Concordant inter-laboratory derived concentrations of ceramides in human plasma reference materials via authentic standards.

In this community effort, we compare measurements between 34 laboratories from 19 countries, utilizing mixtures of labelled authentic synthetic standards, to quantify by mass spectrometry four clinically used ceramide species in the NIST (National Institute of Standards and Technology) human blood plasma Standard Reference Material (SRM) 1950, as well as a set of candidate plasma reference materials (RM 8231). Participants either utilized a provided validated method and/or their method of choice. Mean concentration values, and intra- and inter-laboratory coefficients of variation (CV) were calculated using single-point and multi-point calibrations, respectively. These results are the most precise (intra-laboratory CVs ≤ 4.2%) and concordant (inter-laboratory CVs < 14%) community-derived absolute concentration values reported to date for four clinically used ceramides in the commonly analyzed SRM 1950. We demonstrate that calibration using authentic labelled standards dramatically reduces data variability. Furthermore, we show how the use of shared RM can correct systematic quantitative biases and help in harmonizing lipidomics. Collectively, the results from the present study provide a significant knowledge base for translation of lipidomic technologies to future clinical applications that might require the determination of reference intervals (RIs) in various human populations or might need to estimate reference change values (RCV), when analytical variability is a key factor for recall during multiple testing of individuals.

Lunar synchrony, geography, and individual clocks shape autumn migration timing in an avian migrant.

Timing programs in animal migrants have been selected to synchronize movements that coincide with predictable resources on the breeding and nonbreeding grounds. Migrants face potential temporal conflicts if their migration schedules benefit from synchrony to conflicting rhythms associated with annual biogeographical (circannual) cues, lunar (circalunar) cues, or individually repeatable internal clocks. We repeat-tracked individuals of an avian lunaphilic species, Eastern Whip-poor-will (Antrostomus vociferus), for two to three successive autumn migrations to determine the influence of the lunar cycle, breeding location, and individual repeatability on migration timing. Almost all birds avoided departing for migration during a full moon, likely to take advantage of the bright moonlight to facilitate visual foraging and enhance pre-migration fattening. However, groups from two latitudinally distant sampling areas adjusted their autumn departure timing differently relative to the timing of the September full moon, presumably due to differences in seasonal prey availability. Individual repeatability increased throughout autumn migration, suggesting that the factors responsible for shaping migration timing may differ for different migration stages. Our results, that lunar synchrony, local climate, and individual internal clocks appeared to account for much of the variation in migration timing in whip-poor-wills, underscore the value of measuring potentially interacting factors that shape migratory behavior at species, group, and individual levels. It remains unclear if, or how, maintaining individually repeatable annual migration schedules provides an adaptive benefit for whip-poor-wills or other lunaphilic migrants. Further clarifying the reasons for phenotypic variation in whip-poor-will migration timing will improve predictions of their abilities to adjust migratory movements under changing environmental conditions.

Improving the management of hospital waiting lists by using nudges in letters: A Randomised controlled trial.

OBJECTIVE: A commonly adopted intervention to help to reduce wait times for hospital treatment is administrative validation, where administrators write to patients to check if a procedure is still required. The did not return (DNR) rate to validation letters is substantial. We tested whether the DNR rate was reduced by introducing nudges to validation letters. METHODS: Participants from eight public hospitals (N = 2855; in 2017) in Ireland were randomized to receive an existing (control group) or a redesigned validation letter including nudges (intervention group). RESULTS: Participants in the intervention group were less likely not to return it than those in the control group, OR = .756, SE = .069, p = .002. Control and intervention group DNR rates were 23.97% and 19.24%. This is equivalent to 1 in 5 non-responders changing their behaviour because of the redesigned letter. CONCLUSIONS: The redesigned letter increased patient compliance with the validation process. The redesign has subsequently been adopted by public hospitals in Ireland.

