Measure What Matters: Single Assessment Numeric Evaluation (SANE) score As the Critical Measure for Shoulder Outcomes.

As healthcare continues to evolve transforming orthopedics from fee for service to a value-based, a system anchored in patient outcomes is challenged to gain widespread outcome adoption to demonstrate the value of care provided for shoulder conditions. This is in large part due to the administrative burden that current tools create for clinical implementation barriers that limit practical use, and thus leave most clinicians, administrators, payors, and patients without a measure of what matters most, 'Are patients improving?' Thus, we must ask ourselves how do we accurately and efficiently measure and report quality of care in a simple, reliable, and easily communicated manner? We propose that the Single Assessment Numeric Evaluation (SANE) score is the best solution to measure patient improvement and can be used universally for all shoulder conditions. The measure is simple, valid, reliable, sensitive to change, and has the lowest implementation barrier compared to all other outcome measures. We synthesized the available literature (11 studies) that demonstrate strong psychometrics comparable to legacy measures across over 4,000 patients with a wide range of shoulder conditions. Baseline SANE scores range 40-60% for most patients before treatment and at 1 year following therapy range 75-85% depending on the condition, similar to legacy scores like the ASES. Additionally, the SANE shows similar baseline and post care measures across conditions that can be used to guide clinical care (Table 1). This shows that the observed baseline and improvement scores can provide valuable patient assessment as well as in aggregate be used for quality improvement and other value based purposes. We strongly recommend for SANE score as the primary patient outcome measure for patients with all shoulder conditions given the value of measuring 'every patient's' progress and growing pressure to quantify patient outcomes.

The use of artificial intelligence and deep learning reconstruction in urological computed tomography: Dose reduction at ghost level.

Objective: The objective of the study is to demonstrate that with the use of artificial intelligence (AI) in computed tomography (CT), radiation doses of CT kidney-ureter-bladder (KUB) and CT urogram (CTU) can be reduced to less than that of X-ray KUB and CT KUB, respectively, while maintaining the good image quality. Materials and Methods: We reviewed all CT KUBs (n = 121) performed in September 2019 and all CTUs (n = 74) performed in December 2019 at our institution. The dose length product (DLP) of all CT KUBs and each individual phase of CTU were recorded. DLP of each scan done with new scanner (Canon Aquilion One Genesis with AiCE [CAOG]) which uses AI and deep learning reconstruction (DLR) were compared against traditional non-AI scanner (GE OPTIMA 660 [GEO-660]). We also compared DLPs of both scanners against the United Kingdom, National Diagnostic Reference Levels (NDRL) for CT. Results: One hundred and twenty-one patient's CT KUBs and 74 patient's CTUs were reviewed. For CT KUB group, the mean DLP of 81/121 scans done using AI/DLR scanner (CAOG) was 77.8 mGy cm (1.16 mSv), while the mean DLP of 40/121 CT KUB done with GEO-660 was 317.1 mGy cm (4.75 mSv). For CTU group, the mean DLP for 46/74 scans done using AI/DLR scanner (CAOG) was 401.9 mGy cm (6 mSv), compared to mean DLP of 1352.6 mGy cm (20.2 mSv) from GEO-660. Conclusion: We propose that CT scanners using AI/DLR method have the potential of reducing radiation doses of CT KUB and CTU to such an extent that it heralds the extinction of plain film XR KUB for follow-up of urinary tract stones. To the best of our knowledge, this is the first study comparing CT KUB and CTU doses from new scanners utilizing AI/DLR technology with traditional scanners using hybrid iterative reconstruction technology. Moreover, we have shown that this technology can markedly reduce the cumulative radiation burden in all urological patients undergoing CT examinations, whether this is CT KUB or CTU.

Tier-specific contextualised high-intensity running profiles in the English Premier League: more on-ball movement at the top.

