The katanin A-subunits KATNA1 and KATNAL1 act co-operatively in mammalian meiosis and spermiogenesis to achieve male fertility.

Katanins, a class of microtubule-severing enzymes, are potent M-phase regulators in oocytes and somatic cells. How the complex and evolutionarily crucial, male mammalian meiotic spindle is sculpted remains unknown. Here, using multiple single and double gene knockout mice, we reveal that the canonical katanin A-subunit KATNA1 and its close paralogue KATNAL1 together execute multiple aspects of meiosis. We show KATNA1 and KATNAL1 collectively regulate the male meiotic spindle, cytokinesis and midbody abscission, in addition to diverse spermatid remodelling events, including Golgi organisation, and acrosome and manchette formation. We also define KATNAL1-specific roles in sperm flagellum development, manchette regulation and sperm-epithelial disengagement. Finally, using proteomic approaches, we define the KATNA1, KATNAL1 and KATNB1 mammalian testis interactome, which includes a network of cytoskeletal and vesicle trafficking proteins. Collectively, we reveal that the presence of multiple katanin A-subunit paralogs in mammalian spermatogenesis allows for 'customised cutting' via neofunctionalisation and protective buffering via gene redundancy.

Incubation of palatable food craving is associated with brain-wide neuronal activation in mice.

Studies using rodent models have shown that relapse to drug or food seeking increases progressively during abstinence, a behavioral phenomenon termed "incubation of craving." Mechanistic studies of incubation of craving have focused on specific neurobiological targets within preselected brain areas. Recent methodological advances in whole-brain immunohistochemistry, clearing, and imaging now allow unbiased brain-wide cellular resolution mapping of regions and circuits engaged during learned behaviors. However, these whole-brain imaging approaches were developed for mouse brains, while incubation of drug craving has primarily been studied in rats, and incubation of food craving has not been demonstrated in mice. Here, we established a mouse model of incubation of palatable food craving and examined food reward seeking after 1, 15, and 60 abstinence days. We then used the neuronal activity marker Fos with intact-brain mapping procedures to identify corresponding patterns of brain-wide activation. Relapse to food seeking was significantly higher after 60 abstinence days than after 1 or 15 days. Using unbiased ClearMap analysis, we identified increased activation of multiple brain regions, particularly corticostriatal structures, following 60 but not 1 or 15 abstinence days. We used orthogonal SMART2 analysis to confirm these findings within corticostriatal and thalamocortical subvolumes and applied expert-guided registration to investigate subdivision and layer-specific activation patterns. Overall, we 1) identified brain-wide activity patterns during incubation of food seeking using complementary analytical approaches and 2) provide a single-cell resolution whole-brain atlas that can be used to identify functional networks and global architecture underlying the incubation of food craving.

Enterovirus-Cardiomyocyte Interactions: Impact of Terminally Deleted Genomic RNAs on Viral and Host Functions.

Group B enteroviruses, including coxsackievirus B3 (CVB3), can persistently infect cardiac tissue and cause dilated cardiomyopathy. Persistence is linked to 5' terminal deletions of viral genomic RNAs that have been detected together with minor populations of full-length genomes in human infections. In this study, we explored the functions and interactions of the different viral RNA forms found in persistently infected patients and their putative role(s) in pathogenesis. Since enterovirus cardiac pathogenesis is linked to the viral proteinase 2A, we investigated the effect of different terminal genomic RNA deletions on 2A activity. We discovered that 5' terminal deletions in CVB3 genomic RNAs decreased the levels of 2A proteinase activity but could not abrogate it. Using newly generated viral reporters encoding nano-luciferase, we found that 5' terminal deletions resulted in decreased levels of viral protein and RNA synthesis in singly transfected cardiomyocyte cultures. Unexpectedly, when full-length and terminally deleted forms were cotransfected into cardiomyocytes, a cooperative interaction was observed, leading to increased viral RNA and protein production. However, when viral infections were carried out in cells harboring 5' terminally deleted CVB3 RNAs, a decrease in infectious particle production was observed. Our results provide a possible explanation for the necessity of full-length viral genomes during persistent infection, as they would stimulate efficient viral replication compared to that of the deleted genomes alone. To avoid high levels of viral particle production that would trigger cellular immune activation and host cell death, the terminally deleted RNA forms act to limit the production of viral particles, possibly as trans-dominant inhibitors. IMPORTANCE Enteroviruses like coxsackievirus B3 are able to initiate acute infections of cardiac tissue and, in some cases, to establish a long-term persistent infection that can lead to serious disease sequelae, including dilated cardiomyopathy. Previous studies have demonstrated the presence of 5' terminally deleted forms of enterovirus RNAs in heart tissues derived from patients with dilated cardiomyopathy. These deleted RNAs are found in association with very low levels of full-length enterovirus genomic RNAs, an interaction that may facilitate continued persistence while limiting virus particle production. Even in the absence of detectable infectious virus particle production, these deleted viral RNA forms express viral proteinases at levels capable of causing viral pathology. Our studies provide mechanistic insights into how full-length and deleted forms of enterovirus RNA cooperate to stimulate viral protein and RNA synthesis without stimulating infectious viral particle production. They also highlight the importance of targeting enteroviral proteinases to inhibit viral replication while at the same time limiting the long-term pathologies they trigger.