Natural History of the Remnant Pancreatic Duct after Pancreatoduodenectomy for Non-Invasive Intraductal Papillary Mucinous Neoplasm: Results from an International Consortium.

BACKGROUND: Little is known about the prognostic significance of pancreatic duct (PD) dilation following pancreatoduodenectomy for intraductal papillary mucinous neoplasms (IPMN). Although PD dilation is typically the hallmark radiographic feature of IPMN, other causes of PD dilation exist, including anastomotic stricture, pancreatitis, senescence, and postsurgical passive dilation. Therefore, PD dilation after pancreatoduodenectomy for IPMN represents a diagnostic and management dilemma. The purpose of this study was to evaluate the significance of PD dilation after pancreatoduodenectomy for noninvasive IPMN. METHODS: All patients who underwent pancreatoduodenectomy for noninvasive IPMN at nine pancreatic academic centers between 2013 and 2018 were included. Variables were entered prospectively into institutional databases and retrospectively reviewed for the purpose of this study. Dilation of the PD remnant was defined as a duct diameter of ≥5 mm, according to international guidelines. RESULTS: Four-hundred and eighty-one patients were included in this study. The mean age of the patients was 66 years (range 30-90). Patients were surveilled for a median of 4.5 (+/-2.3; max 10.6) years. During follow-up, 132 patients (27.4%) developed PD dilation in the remnant tissue after a median of 3.3 years. Multivariable analysis demonstrated that older age at the time of pancreatoduodenectomy (P=0.01) and longer surveillance duration (P=0.002) were predictors of PD dilation. Interestingly, neither the pathological IPMN subtype (branch-duct vs. main duct/mixed, P=0.96) nor the preoperative PD diameter (P=0.14) was associated with an increased risk of PD dilation in the remnant. During follow-up, IPMN recurrence was suspected in the remaining 72 patients (18.4%), solely because of ductal dilation on cross-sectional imaging in 97% (70/72). Completion pancreatectomy was performed in only 16 patients (3.3%), of whom only four (0.8%) had invasive carcinoma. Three of these four patients had high-grade dysplasia in the original pancreatoduodenectomy specimen, whereas only one had a low-grade dysplastic lesion initially. On multivariable analysis, no variable was predictive of IPMN recurrence in the remnant. CONCLUSIONS: New main duct dilation in the pancreatic remnant after pancreatoduodenectomy for IPMN is common, occurring in 27% of the patients. The duration of surveillance is the main factor associated with remnant PD dilation, suggesting that this is likely a physiologic phenomenon. Although recurrence of IPMN in the remnant is often suspected, only 0.8% of patients develop an invasive carcinoma in the pancreatic remnant requiring completion pancreatectomy.

Impella 5.5: A Systematic Review of the Current Literature.

OBJECTIVE: Impella 5.5 (Abiomed, Danvers, MA, USA) is a temporary mechanical circulatory support device used for patients in cardiogenic shock. This review provides a comprehensive overview of the device's clinical effectiveness, safety profile, patient outcomes, and relevant procedural considerations. METHODS: We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed/MEDLINE database. The search query included articles available from October 6, 2022, through January 13, 2023. Our initial search identified 75 studies. All records were screened by 2 independent reviewers using the Covidence software for adherence to our inclusion criteria, and 8 retrospective cohort studies were identified as appropriate for inclusion. RESULTS: Across the included studies, the sample size ranged from 4 to 275, with predominantly male cohorts. Indications for Impella support varied, and the duration of support ranged from 9.8 to 70 days. Overall, Impella support appeared to be associated with favorable survival rates and manageable complications in various patient populations. Complications associated with Impella use included bleeding, stroke, and device malfunctions. Two studies compared prolonged and Food and Drug Administration-approved Impella support, showing similar outcomes and adverse events. CONCLUSIONS: Impella 5.5 continues to be an attractive option for bridging patients to definitive therapy. Survival during and after Impella 5.5 was favorable for patients regardless of initial indication. However, device use was associated with several important complications, which calls for judicious use and a precontemplated exit strategy. Limitations of this literature review include biases inherent to the retrospective studies included, such as selection and publication bias.

