: The treatment of clavicle fractures has historically been nonoperative, but several studies have recently shown the merits of operative management for specific fractures patterns. We developed a novel technique utilizing a 6.5-mm cannulated screw for fixation of displaced midshaft clavicle fractures. MATERIALS AND METHODS: We present 15 consecutive patients treated with this technique between 2007 and 2012. All patients were male, and all 15 suffered a traumatic injury involving a fall directly onto the affected side. Mean time from injury to surgery was 12 days (range 3-24 days). Decision for surgery was based on the displacement and shortening of the fracture, either at least 20 mm of shortening or displacement with no bony apposition. After surgery, all patients were placed in an abduction brace for 6 weeks. No motion was allowed for the first 3 weeks, followed by passive shoulder motion below 90° of forward flexion under the supervision of a therapist for the next 3 weeks. RESULTS: All 15 patients progressed to union at an average of 5.7 months (range 3-12). Three patients had superficial wound infections. Hardware removal was performed in 6 of the 15 patients at an average of 12 months (range 5-24). All patients regained full range of motion and strength in comparison with contralateral extremity. CONCLUSION: This novel technique limits soft tissue stripping. It has the advantages of using an implant familiar to most orthopedists and available in most hospital settings. We believe this technique is ideally suited for transverse fractures patterns, less than 14 days old, in males greater than 180 cm with clavicles large enough to accommodate a 6.5-mm screw.

Does a brace influence clinical outcomes after arthroscopic rotator cuff repair?

PURPOSE: The goal of this study was to report the clinical effects of two different braces after rotator cuff repair. METHODS: Forty patients who underwent an arthroscopic rotator cuff repair were prospectively allocated in this study. Twenty patients were immobilized in 15° external rotation brace (ER Group), and twenty were immobilised in an internal rotation sling (IR Group). For all patients, four surveys were done: in the immediate pre-operative period (T0), at 1 month (T1), at 3 months (T2) and at 6 months after surgery (T3). Range of motion and pain were evaluated by an independent physician. Self-Assessment Scales [(University California Los Angeles Shoulder Rating Scale (UCLA), Disability of the Arm Shoulder and Hand (DASH), Visual Analog Scale (VAS), Simple Shoulder Test (SST) and Physician Assessment Scale (Constant)] were also administered. RESULTS: Abduction and ER2 (external rotation with arm in abduction) were significantly greater in the ER group at T1, T2 and T3, ER1 (external rotation with arm at side) was significantly greater in the ER group at T1 and T2, IR2 (internal rotation) was significantly greater in the ER group at T1, and FFL (forward flexion) was significantly greater in the ER group at T1. VAS was significantly lower in the ER group at T1 and T2 and T3. About the Self-Assessment Shoulder Scales after 3 and 6 months, no differences were found. SST showed a lesser functional limitation for the ER group at T3. CONCLUSIONS: Patients operated with isolated superior or posterosuperior rotator cuff tear immobilised with brace in 15° of ER position showed less pain and a better passive range of motion at short time after surgery.

Does gait analysis change clinical decision-making in poststroke patients? Results from a pragmatic prospective observational study.