Investigating Steric and Electronic Effects in the Synthesis of Square Planar 6d1 Th(III) Complexes.

The factors affecting the formation and crystal structures of unusual 6d1 Th(III) square planar aryloxide complexes, as exemplified by [Th(OArMe)4]1- (OArMe = OC6H2tBu2-2,6-Me-4), were explored by synthetic and reduction studies of a series of related Th(IV) tetrakis(aryloxide) complexes, Th(OArR)4 (OArR = OC6H2tBu2-2,6-R-4). Specifically, electronic, steric, and countercation effects were explored by varying the aryloxide ligand, the alkali metal reducing agent, and the alkali metal chelating agent. Salt metathesis reactions between ThBr4(DME)2 (DME = 1,2-dimethoxyethane) and 4 equiv of the appropriate potassium aryloxide salt were used to prepare a series of Th(IV) aryloxide complexes in high yields: Th(OArH)4 (OArH = OC6H3tBu2-2,6), Th(OArtBu)4 (OArtBu = OC6H2tBu3-2,4,6), Th(OArOMe)4 (OArOMe = OC6H2tBu2-2,6-OMe-4), and Th(OArPh)4 (OArPh = OC6H2tBu2-2,6-Ph-4). Th(OArH)4 can be reduced by KC8, Na, or Li in the absence or presence of 2.2.2-cryptand (crypt) or 18-crown-6 (crown) to form dark purple solutions that have EPR and UV-visible spectra similar to those of the square planar Th(III) complex, [Th(OArMe)4]1-. Hence, the para position of the aryloxide ligand does not have to be alkylated to obtain the Th(III) complexes. Furthermore, reduction of Th(OArOMe)4, Th(OArtBu)4, and Th(OArPh)4 with KC8 in THF generated purple solutions with EPR and UV-visible spectra that are similar to those of the previously reported Th(III) anion, [Th(OArMe)4]1-. Although many of these reduction reactions did not produce single crystals suitable for study by X-ray diffraction, reduction of Th(OArH)4, Th(OArtBu)4, and Th(OArOMe)4 with Li provided X-ray quality crystals whose structures had square planar coordination geometries. Reduction of Th(OArPh)4 with Li also gave a product with EPR and UV-visible spectra that matched those of [Th(OArMe)4]1-, but X-ray quality crystals of the reduction product were too unstable to provide data. Neither Th(Odipp)4(THF)2 (Odipp = OC6H3iPr2-2,6) nor Th(Odmp)4(THF)2 (Odmp = OC6H3Me2-2,6) could be reduced to Th(III) products under similar conditions. Reduction of U(OArH)3(THF) with KC8 in the presence of 2.2.2-cryptand (crypt) was examined for comparison and formed [K(crypt)][U(OArH)4], which has a tetrahedral arrangement of the aryloxide ligands. Moreover, no further reduction was observed when either [K(crypt)][U(OArH)4] or [K(crown)(THF)2][U(OArH)4] were treated with KC8 or Li.

Robotic-arm-assisted lateral unicompartmental knee arthroplasty leads to high implant survival and patient satisfaction at mean 10-year follow-up.

BACKGROUND: There is a lack of literature reporting on long-term outcomes following robotic-arm-assisted lateral unicompartmental knee arthroplasty (UKA). This study assessed the long-term survivorship, patient-reported satisfaction and pain scores following robotic-arm-assisted lateral UKA for lateral compartment osteoarthritis (OA). METHODS: A single surgeon's database was reviewed to identify all patients who underwent robotic-arm-assisted lateral UKA with a cemented, fixed-bearing prosthesis prior to May 2015. Patients were contacted to determine implant survivorship, satisfaction and pain. Kaplan-Meier models were applied to analyse survival. RESULTS: A total of 77 knees (70 patients) with a mean follow-up of 10.2 ± 1.5 years (range: 8.1-13.3) were included. Five knees were revised, corresponding to a 10-year survivorship of 96.1% and estimated survival time of 12.7 ± 0.3 years (95% confidence interval: 12.2-13.2) with all-cause revision as the endpoint. Unexplained pain (40.0%) and progression of OA (40.0%) in contralateral compartments were the most reported reasons for revision. Among patients without revision, 94.4% were either satisfied or very satisfied with their lateral UKA and the average pain score was 1.1. CONCLUSION: Robotic-arm-assisted lateral UKA led to high implant survivorship and patient satisfaction, and low pain scores at long-term follow-up. Progression of OA in contralateral compartments and unexplained pain were the most frequent reasons for revision. These findings support the continued use of robotic-arm-assisted lateral UKA for lateral compartment OA; however, its clinical value over conventional techniques remains to be established in prospective comparative studies. LEVEL OF EVIDENCE: Therapeutic Level IV.