Acute Toxic Cerebellar Leukoencephalopathy in an Eight-Year-Old Child Following Illicit Fentanyl and Cocaine Ingestion: A Case Report of Full Clinical Recovery.

During the current opioid epidemic, the number of children with illicit toxic ingestions is increasing. Children presenting with altered mental status and neurologic, particularly cerebellar symptoms of unclear etiology, should be considered to undergo brain imaging as well as toxicology screening to not miss the possible complication of acute toxic leukoencephalopathy. We report the case of an eight-year-old child who presented with somnolence and respiratory depression of unclear etiology, responding profoundly to naloxone, quickly raising concern for drug ingestion. The toxicology screen was positive for fentanyl, cocaine metabolites, caffeine, and diphenhydramine, but not available until day 3 of the hospital stay. In the interim, head CT and brain MRI findings revealed concerning bilateral cerebellar hypodensities, suggestive of opioid-induced leukoencephalopathy. This condition has been described as potentially malignant and fatal, but very few cases of this pathology have been described in children so far. Fortunately, all neurological symptoms in our patient, including altered mental status, respiratory depression, atactic gait, blurry vision, and lower extremity pain, completely resolved within five days of presentation and the patient seemingly underwent a full clinical recovery without residual symptoms. Awareness and prompt recognition of acute toxic leukoencephalopathy in children presenting with altered mental status or neurological symptoms of unclear etiology is of utmost importance to prevent deterioration and optimize treatment, especially during times of a worsening opioid epidemic in our country.

Serum lipidome associates with neuroimaging features in patients with traumatic brain injury.

Acute traumatic brain injury (TBI) is associated with substantial abnormalities in lipid biology, including changes in the structural lipids that are present in the myelin in the brain. We investigated the relationship between traumatic microstructural changes in white matter from magnetic resonance imaging (MRI) and quantitative lipidomic changes from blood serum. The study cohort included 103 patients from the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Diffusion tensor fitting generated fractional anisotropy (FA) and mean diffusivity (MD) maps for the MRI scans while ultra-high-performance liquid chromatography quadrupole time-of-flight mass spectrometry was applied to analyze the lipidome. Increasing severity of TBI was associated with higher MD and lower FA values, which scaled with different lipidomic signatures. There appears to be consistent patterns of lipid changes associating with the specific microstructure changes in the CNS white matter, but also regional specificity, suggesting that blood-based lipidomics may provide an insight into the underlying pathophysiology of TBI.

Arbuscular mycorrhizal fungi equalize differences in plant fitness and facilitate plant species coexistence through niche differentiation.

Mycorrhizal fungi are essential to the establishment of the vast majority of plant species but are often conceptualized with contradictory roles in plant community assembly. On the one hand, host-specific mycorrhizal fungi may allow a plant to be competitively dominant by enhancing growth. On the other hand, host-specific mycorrhizal fungi with different functional capabilities may increase nutrient niche partitioning, allowing plant species to coexist. Here, to resolve the balance of these two contradictory forces, we used a controlled greenhouse study to manipulate the presence of two main types of mycorrhizal fungus, ectomycorrhizal fungi and arbuscular mycorrhizal fungi, and used a range of conspecific and heterospecific competitor densities to investigate the role of mycorrhizal fungi in plant competition and coexistence. We find that the presence of arbuscular mycorrhizal fungi equalizes fitness differences between plants and stabilizes competition to create conditions for host species coexistence. Our results show how below-ground mutualisms can shift outcomes of plant competition and that a holistic view of plant communities that incorporates their mycorrhizal partners is important in predicting plant community dynamics.

Combination diuretic therapies in heart failure: Insights from GUIDE-IT.