The present study aimed to determine the physical-tactical profiles of elite football teams and individual players according to final league rankings. A total of 50 English Premier League matches (n = 100 match and 583 player observations) were analysed by coding the player's physical-tactical actions through synchronising tracking data and video. Final league rankings were categorised into Tiers: (A) 1st-5th ranking (n = 25), (B) 6th-10th ranking (n = 26), (C) 11th-15th ranking (n = 26), and (D) 16th-20th ranking (n = 23). One-way analyses of variance were used to compare match performances between different Tiers, and effect size (ES) was determined for the meaningfulness of the difference. Tier A teams covered 39-51% more high-intensity distance for 'Move to Receive/Exploit Space' (ES: 1.3-1.6, P < 0.01) and 'Run with Ball' (ES: 0.9-1.0, P < 0.05) than Tier C and D, and 23-94% more distance for 'Over/Underlap' (ES: 1.0, P < 0.01), 'Run in Behind/Penetrate' (ES: 0.7, P < 0.05), and 'Break into Box' (ES: 0.9, P < 0.05) compared to Tier C. Central and Wide Defensive Players in Tier A covered 65-551% more high-intensity 'Move to Receive/Exploit Space' distance compared to other Tiers (ES: 0.6-1.0, P < 0.01). Moreover, the additional options within the physical-tactical actions and zonal differences unveiled more meaningful insights into 'HOW' the top Tier teams physically and tactically perform. Thus, the amalgamated physical-tactical data help improve our understanding of a team's playing style relative to their competitive standard.

Contextualised high-intensity running profiles of elite football players with reference to general and specialised tactical roles.

The present study aimed to contextualise physical metrics with tactical actions according to general and specialised tactical roles. A total of 244 English Premier League players were analysed by coding player's physical-tactical actions via the fusion of tracking data and video. Data were analysed across 5 general (Central Defensive Players = CDP, Wide Defensive Players = WDP, Central Midfield Players = CMP, Wide Offensive Players = WOP, Central Offensive Players = COP) and 11 specialised positions (Centre Backs = CB, Full-Backs = FB, Wing-Backs = WB, Box-to-Box Midfielders = B2BM, Central Defensive Midfielders = CDM, Central Attacking Midfielders = CAM, Wide Midfielders = WM, Wide Forwards = WF, Centre Forwards = CF). COP covered more distance at high-intensity (> 19.8 km · h-1) when performing actions such as 'Break into Box', Run in Behind/Penetrate', and 'Close Down/Press' than other positions (ES: 0.6-5.2, P < 0.01). WOP covered more high-intensity 'Run with Ball' distance (ES: 0.7-1.7, P < 0.01) whereas WDP performed more 'Over/Underlap' distance than other positions (ES: 0.9-1.4, P < 0.01). CDP and WDP covered more high-intensity 'Covering' distances than other positions (ES: 0.4-2.4, P < 0.01). Nonetheless, data demonstrated that implementing specialised positional analysis relative to a generalised approach is more sensitive in measuring physical-tactical performances of players with the latter over or underestimating the match demands of the players compared to the former. A contextualised analysis may assist coaches and practitioners when designing position or even player-specific training drills since the data provides unique physical-tactical trends across specialised roles.

Assessment of glenoid baseplate initial micromotion and fixation strength in reverse total shoulder arthroplasty designs using a direct shear force methodology.

Background: In a reverse total shoulder arthroplasty, the altered glenohumeral joint center of rotation subjects the glenoid baseplate to increased shear forces and potential loosening. Methods: This study examined glenoid baseplate micromotion and initial fixation strength with the application of direct shear force in a Sawbone model. The reverse total shoulder arthroplasty systems examined were the DJO Reverse® Shoulder Prosthesis, the Exactech Equinoxe® Reverse System, and the Tornier AequalisTM Reverse Shoulder Prosthesis. Specimens were cyclically tested with increasing shear loads until 150 µm of displacement between the implant and glenoid was achieved, and subsequently until failure, classified as either 1 cm of implant/glenoid displacement or fracture. Results: The average load withstood for the 150 µm threshold for DJO, Tornier, and Exactech was 460 ± 88 N, 525 ± 100 N, and 585 ± 160 N, respectively. The average total load at device failure for DJO, Tornier, and Exactech was 980 ± 260 N, 1260 ± 120 N, and 1350 ± 230 N, respectively. Discussion: The Exactech implant design trended toward requiring more load to induce micromotion at each threshold and to induce device failure, most commonly seen as inferior screw pull out. This study proposes design features that may enhance fixation and suggests little risk of initial micromotion or failure during initial post-operative recovery.