A Consecutive Series of Vancouver B2 Periprosthetic Femur Fractures Treated With Contemporary Monoblock Versus Modular Revision Stems: Clinical and Radiographic Outcomes.

BACKGROUND: Tapered fluted titanium (TFT) stems are the implant design of choice for managing Vancouver B2 periprosthetic femur fractures (PFFs), producing reliable results over the past few decades. The aim of this study was to compare the radiographic and clinical outcomes of Vancouver B2 PFFs treated with contemporary monoblock versus modular TFTs. METHODS: A consecutive series of 113 patients (72 women, 64%, mean age 70 years [range, 26 to 96]) who had a B2 PFF were treated with either a monoblock (n = 42) or modular (n = 71) TFT stem between 2008 and 2021. The mean body mass index was 30 ± 7. The mean follow-up was 2.9 years. A radiographic review was performed to assess leg length and offset restoration, endosteal cortical contact length, and stem subsidence. Kaplan-Meier analyses were used to determine survivorship without revision, reoperation, or dislocation. RESULTS: There was no difference in the restoration of leg length (0.3 ± 8.0 mm) or offset (2.8 ± 8.2 mm) between the monoblock and modular cohorts (P > .05). Mean endosteal cortical contact length (47.2 ± 26.6 versus 46.7 ± 2 6.4 mm, P = .89) and stem subsidence (2.7 ± 3.5 versus 2.4 ± 3.2 mm, P = .66) did not differ. No difference in patient-reported outcome measures (Hip Disability and Osteoarthritis Outcome Score-Joint Replacement; Veterans RAND 12 Item Health Survey Physical and Mental; visual analog score; and Lower Extremity Activity Scale) between the groups was observed. Survivorship at 2 years free from reoperation, revision, and dislocation was 90.4, 90.3, and 97.6%, respectively, for the monoblock cohort; and 84.0, 86.9, and 90.0%, respectively, for the modular cohort. CONCLUSIONS: No significant differences in radiographic or clinical outcomes were observed between patients treated with monoblock or modular TFTs in this large series of B2 PFFs.

DDB1- and CUL4-associated factor 12-like protein 1 (Dcaf12l1) is not essential for male fertility in mice.

Male infertility is a common condition affecting at least 7% of men worldwide and is often genetic in origin. Using whole exome sequencing, we recently discovered three hemizygous, likely damaging variants in DDB1- and CUL4-associated factor 12-like protein 1 (DCAF12L1) in men with azoospermia. DCAF12L1 is located on the X-chromosome and as identified by single cell sequencing studies, its expression is enriched in human testes and specifically in Sertoli cells and spermatogonia. However, very little is known about the role of DCAF12L1 in spermatogenesis, thus we generated a knockout mouse model to further explore the role of DCAF12L1 in male fertility. Knockout mice were generated using CRISPR/Cas9 technology to remove the entire coding region of Dcaf12l1 and were assessed for fertility over a broad range of ages (2-8 months of age). Despite outstanding genetic evidence in men, loss of DCAF12L1 had no discernible impact on male fertility in mice, as highlighted by breeding trials, histological assessment of the testis and epididymis, daily sperm production and evaluation of sperm motility using computer assisted methods. This disparity is likely due to the parallel evolution, and subsequent divergence, of DCAF12 family members in mice and men or the presence of compounding environmental factors in men.

Acute Kidney Injury and Mortality After Fenestrated Endovascular Aortic Repair.

INTRODUCTION: Acute kidney injury (AKI) is a common complication following endovascular aortic repair (EVAR). An association of AKI with patient survival after fenestrated EVAR (FEVAR) is currently under investigation. METHODS: Patients undergoing FEVAR between April 2013 and June 2020 were included in the study. AKI was defined according to acute kidney injury network criteria. Demographic and perioperative data, complications, and survival are reported for the study cohort. The data were analyzed to identify possible predictors of AKI. RESULTS: Two hundred and seventeen patients underwent FEVAR during the study period. Survival at last follow-up (20.4 ± 20.1 mo) was 75.1%. Thirty patients experienced AKI (13.8%). Six of 30 patients with AKI (20%) died within 30 days or in-hospital and 1 (3.3%) progressed to hemodialysis. Within 1 y, renal function had recovered in 23 patients (76.7%). In-hospital mortality was higher in patients with AKI (20% versus 4.3%, P = 0.006). A higher rate of AKI was seen in patients in whom an intraoperative technical complication had been documented (38.5% versus 8.4%, P = 0.001). CONCLUSIONS: Patients undergoing FEVAR are at risk of developing AKI, especially if they experience technical intraoperative complications. Most patients see recovery of renal function within the first 30 days to 1 y, but AKI remains associated with significantly increased in-hospital mortality.