Introduction: Diuretics are the mainstay of maintaining and restoring euvolemia in the management of heart failure. Loop diuretics are often preferred, however, combination diuretic therapy (CDT) with a thiazide diuretic is often used to overcome diuretic resistance and increase diuretic effect. We performed an analysis of the GUIDE-IT study to assess all-cause mortality and time to first hospitalizations in patients necessitating CDT. Methods: Patients from the GUIDE-IT dataset were stratified by their requirement for CDT with a thiazide to achieve euvolemia. A total of 894 patients were analyzed, 733 of which were treated with loop diuretics alone vs 161 used either chlorothiazide or metolazone in addition to loop diuretics. Kaplan-Meir curves were derived with log-rank p-values to evaluate for differences between the groups. Results: There was no significant difference in all-cause mortality regardless of CDT utilization status (mean survival of 612.704 days vs 603.326 days, p = 0.083). On subgroup analysis, there was no significant difference in all-cause mortality amongst those using loop diuretics compared to CDT in the BNP-guided therapy group, (mean survival time 576.385 days vs 620.585 days, p = 0.0523), nor the control group (614.1 days vs 588.9 days; p = 0.5728). Time to first hospitalization was reduced in all using CDT compared to loop diuretics alone (280.5 days vs 407.2 days, p < 0.0001). On subgroup analysis, both the BNP-guided group as well as the control group had reduced time to first hospitalization in the CDT group compared to those who did not require CDT (BNP group: 287.503 days vs 402.475 days, p ≤0.0001; control group 248.698 days vs 399.035 days, p = 0.0009). Conclusion: Use of CDT is associated with earlier time to hospitalization, though no association was identified with increased all-cause mortality. Further prospective studies are likely needed to determine the true risk and benefits of combination diuretic therapy.

Natural recovery of cardiac allograft diastolic function, a retrospective longitudinal report.

Cardiac allografts suffer diastolic dysfunction early post-heart transplantation (HTx) due to ischemic injury, however the natural course of diastology recovery post HTx remains unknown (Tallaj et al., 2007 [1]). We retrospectively reviewed 60 adult HTx patients between 2015 and 2021 at a single site. Invasive hemodynamics and echocardiograms were obtained at 2 weeks and 1, 3, 6, and 12 months post-HTx. RA strain by 2D feature tracking was compared to intracardiac pressure measurements. In all patients, we observed normalization of RV and RA filling pressures by post-operative week 12 and recovery of diastolic dysfunction by month 6. There was an inverse correlation between RV end-diastolic pressure and RA contractile (r = -0.192, p < 0.05) and reservoir (r = -0.128, p < 0.05) functions in the allograft. As the post-transplant care paradigm shifts away from invasive procedures, right atrial indices should be included in imaging-based allograft surveillance studies.

Bioinductive Collagen Implant Has Potential To Improve Rotator Cuff Healing - A Systematic Review.

PURPOSE: The purpose of this study was to systematically review the literature to evaluate the clinical studies on bioinductive collagen implant (BCI) for the treatment of rotator cuff tears. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies reporting following BCI for rotator cuff tears were included. Quantitive and qualitative data was evaluated. RESULTS: A total of 21 studies were included. In patients with full thickness tears, 7 of the 8 studies with pre- to postoperative ASES scores demonstrated statistically significant improvements in mean pre- to postoperative ASES scores, with 75%-100% of patients meeting the MCID. In those with partial thickness tears, 7 of the 8 studies with pre- to postoperative ASES scores demonstrated statistically significant improvements in mean pre- to postoperative ASES scores, with 54.4%-100% of patients meeting the MCID. For studies that quantified percent increases in tendon thickness, the reported increases ranged from 13% in 44% full thickness tears, and 14% to 60% in partial thickness tears. There were 6 studies that evaluated rotator cuff re-tears after BCI treatment in the full thickness cohort, with rates reported ranging from 0-9%. There were 5 studies that evaluated rotator cuff re-tears after BCI treatment in the partial thickness cohort, with rates reported ranging from 0-18%. Two of the included studies found that BCI was cost-effective due to the increased tendon healing with cost savings of $5,338-$13,061 per healed rotator cuff tendon. CONCLUSION: The literature on rotator cuff tear augmentation with BCI has shown consistently reported good results. Additionally, there was evidence of low retear rates and consistently improved tendon thickness with BCI, with two randomized controlled trials showing improved tendon healing with BCI. However, there appears to be a higher rate of adhesive capsulitis reported. LEVEL OF EVIDENCE: Level IV, Systematic review of Level I, III and IV studies.