BACKGROUND: Gait analysis (GA) was demonstrated to change presurgical planning and improve gait outcomes in children with Cerebral Palsy. GA is often used also to assess walking capability of poststroke subjects, although its influence in the clinical management of these patients has not yet been established. OBJECTIVE: To assess the impact of GA on clinical decision-making in adult chronic poststroke patients. DESIGN: Pragmatic prospective observational study. SETTING: Rehabilitation hospital, both outpatients and inpatients. POPULATION: Forty-nine patients (age: 53.3±14.5 years) who had had a cerebrovascular accident 35.2±26.4 months before and were referred to the gait analysis service. METHODS: Recommendations of therapeutic treatments before and after the analysis of GA data were compared, together with the confidence level of recommendations on a 10-point scale. Frequency of changes of post-GA vs pre-GA recommendations were computed for each recommendation type: surgery, botulinum toxin (BT), orthotic management and physiotherapy. RESULTS: Based on the analysis of GA data, 71% of poststroke subjects had their treatment planning changed in some components. Indeed, 73% of patients with indications for surgery had their surgical planning changed; 81%, 37% and 32% had, respectively, their BT, orthotic and physiotherapy planning changed. Confidence level of recommendations increased significantly after GA, in both the whole group of patients (from 6.7±1.4 to 8.7±0.6, P<0.01) and the subgroup whose recommendations had not changed (7.0±1.5 vs. 8.8±0.4, P<0.01). CONCLUSION: GA significantly influences the therapeutic planning and reinforces decision-making for chronic poststroke patients. Further work should be done to better translate GA results into indications for specific physiotherapy. CLINICAL REHABILITATION IMPACT: The use of GA as a tool to better define the rehabilitation planning in post-stroke patients should be fostered, particularly when surgery or botulinum toxin are considered and/or the prescription of orthoses is hypothesised.

Etravirine plasma exposure is associated with virological efficacy in treatment-experienced HIV-positive patients.

Etravirine is a non-nucleoside reverse transcriptase inhibitor used in combination with other antiretrovirals for the treatment of HIV infection. Given previous conflicting results aim of this study was to investigate whether etravirine plasma exposure was associated with virological outcome. Adult HIV-positive patients starting etravirine with detectable HIV viral loads were included if highly adherent (<90% of the doses) and if steady-state plasma concentrations were available (measured through a validated HPLC-PDA method). Virological success was defined as reaching and maintaining viral suppression (HIV RNA <50copies/mL) during follow up. Fifty-nine (84.7% male) patients were included: baseline CD4+ T-lymphocyte and HIV RNA were 276cells/µL (101-419) and 3.99Log10copies/mL (3.11-4.91), respectively. Darunavir/ritonavir (n=21, 35.6%) and raltegravir plus maraviroc (n=33, 55.9%) were the most common associated antiretrovirals. 240 trough samples were available (3-7 per patient); etravirine trough concentrations (Ctrough) and weighted genotypic inhibitory quotients (wgIQ) were 426ng/mL (266-763) and 408ng/mL/mutation (227-663), respectively. Virological success was observed in 49 patients (83.1%). Genotypic sensitivity of associated drugs (GSS) ⩾2 (p=0.03), etravirine Ctrough >300ng/mL (p=0.02) and etravirine wgIQ >276ng/mL/mutation (p=0.02) were associated with virological success; at multivariate Cox proportional analysis etravirine wgIQ <276ng/mL/mutation (p=0.012) and baseline CD4 <200cell/µL (p=0.043) were independently associated with virological failure. In a cohort of experienced patients etravirine exposure as well as immune status were associated with virological success; two cut off values (300ng/mL and 276ng/mL) were proposed for etravirine Ctrough and wgIQ and need to be confirmed in prospective studies.

Destructive septic arthritis of shoulder in adults.

BACKGROUND: Late sequelae of septic arthritis of the glenohumeral joint are very rare and represent a potentially devastating condition that can result in irreversible changes at the level of joint and surrounding soft tissues. MATERIALS AND METHODS: Between January 2001 and December 2010, ten patients were treated at our institution for late sequelae of septic arthritis of the shoulder. There were eight men and two women with a mean age of 67.9 years (range 62-74 years). Eight of ten patients had previously received three or more intra-articular or subacromial injections. Surgical treatment consisted of open joint debridement, humeral head resection and implantation of an antibiotic spacer followed by a 6-8-week course of intravenous antibiotics. RESULTS: White blood cell count, C-reactive protein and erythrocyte sedimentation rate normalized between 6 and 8 weeks postoperatively in all patients. No recurrent infection was observed in any patient. Postoperatively, the mean Constant score was 37 (range 28-46) and mean DASH score was 54 (range 40-69), demonstrating a very limited function in these patients. There was a trend toward improved outcome scores in patients who underwent early surgical debridement. Five patients underwent delayed reconstruction with a reverse shoulder prosthesis, and at minimum 1-year follow-up, the mean Constant score was 56 (range 47-69) and mean DASH score was 33 (31-38). CONCLUSIONS: Antibiotic spacers are able to deliver antibiotics locally to the infected tissue while reducing the dead space and stabilizing the glenohumeral joint. An early, aggressive management of the infection is essential to maximize clinical outcomes and avoid either significant destruction or ankylosis of the shoulder joint.