The effector mechanism of siRNA spherical nucleic acids.

Spherical nucleic acids (SNAs) are nanostructures formed by chemically conjugating short linear strands of oligonucleotides to a nanoparticle template. When made with modified small interfering RNA (siRNA) duplexes, SNAs act as single-entity transfection and gene silencing agents and have been used as lead therapeutic constructs in several disease models. However, the manner in which modified siRNA duplex strands that comprise the SNA lead to gene silencing is not understood. Herein, a systematic analysis of siRNA biochemistry involving SNAs shows that Dicer cleaves the modified siRNA duplex from the surface of the nanoparticle, and the liberated siRNA subsequently functions in a way that is dependent on the canonical RNA interference mechanism. By leveraging this understanding, a class of SNAs was chemically designed which increases the siRNA content by an order of magnitude through covalent attachment of each strand of the duplex. As a consequence of increased nucleic acid content, this nanostructure architecture exhibits less cell cytotoxicity than conventional SNAs without a decrease in siRNA activity.

Rapid lumbar MRI protocol using 3D imaging and deep learning reconstruction.

BACKGROUND AND PURPOSE: Three-dimensional (3D) imaging of the spine, augmented with AI-enabled image enhancement and denoising, has the potential to reduce imaging times without compromising image quality or diagnostic performance. This work evaluates the time savings afforded by a novel, rapid lumbar spine MRI protocol as well as image quality and diagnostic differences stemming from the use of an AI-enhanced 3D T2 sequence combined with a single Dixon acquisition. MATERIALS AND METHODS: Thirty-five subjects underwent MRI using standard 2D lumbar imaging in addition to a "rapid protocol" consisting of 3D imaging, enhanced and denoised using a prototype DL reconstruction algorithm as well as a two-point Dixon sequence. Images were graded by subspecialized radiologists and imaging times were collected. Comparison was made between 2D sagittal T1 and Dixon fat images for neural foraminal stenosis, intraosseous lesions, and fracture detection. RESULTS: This study demonstrated a 54% reduction in total acquisition time of a 3D AI-enhanced imaging lumbar spine MRI rapid protocol combined with a sagittal 2D Dixon sequence, compared to a 2D standard-of-care protocol. The rapid protocol also demonstrated strong agreement with the standard-of-care protocol with respect to osseous lesions (κ = 0.88), fracture detection (κ = 0.96), and neural foraminal stenosis (ICC > 0.9 at all levels). CONCLUSION: 3D imaging of the lumbar spine with AI-enhanced DL reconstruction and Dixon imaging demonstrated a significant reduction in imaging time with similar performance for common diagnostic metrics. Although previously limited by long postprocessing times, this technique has the potential to enhance patient throughput in busy radiology practices while providing similar or improved image quality.

Thematic and Demographic Analysis of Crowdsourcing Practices for Plastic Surgery.

BACKGROUND: In this study, we investigate the characterization of medical crowdsourcing on GoFundMe for plastic surgery procedures, with overall funds raised being the primary end point. HYPOTHESIS: Certain demographic factors such as sex and race mentioned in campaign narratives are associated with the effectiveness of medical crowdfunding campaigns. METHODS: Search terms were used to aggregate fundraising campaigns for plastic surgery medical procedures on GoFundMe. These studies were then stratified by demographics based on campaign text or author consensus, and were further subdivided into categories based on procedure type. RESULTS: Men were found to have higher median shares than women-raising an average of $609 more than female counterparts ( P < 0.05). Fundraising for themes such as lack of insurance, travel costs, lifesaving treatment, and end-of-life expenses were more successful than the theme of psychosocial effects of disease or social impairment. In addition, those that included a smiling picture of the recipient and those created by a friend/relative raised more funds. Although no significant difference was found in fundraising between demographics based on race, a majority (72.8%) of campaigners were White. Across ~2000 plastic surgery campaigns, a total of $10,186,687 were raised from these data. CONCLUSIONS: We identified both modifiable and nonmodifiable factors that influence success. These successful campaigns can serve as a learning opportunity for many who have been marginalized by the medical and pharmaceutical industry, and they demonstrate a promising area for demographic studies.