Multiple direct and indirect roles of the Paf1 complex in transcription elongation, splicing, and histone modifications.

The polymerase-associated factor 1 (Paf1) complex (Paf1C) is a conserved protein complex with critical functions during eukaryotic transcription. Previous studies showed that Paf1C is multi-functional, controlling specific aspects of transcription ranging from RNA polymerase II (RNAPII) processivity to histone modifications. However, it is unclear how specific Paf1C subunits directly impact transcription and coupled processes. We have compared conditional depletion to steady-state deletion for each Paf1C subunit to determine the direct and indirect contributions to gene expression in Saccharomyces cerevisiae. Using nascent transcript sequencing, RNAPII profiling, and modeling of transcription elongation dynamics, we have demonstrated direct effects of Paf1C subunits on RNAPII processivity and elongation rate and indirect effects on transcript splicing and repression of antisense transcripts. Further, our results suggest that the direct transcriptional effects of Paf1C cannot be readily assigned to any particular histone modification. This work comprehensively analyzes both the immediate and the extended roles of each Paf1C subunit in transcription elongation and transcript regulation.

Serotonin transporter deficiency in mice results in an increased susceptibility to HTR2B-dependent pro-fibrotic mechanisms in the cardiac valves and left ventricular myocardium.

Increased serotonin (5HT) concentration and signaling, can lead to pathological remodeling of the cardiac valves. We previously showed that a reduction of the 5HT transporter (SERT) expression in the mitral valve (MV) contributes to the progression of degenerative MV regurgitation (MR). We sought to investigate the myocardial and valvular phenotype of SERT-/- mice in order to identify remodeling mechanisms specific to the MV and left ventricular (LV) remodeling. Using 8- and 16-week-old WT and SERT-/- mice we show that male and female animals deficient of SERT have pathological remodeling of the cardiac valves, myocardial fibrosis, diminished ejection fraction and altered left ventricular dimensions. In the MV and intervalvular area of the aortic valve (AV)-MV, gene expression, including Col1a1 mRNA, was progressively altered with age up until 16 weeks of age. In contrast, in the AV and myocardium, most gene expression changes occurred earlier and plateaued by 8 weeks. To explore basal differences in susceptibility to remodeling stimuli among cardiac valves, valve interstitial cells (VIC) were isolated from AV, MV, tricuspid valve (TV), pulmonary valve (PV) and fibroblasts (Fb) from the myocardial apex from 16 weeks old wild type (WT) mice. After 24h stimulation with 10 µM of 5HT, the gene expression of Col1a1 and Acta2 were upregulated in MVIC to a higher degree than in VIC from other valves and Fb. Treatment with TGFß1 similarly upregulated Cola1 and Acta2 in MVIC and AVIC, while the increase was milder in right heart VIC and Fb. Experiments were also carried out with human VIC. In comparison to mice, human left heart VIC were more sensitive to 5HT and TGFß1, upregulating COL1A1 and ACTA2; TGFß1 upregulated HTR2B expression in all VIC. Our results support the hypothesis that a deleterious cardiac effect of SERT downregulation may be mediated by increased susceptibility to HTR2B-dependent pro-fibrotic mechanisms, which are distinct among VIC populations and cardiac fibroblasts, regardless of SERT activity. Given that HTR2B mechanisms involved in VIC and myocardial remodeling response are due to both 5HT and also to downstream related TGFß1 and TNFα activity, targeting HTR2B could be a therapeutic strategy for dual treatment of MR and LV remodeling.