Contextualised peak periods of play in English Premier League matches.

The present study aimed to determine the physical-tactical trends of elite players/teams during peak 1-, 3- and 5-min periods of match-play. A total of 50 English Premier League matches (n = 583 player observations) were analysed by coding the players' physical-tactical activities through the synchronisation of tracking data and video. The contextualised data showed that during the peak periods (i.e., the most demanding passage of play), players/teams covered the largest distances for 'Recovery Run' (28-37%) out of possession and 'Support Play' (9-13%) in possession. In the following periods, players covered less high-intensity distance versus the average with a more pronounced decline in the next 1-min period than longer duration 3- and 5-min periods (48% vs ~25-30%, ES: 0.4-0.5, P < 0.01); team data showed similar trends with different relative patterns (31% vs 17-30%, ES: 0.5-0.8, P < 0.01). After peak periods, players/teams performed 20-53% less high-intensity distances for 'Covering' and 'Recovery Run' (ES: 0.2-0.7, P < 0.01) out of possession. However, players covered 28-91% less distance for 'Run with Ball' (ES: 0.1-0.5, P < 0.05) when in possession. Some physical-tactical actions exhibited inconsistency in different time durations of the next periods; however, these physical-tactical data were position-specific. This may signify that each position has certain physical-tactical actions to execute even after the peak periods, especially when they are tactically required to do so. As the data demonstrates unique physical-tactical trends of players/teams during the peak and next periods of play, this could help practitioners prescribe position- and player-specific drills, and better understand transient decrements in high-intensity running after intense passages of play.

Chemical editing of proteoglycan architecture.

Proteoglycans are heterogeneous macromolecular glycoconjugates that orchestrate many important cellular processes. While much attention has focused on the poly-sulfated glycosaminoglycan chains that decorate proteoglycans, other important elements of their architecture, such as core proteins and membrane localization, have garnered less emphasis. Hence, comprehensive structure-function relationships that consider the replete proteoglycan architecture as glycoconjugates are limited. Here we present an extensive approach to study proteoglycan structure and biology by fabricating defined semisynthetic modular proteoglycans that can be tailored for cell surface display. The expression of proteoglycan core proteins with unnatural amino acids permits bioorthogonal click chemistry with functionalized glycosaminoglycans for methodical dissection of the parameters required for optimal binding and function of various proteoglycan-binding proteins. We demonstrate that these sophisticated materials can recapitulate the functions of native proteoglycan ectodomains in mouse embryonic stem cell differentiation and cancer cell spreading while permitting the analysis of the contributing architectural elements toward function.

Autograft Long Head Biceps Tendon Can Be Used as a Scaffold for Biologically Augmenting Rotator Cuff Repairs.