Proximal bone block with distal screw trajectory improves mechanical stability during distalization tibial tubercle osteotomy.

PURPOSE: The purpose of this study was to quantify differences in mechanical stability of a wedge-shaped distalization tibial tubercle osteotomy (TTO) with a standard technique, versus a modified technique with use of a proximal bone block and distally angled screw trajectory. METHODS: Ten fresh-frozen cadaver lower extremity specimens (five matched pairs) were utilized. Within each specimen pair, one specimen was randomly assigned to undergo a standard distalization osteotomy fixed with two bicortical 4.5-mm screws oriented perpendicular to the long axis of the tibia, and the other to undergo a distalization osteotomy with modified fixation utilizing a proximal bone block and distally angled screw trajectory. Each specimen's patella and tibia were mounted on a servo-hydraulic load frame using custom fixtures (MTS Instron). The patellar tendon was dynamically loaded to 400 N at a rate of 200 N/second for 500 cycles. Following the cyclic loading, loading to failure was done at 25 mm/min. RESULTS: The modified distalization TTO technique demonstrated significantly higher average load to failure compared to the standard distalization TTO technique (1339 N vs. 844.1 N, p < 0.001). Average maximum tibial tubercle displacement during cyclic loading was significantly smaller in the modified TTO technique group compared to the standard TTO technique (1.1 mm vs. 4.7 mm, p < 0.001). CONCLUSION: This study demonstrates that distalization TTO utilizing a modified technique with a proximal bone block and distally aimed screws is biomechanically superior to standard distalization TTO without proximal bone block and screw trajectory perpendicular to the long axis of the tibia. This increased stability may aid in reducing the reported higher complication rates (including loss of fixation, delayed union and nonunion) following distalization TTO, although future clinical outcome studies are warranted.

The Risk Assessment and Prediction Tool (RAPT) Score Predicts Discharge Destination, Length of Stay, and Postoperative Mobility After Total Joint Arthroplasty.

BACKGROUND: Predicting an arthroplasty patient's discharge disposition, length of stay (LOS), and physical function is helpful because it allows for preoperative patient optimization, expectation management, and discharge planning. The goal of this study was to evaluate the ability of the Risk Assessment and Prediction Tool (RAPT) score to predict discharge destination, LOS, and postoperative mobility in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: Primary unilateral TKAs (n = 9,064) and THAs (n = 8,649) performed for primary osteoarthritis at our institution from 2018 to 2021 (excluding March to June 2020) were identified using a prospectively maintained institutional registry. We evaluated the associations between preoperative RAPT score and (1) discharge destination, (2) LOS, and postoperative mobility as measured by (3) successful ambulation on the day of surgery and (4) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score. RESULTS: On multivariable analyses adjusting for multiple covariates, every one-point increase in RAPT score among TKA patients was associated with a 1.82-fold increased odds of home discharge (P < .001), 0.22 days shorter LOS (P < .001), 1.13-fold increased odds of ambulating on postoperative day 0 (P < .001), and 0.25-point higher Activity Measure for Post-Acute Care score (P < .001). Similar findings were seen among THAs. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict home discharge. CONCLUSION: Among nearly 18,000 TKA and THA patients, RAPT score was predictive of discharge disposition, LOS, and postoperative mobility. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict discharge to home. In contrast to prior studies of the RAPT score which have grouped TKAs and THAs together, this study ran separate analyses for TKAs and THAs and found that THA patients seemed to perform better than TKA patients with equal RAPT scores, suggesting that RAPT may behave differently between TKAs and THAs, particularly in the intermediate risk RAPT range.

Exploring Correlations Between Pain and Deformity in Idiopathic Scoliosis With Validated Self-reported Pain Scores, Radiographic Measurements, and Trunk Surface Topographic Measurements.