Designing a Perioperative Mind-Body Intervention for Peripheral Vascular Interventions.

Background: Peripheral vascular interventions (PVIs) performed under procedural sedation and analgesia (PSA) can be associated with anxiety and poor compliance with patient instructions during surgery. Mind-body interventions (MBIs) such as meditation have demonstrated the potential to decrease perioperative anxiety, though this area is understudied, and no tailored interventions have been developed for the vascular surgical patient population. Objectives: We aimed to design a perioperative MBI that specifically targeted vascular surgical patients undergoing PVIs under PSA. We sought to perform this in a scientifically rigorous, multi-disciplinary collaborative manner. Methods: Following the Obesity-Related Behavioral Intervention Trials (ORBIT) model, we designed (Phase 1a) and then refined (Phase 1b) a MBI for patients undergoing PVIs under PSA to decrease perioperative anxiety and sedation and facilitate patient intraoperative compliance. Phase 1a involved a literature review, informal information gathering and synthesis, and drafting a preliminary protocol for a perioperative MBI. Phase 1b involved assembling a multi-disciplinary expert panel of perioperative and mind-body clinicians and researchers to improve the MBI using an iterative, modified Delphi approach. Results: The modified Delphi process was completed, and a consensus was reached after three iterations. The resulting MBI consisted of two seven-minute preoperative guided meditations on the day of surgery, including diaphragmatic breathing, body scans, and guided imagery emphasizing awareness of the ipsilateral leg where the vascular surgery was performed. A document delineating the integration of the MBI into the operating room workflow was produced, including details regarding the intervention's timing, duration, and modality. Conclusion: Using a multi-specialty expert panel, we designed a novel MBI in the form of a guided meditation with elements of mindfulness and guided imagery to decrease anxiety and increase intraoperative compliance for patients undergoing PVIs under PSA. A prospective pilot study is being planned to test the program's feasibility.

Disruption of nucleotide biosynthesis reprograms mitochondrial metabolism to inhibit adipogenesis.

A key organismal response to overnutrition involves the development of new adipocytes through the process of adipogenesis. Preadipocytes sense changes in the systemic nutrient status and metabolites can directly modulate adipogenesis. We previously identified a role of de novo nucleotide biosynthesis in adipogenesis induction, whereby inhibition of nucleotide biosynthesis suppresses the expression of the transcriptional regulators PPARγ and C/EBPα. Here, we set out to identify the global transcriptomic changes associated with the inhibition of nucleotide biosynthesis. Through RNA sequencing (RNAseq), we discovered that mitochondrial signatures were the most altered in response to inhibition of nucleotide biosynthesis. Blocking nucleotide biosynthesis induced rounded mitochondrial morphology, and altered mitochondrial function, and metabolism, reducing levels of tricarboxylic acid cycle intermediates, and increasing fatty acid oxidation (FAO). The loss of mitochondrial function induced by suppression of nucleotide biosynthesis was rescued by exogenous expression of PPARγ. Moreover, inhibition of FAO restored PPARγ expression, mitochondrial protein expression, and adipogenesis in the presence of nucleotide biosynthesis inhibition, suggesting a regulatory role of nutrient oxidation in differentiation. Collectively, our studies shed light on the link between substrate oxidation and transcription in cell fate determination.

Discovery of highly anisotropic dielectric crystals with equivariant graph neural networks.