PURPOSE: We create a viable, mechanically expanded autograft long head biceps tendon (LHBT) scaffold for biologically augmenting the repair of torn rotator cuffs. METHODS: The proximal aspect of the tenotomized LHBTs was harvested from patients during rotator cuff repair surgery and was mechanically formed into porous scaffolds using a surgical graft expander. LHBT scaffolds were evaluated for change in area, tensile properties, and tenocyte viability before and after expansion. The ability of endogenous tenocytes derived from the LHBT scaffold to promote tenogenic differentiation of human adipose-derived mesenchymal stromal cells (ADMSCs) was also determined. RESULTS: Autograft LHBTs were successfully expanded using a modified surgical graft expander to create a porous scaffold containing viable resident tenoctyes from patients undergoing rotator cuff repair. LHBT scaffolds had significantly increased area (length: 24.91 mm [13.91, 35.90] × width: 22.69 mm [1.87, 34.50]; P = .011) compared with the native LHBT tendon (length: 27.16 mm [2.70, 33.62] × width: 6.68 mm [5.62, 7.74]). The structural properties of the autograft were altered, including the ultimate tensile strength (LHBT scaffold: .56 MPa [.06, 1.06] vs. native LHBT: 2.35 MPa [1.36, 3.33]; P = .002) and tensile modulus (LHBT scaffold: 4.72 MPa [-.80, 1.24] versus native LHBT: 37.17 MPa [24.56, 49.78]; P = .001). There was also a reduction in resident tenocyte percent viability (LHBT scaffold: 38.52% [17.94, 59.09] vs. native LHBT: 68.87% [63.67, 74.37]; P =.004). Tenocytes derived from the LHBT scaffold produced soluble signals that initiated ADMSC differentiation into an immature tenocyte-like phenotype, as indicated by an 8.7× increase in scleraxis (P = .040) and a 3.6× increase in collagen type III mRNA expression (P = .050) compared with undifferentiated ADMSC controls. CONCLUSIONS: The ability to produce a viable autologous scaffold from the proximal biceps tendon having dimensions, porosity, mechanical characteristics, native ECM components, and viable tenocytes that produce bioactive signals conducive to supporting the biologic augmentation of rotator cuff repair surgery has been demonstrated. CLINICAL RELEVANCE: This biologically active construct may help to improve the quality of healing and regeneration at the repair site of rotator cuff tears, especially those at high risk for retear.

Activation of Crtc2/Creb1 in skeletal muscle enhances weight loss during intermittent fasting.

The Creb-Regulated Transcriptional Coactivator (Crtc) family of transcriptional coregulators drive Creb1-mediated transcription effects on metabolism in many tissues, but the in vivo effects of Crtc2/Creb1 transcription on skeletal muscle metabolism are not known. Skeletal muscle-specific overexpression of Crtc2 (Crtc2 mice) induced greater mitochondrial activity, metabolic flux capacity for both carbohydrates and fats, improved glucose tolerance and insulin sensitivity, and increased oxidative capacity, supported by upregulation of key metabolic genes. Crtc2 overexpression led to greater weight loss during alternate day fasting (ADF), selective loss of fat rather than lean mass, maintenance of higher energy expenditure during the fast and reduced binge-eating during the feeding period. ADF downregulated most of the mitochondrial electron transport genes, and other regulators of mitochondrial function, that were substantially reversed by Crtc2-driven transcription. Glucocorticoids acted with AMPK to drive atrophy and mitophagy, which was reversed by Crtc2/Creb1 signaling. Crtc2/Creb1-mediated signaling coordinates metabolic adaptations in skeletal muscle that explain how Crtc2/Creb1 regulates metabolism and weight loss.

Professional Pitchers Display Differences in UCL Morphology and Elbow Gapping During Moving Valgus Stress Testing After UCL Reconstruction.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction (UCLR) of the elbow has received much attention given the rise in incidence among baseball pitchers. Stress ultrasonography has been demonstrated to be a critical evaluation tool of the UCL. No study has dynamically evaluated the ability of UCLR to restore normal kinematics. PURPOSE/HYPOTHESIS: The purpose of this study was to compare ulnohumeral gapping during a moving valgus stress test as well as UCL thickness between professional pitchers with and without UCLR. We hypothesized that the ulnohumeral joint will display greater gapping and the UCL graft will be thicker in pitchers after UCLR compared with uninjured pitchers. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Ultrasonography was used to measure the medial ulnohumeral joint distance and the UCL thickness of 70 asymptomatic professional baseball pitchers; 6 of the participants had a history of UCLR. Images were captured of the dominant (D) and nondominant (ND) elbows at the maximal cocking position under 2 loaded conditions within the moving valgus stress test arc: (1) gravity stress and (2) 2.5 kg (5.5 lb) of valgus force using a dynamometer. Intra- and interrater reliability of the measurements was established with intraclass correlation coefficients (ICCs). Separate mixed-model analyses of variance (D side × UCL) were used to compare the D and ND elbow variables between pitchers with and without a history of UCLR. RESULTS: All measurements displayed good reliability according to ICCs. Pitchers with a history of UCLR demonstrated less gapping (5.6 ± 2.9 vs 4.2 ± 1.2 mm; P = .002) and greater UCL graft thickness (0.17 ± 0.07 vs 0.11 ± 0.08 mm; P = .03) compared with the native ligament in pitchers without prior UCL injury. CONCLUSION: Our data demonstrated that the UCLR results in a thicker, stiffer construct with less medial elbow gapping than the anatomical UCL. Using ultrasound to evaluate the UCL was a reliable, efficient, and clinically feasible method to assess UCL thickness and joint gapping in players with a history of UCLR. Future studies may consider this approach to evaluate surgical techniques and graft types for UCLR.