BACKGROUND: Up to 75% of patients with idiopathic scoliosis (IS) report back pain, but the exact contributors are unclear. This study seeks to assess how pain correlates with demographics, radiographic and surface topographic (ST) measurements, and patient-reported outcome measures (PROMs) in patients with IS. METHODS: Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference (PI) and Scoliosis Research Society revised (SRS-22r) pain domain from an IRB approved prospectively collected registry containing patients 11 to 21 years old with IS were correlated (Spearman coefficients) with measurements from whole-body EOS radiography and ST scanning, PROMIS 1.0 PROMs, Trunk Appearance Perception Scale (TAPS), and SRS-22r domains. SRS-22r and PROMIS-PI were also compared between different sex, scoliosis severities, and primary curve locations with Mann-Whitney U or Kruskal-Wallis tests, and if significant differences were found, included with the 5 highest univariate correlated variables into stepwise multivariate linear regression models ( P <0.05 to enter, P >0.1 to remove) predicting SRS-22r pain and PROMIS-PI. RESULTS: One hundred and forty-nine patients (14.5 ± 2.0 y, body mass index 20.6 ± 4.1 kg/m 2 , 96 (64%) female, mean major coronal curve 40 ± 19 deg, range: 10 deg, 83 deg) reported mean PROMIS-PI of 42.2 ± 10.0 and SRS-22r pain of 4.4 ± 0.6. SRS-22r self-image was the most correlated variable with both SRS-22r pain (rho=0.519) and PROMIS-PI (rho=-0.594). Five variables, none of which were ST or radiographic measures, strongly predicted SRS pain domain (R=0.711, R2=0.505, N=138). Two variables (SRS-22r self-image and SRS-22r function) were utilized by a model correlated with PROMIS-PI (R=0.687, R2=0.463, N=124). CONCLUSIONS: SRS-22r function and self-image domains were more strongly correlated with SRS-22r pain and PROMIS-PI than any radiographic or ST measurements. LEVEL OF EVIDENCE: Level II-retrospective study.

Evaluation of deep learning reconstructed high-resolution 3D lumbar spine MRI.

OBJECTIVES: To compare interobserver agreement and image quality of 3D T2-weighted fast spin echo (T2w-FSE) L-spine MRI images processed with a deep learning reconstruction (DLRecon) against standard-of-care (SOC) reconstruction, as well as against 2D T2w-FSE images. The hypothesis was that DLRecon 3D T2w-FSE would afford improved image quality and similar interobserver agreement compared to both SOC 3D and 2D T2w-FSE. METHODS: Under IRB approval, patients who underwent routine 3-T lumbar spine (L-spine) MRI from August 17 to September 17, 2020, with both isotropic 3D and 2D T2w-FSE sequences, were retrospectively included. A DLRecon algorithm, with denoising and sharpening properties was applied to SOC 3D k-space to generate 3D DLRecon images. Four musculoskeletal radiologists blinded to reconstruction status evaluated randomized images for motion artifact, image quality, central/foraminal stenosis, disc degeneration, annular fissure, disc herniation, and presence of facet joint cysts. Inter-rater agreement for each graded variable was evaluated using Conger's kappa (κ). RESULTS: Thirty-five patients (mean age 58 ± 19, 26 female) were evaluated. 3D DLRecon demonstrated statistically significant higher median image quality score (2.0/2) when compared to SOC 3D (1.0/2, p < 0.001), 2D axial (1.0/2, p < 0.001), and 2D sagittal sequences (1.0/2, p value < 0.001). κ ranges (and 95% CI) for foraminal stenosis were 0.55-0.76 (0.32-0.86) for 3D DLRecon, 0.56-0.73 (0.35-0.84) for SOC 3D, and 0.58-0.71 (0.33-0.84) for 2D. Mean κ (and 95% CI) for central stenosis at L4-5 were 0.98 (0.96-0.99), 0.97 (0.95-0.99), and 0.98 (0.96-0.99) for 3D DLRecon, 3D SOC and 2D, respectively. CONCLUSIONS: DLRecon 3D T2w-FSE L-spine MRI demonstrated higher image quality and similar interobserver agreement for graded variables of interest when compared to 3D SOC and 2D imaging. KEY POINTS: • 3D DLRecon T2w-FSE isotropic lumbar spine MRI provides improved image quality when compared to 2D MRI, with similar interobserver agreement for clinical evaluation of pathology. • 3D DLRecon images demonstrated better image quality score (2.0/2) when compared to standard-of-care (SOC) 3D (1.0/2), p value < 0.001; 2D axial (1.0/2), p value < 0.001; and 2D sagittal sequences (1.0/2), p value < 0.001. • Interobserver agreement for major variables of interest was similar among all sequences and reconstruction types. For foraminal stenosis, κ ranged from 0.55 to 0.76 (95% CI 0.32-0.86) for 3D DLRecon, 0.56-0.73 (95% CI 0.35-0.84) for standard-of-care (SOC) 3D, and 0.58-0.71 (95% CI 0.33-0.84) for 2D.

Structure of the PCBP2/stem-loop IV complex underlying translation initiation mediated by the poliovirus type I IRES.