Anisotropy in crystals plays a pivotal role in many technological applications. For example, anisotropic electronic and thermal transport are thought to be beneficial for thermoelectric applications, while anisotropic mechanical properties are of interest for emerging metamaterials, and anisotropic dielectric materials have been suggested as a novel platform for dark matter detection. Understanding and tailoring anisotropy in crystals is therefore essential for the design of next-generation functional materials. To date, however, most data-driven approaches have focused on the prediction of scalar crystal properties, such as the spherically averaged dielectric tensor or the bulk and shear elastic moduli. Here, we adopt the latest approaches in equivariant graph neural networks to develop a model that can predict the full dielectric tensor of crystals. Our model, trained on the Materials Project dataset of c.a. 6700 dielectric tensors, achieves state-of-the-art accuracy in scalar dielectric prediction in addition to capturing the directional response. We showcase the performance of the model by discovering crystals with almost isotropic connectivity but highly anisotropic dielectric tensors, thereby broadening our knowledge of the structure-property relationships in dielectric crystals.

Sheared turbulent flows and wake dynamics of an idled floating tidal turbine.

Ocean energy extraction is on the rise. While tides are the most predictable amongst marine renewable resources, turbulent and complex flows still challenge reliable tidal stream energy extraction and there is also uncertainty in how devices change the natural environment. To ensure the long-term integrity of emergent floating tidal turbine technologies, advances in field measurements are required to capture multiscale, real-world flow interactions. Here we use aerial drones and acoustic profiling transects to quantify the site- and scale-dependent complexities of actual turbulent flows around an idled, utility-scale floating tidal turbine (20 m rotor diameter, D). The combined spatial resolution of our baseline measurements is sufficiently high to quantify sheared, turbulent inflow conditions (reversed shear profiles, turbulence intensity >20%, and turbulence length scales > 0.4D). We also detect downstream velocity deficits (approaching 20% at 4D) and trace the far-wake propagation using acoustic backscattering techniques in excess of 30D. Addressing the energy-environment nexus, our oceanographic lens on flow characterisation will help to validate multiscale flow physics around offshore energy platforms that have thus far only been simulated.

Open Bankart Repair with Subscapularis Split.

Background: Anterior shoulder dislocations are a common injury, especially in the young, active, male population1. Soft-tissue treatment options for shoulder instability include arthroscopic or open Bankart repair, with open Bankart repair historically having lower rates of recurrence and reoperation, faster return to activity2-4, and a similar quality of life compared with arthroscopic repair5. More recent literature has suggested similar recurrence rates between arthroscopic and open procedures6. However, open Bankart repair may be indicated in cases of recurrent instability, especially if the patient participates in high-risk sports, because open repair can provide more capsular shift through the use of extra-capsular knots7. Performing a subscapularis split decreases the likelihood of subscapularis tendon avulsion following subscapularis tendon tenotomy and subsequent repair, as has been described in the literature8. Description: Indications for open Bankart repair include failure of arthroscopic Bankart repair, multiple dislocations, with subcritical bone loss. This surgical technique is performed via the deltopectoral approach. The subscapularis tendon is exposed and "spared" by splitting the fibers with use of a longitudinal incision between the upper 2/3 and lower 1/3 of the subscapularis. We begin the split medially near the myotendinous junction. Because the subscapularis becomes increasingly difficult to separate from the capsule as it tracks laterally, a RAY-TEC sponge is utilized to bluntly dissect. A T-shaped laterally based capsulotomy is made to expose the glenohumeral joint. The vertical aspect is made first, followed by the horizontal aspect from lateral to medial, extending to the labrum. A Fukuda retractor is placed through the split to hold the humeral head laterally. The labrum is elevated, and the glenoid is prepared with rasp. Then labrum is repaired with knotted suture anchors until it is secure. One anchor is utilized for each "hour" of the clock face, with a minimum of 3 anchors. The anchors are placed on the articular margin of the glenoid. Sutures are passed from the anchor through the capsule and tied outside the capsule. The capsulotomy is then repaired with use of a suture. The suture is utilized to pull the inferior portion superiorly. The inferior portion is taken superiorly, and the superior leaflet is imbricated over the top. Finally, an examination is performed to ensure that the humeral head can be translated to but not over the anterior and posterior glenoid rims. No repair of the subscapularis tendon insertion is required. The incision is closed with deep dermal and subcuticular suture. Alternatives: Nonoperative treatment options include rotator cuff and periscapular strengthening or immobilization. Operative treatment options include open Bankart repair with subscapularis tenotomy and repair, arthroscopic Bankart repair, or bone block augmentation procedures. Rationale: This procedure is different from the alternative treatments in that it is an open procedure, which allows for a more robust repair because the capsule can be shifted and doubled over, leading to the described decreased recurrence and reoperation rates. Open Bankart repair is better suited for large lesions that would be difficult to repair via arthroscopy. This procedure differs from other open Bankart techniques because the subscapularis is split rather than tenotomized, which removes the need to repair the tendon and decreases the rate of avulsion of the subscapularis tendon repair. Finally, this procedure is less invasive than the Latarjet procedure because it does not require osseous osteotomies and fixation. Expected Outcomes: This procedure provides adequate capsular shift and visualization of the Bankart lesion without the increased risk of postoperative subscapularis tendon injury. Important Tips: If the subscapularis split alone does not provide adequate visualization, portions of the subscapularis tendon can be released from the lesser tuberosity.The location and origin of the upper and lower subscapular nerves can have variable courses, which could theoretically put them at risk for iatrogenic injury; however, studies have shown this subscapularis split technique to be safe from and prevent denervation of the muscle. Acronyms and Abbreviations: GBL = glenoid bone lossEUA = examination under anesthesiaMRI = magnetic resonance imagingHSL = Hill-Sachs lesionAHCA = anterior humeral circumflex artery.