Evaluation of fully-functionalized diazirine tags for chemical proteomic applications.

The use of photo-affinity reagents for the mapping of noncovalent small molecule-protein interactions has become widespread. Recently, several 'fully-functionalized' (FF) chemical tags have been developed wherein a photoactivatable capture group, an enrichment handle, and a functional group for synthetic conjugation to a molecule of interest are integrated into a single modular tag. Diazirine-based FF tags in particular are increasingly employed in chemical proteomic investigations; however, despite routine usage, their relative utility has not been established. Here, we systematically evaluate several diazirine-containing FF tags, including a terminal diazirine analog developed herein, for chemical proteomic investigations. Specifically, we compared the general reactivity of five diazirine tags and assessed their impact on the profiles of various small molecules, including fragments and known inhibitors revealing that such tags can have profound effects on the proteomic profiles of chemical probes. Our findings should be informative for chemical probe design, photo-affinity reagent development, and chemical proteomic investigations.

Infraspinatus or teres minor fatty infiltration does not influence patient outcomes after reverse shoulder arthroplasty with a lateralized glenoid.

BACKGROUND: Previous studies show that reverse shoulder arthroplasty (RSA) may improve forward elevation (FE) but external rotation may remain impaired with substantial teres minor fatty infiltration. The purpose of this study was to examine the influence of fatty infiltration on postoperative range of motion (ROM) and patient-reported outcomes (PROs) after RSA with a more lateralized center of rotation. METHODS: About 69 patients (average age 69 years; 44 women, 25 men) with preoperative MRI, 1-year postoperative ROM, 2-year Veteran's Rand Survey, American Shoulder and Elbow Surgeons subjective form, and Single Alpha-Numeric Evaluation scores who underwent RSA with a lateralized glenoid component between 2010 and 2014 were identified. Patients with Fuchs stage 3 fatty degeneration were compared with patients with Fuchs stage ≤ 2 using a one-way ANOVA. RESULTS: Eleven patients had Fuchs stage 3 in the teres minor and 28 with stage 3 in the infraspinatus. Charlson comorbidity indices, Veteran's Rand Survey scores, age, and BMI were not different between groups. There were no differences after one year (follow-up = 15 ± 14 months) in FE (FE = 128 ± 29) or external rotation (33 ± 13) between groups. There were no differences in two-year minimum (follow-up = 42.9 ± 17.9 months) American Shoulder and Elbow Surgeons scores between degenerated teres minor (76.4 ± 20) or infraspinatus (69.1 ± 24) groups. CONCLUSION: This is the first study to assess the influence of teres minor and infraspinatus fatty infiltration on the postoperative ROM and PROs with a more lateralized glenoid RSA implant. Our results show that in a more lateralized RSA, neither teres minor nor infraspinatus fatty infiltration appear to negatively influence ROM or PROs.

Current concepts in the evolution of arthroscopic rotator cuff repair.

Arthroscopic rotator cuff repair has become one of the most common and successful surgeries performed in orthopedics. It represents the culmination of advances in many diverse fields such as optics, fluid dynamics, mechanical engineering, and most recently, orthobiologics. This article reviews the current state of the art of arthroscopic rotator cuff repair, through the lens of its historical context and evolution to our present understanding. We review the limitations in the current approach, and glance toward the future of rotator cuff regeneration with emerging technologies.