The poliovirus type I IRES is able to recruit ribosomal machinery only in the presence of host factor PCBP2 that binds to stem-loop IV of the IRES. When PCBP2 is cleaved in its linker region by viral proteinase 3CD, translation initiation ceases allowing the next stage of replication to commence. Here, we investigate the interaction of PCBP2 with the apical region of stem-loop IV (SLIVm) of poliovirus RNA in its full-length and truncated form. CryoEM structure reconstruction of the full-length PCBP2 in complex with SLIVm solved to 6.1 Å resolution reveals a compact globular complex of PCBP2 interacting with the cruciform RNA via KH domains and featuring a prominent GNRA tetraloop. SEC-SAXS, SHAPE and hydroxyl-radical cleavage establish that PCBP2 stabilizes the SLIVm structure, but upon cleavage in the linker domain the complex becomes more flexible and base accessible. Limited proteolysis and REMSA demonstrate the accessibility of the linker region in the PCBP2/SLIVm complex and consequent loss of affinity of PCBP2 for the SLIVm upon cleavage. Together this study sheds light on the structural features of the PCBP2/SLIV complex vital for ribosomal docking, and the way in which this key functional interaction is regulated following translation of the poliovirus genome.

The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study.

INTRODUCTION: Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients. METHODS: This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs. RESULTS: A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score. CONCLUSIONS: The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

A wake-like state in vitro induced by transmembrane TNF/soluble TNF receptor reverse signaling.

Tumor necrosis factor alpha (TNF) has sleep regulatory and brain development roles. TNF promotes sleep in vivo and in vitro while TNF inhibition diminishes sleep. Transmembrane (tm) TNF and the tmTNF receptors (Rs), are cleaved by tumor necrosis factor alpha convertase to produce soluble (s) TNF and sTNFRs. Reverse signaling occurs in cells expressing tmTNF upon sTNFR binding. sTNFR administration in vivo inhibits sleep, thus we hypothesized that a wake-like state in vitro would be induced by sTNFR-tmTNF reverse signaling. Somatosensory cortical neuron/glia co-cultures derived from male and female mice lacking both TNFRs (TNFRKO), or lacking TNF (TNFKO) and wildtype (WT) mice were plated onto six-well multi-electrode arrays. Daily one-hour electrophysiological recordings were taken on culture days 4 through 14. sTNFR1 (0.0, 0.3, 3, 30, 60, and 120 ng/µL) was administered on day 14. A final one-hour recording was taken on day 15. Four measures were characterized that are also used to define sleep in vivo: action potentials (APs), burstiness index (BI), synchronization of electrical activity (SYN), and slow wave power (SWP; 0.25-3.75 Hz). Development rates of these emergent electrophysiological properties increased in cells from mice lacking TNF or both TNFRs compared to cells from WT mice. Decreased SWP, after the three lowest doses (0.3, 3 and 30 ng/µL) of the sTNFR1, indicate a wake-like state in cells from TNFRKO mice. A wake-like state was also induced after 3 ng/µl sTNFR1 treatment in cells from TNFKO mice, which express the TNFR1 ligand, lymphotoxin alpha. Cells from WT mice showed no treatment effects. Results are consistent with prior studies demonstrating involvement of TNF in brain development, TNF reverse signaling, and sleep regulation in vivo. Further, the current demonstration of sTNFR1 induction of a wake-like state in vitro is consistent with the idea that small neuronal/glial circuits manifest sleep- and wake-like states analogous to those occurring in vivo. Finally, that sTNF forward signaling enhances sleep while sTNFR1 reverse signaling enhances a wake-like state is consistent with other sTNF/tmTNF/sTNFR1 brain actions having opposing activities.

How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents?