Patients With ST-Segment Elevation Myocardial Infarction and Cerebrovascular Accidents: Impact of COVID-19 Vaccination on Mortality.

Background: Coronavirus disease 2019 (COVID-19) infection is associated with proinflammatory states and adverse health outcomes such as ST-segment elevation myocardial infarction (STEMI) and cerebrovascular accidents (CVA). Limited evidence suggests that COVID-19 vaccination may decrease the adverse impact of COVID-19 infections. This study was designed to determine if patients who received COVID-19 vaccination had lower mortality from STEMI and CVA. Methods: This is a retrospective comparative analysis of 3,050 patients, who were admitted to the hospital and diagnosed with STEMI or CVA between April 1, 2019, and April 1, 2022. Patients were divided into three different timeframes: pre-COVID (April 1, 2019, to March 31, 2020), COVID (April 1, 2020 to March 31, 2021), and post-COVID (April 1, 2021 to March 31, 2022). Chi-square analysis was completed to analyze associations between STEMI, CVA, and vaccination status. A multinominal logistic regression was used to determine significant predictors for in-hospital mortality. Results: A total of 3,050 patients were admitted (1,873 STEMI and 1,177 CVA). STEMI accounted for about 60% of cases in each of the three time periods. There was no statistical difference in STEMI or CVA percentages in the three time periods. There was increased mortality in STEMI and CVA patients (odds ratio (OR) = 11.4; P < 0.001), but patients who received the COVID-19 vaccine were less likely to die (OR = 0.51, 95% confidence interval (CI): 0.28 - 0.93; P < 0.027) when compared to those who were unvaccinated. There was increased risk of death in patients with atrial fibrillation (AFIB) (OR = 2.43; P < 0.001) and chronic heart failure (CHF) (OR = 1.76; P = 0.004). There was increased mortality risk associated with age (OR =1.03; P = 0.001). Patients with coronary artery disease (CAD) (OR = 0.45; P = 0.014) and hyperlipidemia (OR = 0.29; P < 0.001) were less likely to die. Conclusions: Vaccination against COVID-19 was associated with reduced mortality rates in patients hospitalized with STEMI and CVA. Patients with pre-existing cardiovascular comorbidities such as CAD and hyperlipidemia also had lower mortality.