Placenta accreta spectrum disorders - Peri-operative management: The role of the anaesthetist.

The incidence of placenta accreta spectrum (PAS) is increasing and will become more commonly encountered by obstetric anaesthetists in the elective and emergency settings. Significant maternal and neonatal morbidity is associated with these disorders, and hence it is important for anaesthetists to have early involvement in perioperative planning. Major haemorrhage should be anticipated and requires robust perioperative preparation including Patient Blood Management (PBM) and use of intraoperative strategies for haemorrhage management wherever possible. Several institutions have demonstrated good outcomes with regional anaesthesia alone, but the choice of anaesthetic technique requires individualised planning considering patient, anaesthetic and surgical factors. Optimisation of postoperative analgesia needs additional consideration; it is key to good recovery, minimising the impact on quality of life and reducing the risk of persistent post-surgical pain. Further research is required to ascertain the optimal multi-modal analgesic regime including the role of peripheral nerve blockade.

Does Functional Bracing of the Unstable Shoulder Improve Return to Play in Scholastic Athletes? Returning the Unstable Shoulder to Play.

BACKGROUND: Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not. HYPOTHESIS: The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome. RESULTS: There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes (P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) (P = 0.47). CONCLUSION: This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing. CLINICAL RELEVANCE: The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability.

The Accelerating Change in Medical Education Consortium: Key Drivers of Transformative Change.

The American Medical Association's (AMA's) Accelerating Change in Medical Education (ACE) initiative, launched in 2013 to foster advancements in undergraduate medical education, has led to the development and scaling of innovations influencing the full continuum of medical training. Initial grants of $1 million were awarded to 11 U.S. medical schools, with 21 schools joining the consortium in 2016 at a lower funding level. Almost one-fifth of all U.S. MD- and DO-granting medical schools are represented in the 32-member consortium. In the first 5 years, the consortium medical schools have delivered innovative educational experiences to approximately 19,000 medical students, who will provide a potential 33 million patient care visits annually. The core initiative objectives focus on competency-based approaches to medical education and individualized pathways for students, training in health systems science, and enhancing the learning environment. At the close of the initial 5-year grant period, AMA leadership sought to catalogue outputs and understand how the structure of the consortium may have influenced its outcomes. Themes from qualitative analysis of stakeholder interviews as well as other sources of evidence aligned with the 4 elements of the transformational leadership model (inspirational motivation, intellectual stimulation, individualized consideration, and idealized influence) and can be used to inform future innovation interventions. For example, the ACE initiative has been successful in stimulating change at the consortium schools and propagating those innovations broadly, with outputs involving medical students, faculty, medical schools, affiliated health systems, and the broader educational landscape. In summary, the ACE initiative has fostered a far-reaching community of innovation that will continue to drive change across the continuum of medical education.

Mapping glycan-mediated galectin-3 interactions by live cell proximity labeling.

Galectin-3 is a glycan-binding protein (GBP) that binds ß-galactoside glycan structures to orchestrate a variety of important biological events, including the activation of hepatic stellate cells and regulation of immune responses. While the requisite glycan epitopes needed to bind galectin-3 have long been elucidated, the cellular glycoproteins that bear these glycan signatures remain unknown. Given the importance of the three-dimensional (3D) arrangement of glycans in dictating GBP interactions, strategies that allow the identification of GBP receptors in live cells, where the native glycan presentation and glycoprotein expression are preserved, have significant advantages over static and artificial systems. Here we describe the integration of a proximity labeling method and quantitative mass spectrometry to map the glycan and glycoprotein interactors for galectin-3 in live human hepatic stellate cells and peripheral blood mononuclear cells. Understanding the identity of the glycoproteins and defining the structures of the glycans will empower efforts to design and develop selective therapeutics to mitigate galectin-3-mediated biological events.