Irreparable rotator cuff tears: a novel classification system.

BACKGROUND: Irreparable rotator cuff tears can be managed by several approaches. However, current tear classifications fail to reflect the wide variety of their presentation, which has important clinical and prognostic implications. METHODS: We describe a novel classification system based on preoperative imaging findings and intraoperative observation where each cuff tendon (numbered sequentially: 1-supraspinatus, 2-infraspinatus, 3-teres minor, and 4-subscapularis) is assessed intraoperatively for reducibility to the footprint; tendons with reparable lesions are assessed for fatty degeneration (which predicts healing potential) and given a plus if degeneration is <50 % (Fuchs stage I-II/Goutallier stage 0-II) or a minus if it is ≥50 % (Fuchs stage III/Goutallier stage III-IV). RESULTS: The proposed system (1) allows more consistent and reproducible classification of cuff tears where at least one tendon is irreparable; (2) results in more accurate diagnosis; (3) guides in treatment selection; and (4) ensures better outcomes and realistic patient expectations. CONCLUSIONS: The novel classification system can contribute to develop increasingly exhaustive and reproducible classification models.

The incidence of AIDS-defining illnesses at a current CD4 count ≥ 200 cells/µL in the post-combination antiretroviral therapy era.

BACKGROUND: Few studies consider the incidence of individual AIDS-defining illnesses (ADIs) at higher CD4 counts, relevant on a population level for monitoring and resource allocation. METHODS: Individuals from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) aged ≥14 years with ≥1 CD4 count of ≥200 µL between 1998 and 2010 were included. Incidence rates (per 1000 person-years of follow-up [PYFU]) were calculated for each ADI within different CD4 strata; Poisson regression, using generalized estimating equations and robust standard errors, was used to model rates of ADIs with current CD4 ≥500/µL. RESULTS: A total of 12 135 ADIs occurred at a CD4 count of ≥200 cells/µL among 207 539 persons with 1 154 803 PYFU. Incidence rates declined from 20.5 per 1000 PYFU (95% confidence interval [CI], 20.0-21.1 per 1000 PYFU) with current CD4 200-349 cells/µL to 4.1 per 1000 PYFU (95% CI, 3.6-4.6 per 1000 PYFU) with current CD4 ≥ 1000 cells/µL. Persons with a current CD4 of 500-749 cells/µL had a significantly higher rate of ADIs (adjusted incidence rate ratio [aIRR], 1.20; 95% CI, 1.10-1.32), whereas those with a current CD4 of ≥1000 cells/µL had a similar rate (aIRR, 0.92; 95% CI, .79-1.07), compared to a current CD4 of 750-999 cells/µL. Results were consistent in persons with high or low viral load. Findings were stronger for malignant ADIs (aIRR, 1.52; 95% CI, 1.25-1.86) than for nonmalignant ADIs (aIRR, 1.12; 95% CI, 1.01-1.25), comparing persons with a current CD4 of 500-749 cells/µL to 750-999 cells/µL. DISCUSSION: The incidence of ADIs was higher in individuals with a current CD4 count of 500-749 cells/µL compared to those with a CD4 count of 750-999 cells/µL, but did not decrease further at higher CD4 counts. Results were similar in patients virologically suppressed on combination antiretroviral therapy, suggesting that immune reconstitution is not complete until the CD4 increases to >750 cells/µL.