BACKGROUND: Concerning levels of burnout have been reported among orthopaedic surgeons and residents. Defined as emotional exhaustion and depersonalization, physician burnout is associated with decreased productivity, increased medical errors, and increased risk of suicidal ideation. At the center of burnout research, person-centered approaches focusing on individual characteristics and coping strategies have largely been ineffective in solving this critical issue. They have failed to capture and address important institutional and organizational factors contributing to physician burnout. Similarly, little is known about the relationship between burnout and the working environments in which orthopaedic physicians practice, and on how orthopaedic surgeons at different career stages experience and perceive factors relevant to burnout. QUESTIONS/PURPOSES: (1) How does burnout differ among orthopaedic attending surgeons, fellows, and residents? (2) What specific areas of work life are problematic at each of these career stages? (3) What specific areas of work life correlate most strongly with burnout at each of these career stages? METHODS: Two hundred orthopaedic surgeons (residents, fellows, and attending physicians) at a single institution were invited to complete an electronic survey. Seventy-four percent (148 of 200) of them responded; specifically, 43 of 46 residents evenly distributed among training years, 18 of 36 fellows, and 87 of 118 attending physicians. Eighty-three percent (123 of 148) were men and 17% (25 of 148) were women. Two validated questionnaires were used. The Maslach Burnout Inventory was used to assess burnout, measuring emotional exhaustion and depersonalization. The Areas of Worklife Survey was used to measure congruency between participants and their work environment in six domains: workload, control, reward, community, fairness, and values. Participants were invited to openly share their experiences and suggest ways to improve burnout and specific work life domains. The main outcome measures were Maslach Burnout Inventory subdomains of emotional exhaustion and depersonalization, and Areas of Worklife Survey subdomains of workload, control, reward, community, fairness and values. We compared outcome measures of burnout and work life between groups. Simple linear regression models were used to report correlations between subscales. Stratified analyses were used to identify which group demonstrated higher correlations. All open comments were analyzed and coded to fully understand which areas of work life were problematic and how they were perceived in our population. RESULTS: Nine percent (7 of 80) of attending surgeons, 6% (1 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of depersonalization on the Maslach Burnout Inventory (p < 0.001). Mean depersonalization scores were higher (worse) in residents followed by attending surgeons, then fellows (10 ± 6, 5 ± 5, 4 ± 4 respectively; p < 0.001). Sixteen percent (13 of 80) of attending surgeons, 31% (5 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of emotional exhaustion (p = 0.07). Mean emotional exhaustion scores were highest (worse) in residents followed by attending surgeons then fellows (21 ± 12, 17 ± 10, 16 ± 14 respectively; p = 0.11). Workload was the most problematic work life area across all stages of orthopaedic career. Scores in the Areas of Worklife Survey were the lowest (worse) in the workload domain for all subgroups: residents (2.6 ± 0.4), fellows (3.0 ± 0.6), and attending surgeons (2.8 ± 0.7); p = 0.08. Five problematic work life categories were found through open comment analysis: workload, resources, interactions, environment, and self-care. Workload was similarly the most concerning to participants. Specific workload issues identified included administrative load (limited job control, excessive tasks and expectations), technology (electronic medical platform, email overload), workflow (operating room time, patient load distribution), and conflicts between personal, clinical, and academic roles. Overall, worsening emotional exhaustion and depersonalization were most strongly associated with increasing workload (r = - 0.50; p < 0.001; and r = - 0.32; p < 0.001, respectively) and decreasing job control (r = - 0.50; p < 0.001, and r = - 0.41; p < 0.001, respectively). Specifically, in residents, worsening emotional exhaustion and depersonalization most strongly correlated with increasing workload (r = - 0.65; p < 0.001; and r = - 0.53; p < 0.001, respectively) and decreasing job control (r = - 0.49; p = 0.001; and r = - 0.51; p = 0.001, respectively). In attending surgeons, worsening emotional exhaustion was most strongly correlated with increasing workload (r = - 0.50; p < 0.001), and decreasing job control (r = - 0.44; p < 0.001). Among attending surgeons, worsening depersonalization was only correlated with increasing workload (r = - 0.23; p = 0.04). Among orthopaedic fellows, worsening emotional exhaustion and depersonalization were most strongly correlated with decreasing sense of fairness (r = - 0.76; p = 0.001; and r = - 0.87; p < 0.001, respectively), and poorer sense of community (r = - 0.72; p = 0.002; and r = - 0.65; p = 0.01, respectively). CONCLUSIONS: We found higher levels of burnout among orthopaedic residents compared to attending surgeons and fellows. We detected strong distinct correlations between emotional exhaustion, depersonalization, and areas of work life across stages of orthopaedic career. Burnout was most strongly associated with workload and job control in orthopaedic residents and attending surgeons and with fairness and community in orthopaedic fellows. CLINICAL RELEVANCE: Institutions wishing to better understand burnout may use this approach to identify specific work life drivers of burnout, and determine possible interventions targeted to orthopaedic surgeons at each stage of career. Based on our institutional experience, leadership should investigate strategies to decrease workload by increasing administrative support and improving workflow; improve sense of autonomy by consulting physicians in decision-making; and seek to improve the sense of control in residents and sense of community in fellows.

Ultrasound of the distal biceps brachii tendon using four approaches: reproducibility and reader preference.

OBJECTIVES: To determine which sonographic appearance of the distal biceps brachii tendon (DBBT) is preferred by readers, and if images obtained by two different operators are reproducible. METHODS: We performed an IRB-approved prospective sonographic evaluation of the DBBT in 50 healthy elbows using four different approaches (anterior, lateral, medial, posterior) performed by two operators. Five musculoskeletal radiologists independently reviewed the images, and ranked the four approaches based on overall appearance of echogenicity of the tendon, visualized length, and visualization of the insertion. RESULTS: The medial approach was preferred in 79.6% of elbows, anterior in 17.6%, lateral in 2.8%, and the posterior approach was never preferred. The difference was statistically significant (P < 0.001). Kappa values for the five readers were 0.61 to 0.8 for choosing the images produced by the medial approach. CONCLUSION: The appearance of the DBBT using the medial approach is preferred by readers and is reproducible between different operators.