Anatomic variations of the deltoid muscle insertion: a cadaveric study.

Background: The deltoid is a trisegmented muscle with anterior, middle, and posterior components. While the clinical relevance of the presence of anatomic variations of the deltoid origin and insertion continues to be debated, the architecture of the deltoid muscle is more complex than initially believed. This study aimed to evaluate the gross anatomy of the deltoid muscle insertion by qualitatively and quantitatively characterizing the insertion and location of the deltoid muscle's anterior, middle, and posterior components. This information is valuable to surgeons as it raises awareness of potential variants that could be encountered during surgery, promotes mindfulness of neurovascular proximities, and reduces the likelihood of confusion between adjacent muscle fibers. Methods: Eight nonpaired, fresh-frozen clavicle-to-fingertip cadaveric shoulders were acquired for the study (6 left, 2 right). The average age of the cadavers was 79.5 years (range: 64-92). The standard deltopectoral approach was carried out on all specimens. The planes dividing the anterior, middle, and posterior deltoid were identified and marked. Once complete exposure had been achieved, digital calipers were used to record the size of the deltoid insertion. The specimens were qualitatively assessed to characterize the style of insertion they demonstrated. Results: The average length of the deltoid insertion was 39.45 ± 9.33 mm (n = 8). Six of the eight shoulders demonstrated an insertion style previously characterized in the literature. The remaining two shoulders highlighted an insertion pattern not previously described. Conclusion: The current study demonstrates a novel insertion pattern for the deltoid muscle that has not been previously characterized. This "step-off" insertion pattern shows that the anterior, middle, and posterior tendons are inserted superior-medial, directly on, and inferior-lateral to the deltoid tuberosity and was found in 2/8 of our cadaveric specimens.

Examining Community Engagement Research Strategies Used in Flint, Michigan: The Church Challenge.

BACKGROUND: The ways in which researchers may need to adapt traditional community-based participatory research engagement strategies during ongoing community trauma are understudied. We describe our efforts to engage the Flint, Michigan community in community-based participatory research in the aftermath of the Flint Water Crisis. OBJECTIVES: This manuscript describes 1) recruitment strategies selected before the Flint Water Crisis, 2) engagement lessons learned in the context of the Flint Water Crisis, and 3) barriers and facilitators encountered while engaging African American churches. METHODS: Researchers collaborated with community partners to engage and recruit a traumatized Flint community into the Church Challenge, a multilevel intervention to reduce chronic disease burden. LESSONS LEARNED: Recruitment and engagement strategies must be flexible, innovative, and may require nontraditional methods. CONCLUSIONS: Flexibility and adaptability are crucial for engaging with a traumatized community. Community-based participatory research work in traumatized communities must acknowledge and respond to community trauma to be successful.

Cost-effective sequence analysis of 113 genes in 1,192 probands with retinitis pigmentosa and Leber congenital amaurosis.

Introduction: Retinitis pigmentosa (RP) and Leber congenital amaurosis (LCA) are two groups of inherited retinal diseases (IRDs) where the rod photoreceptors degenerate followed by the cone photoreceptors of the retina. A genetic diagnosis for IRDs is challenging since >280 genes are associated with these conditions. While whole exome sequencing (WES) is commonly used by diagnostic facilities, the costs and required infrastructure prevent its global applicability. Previous studies have shown the cost-effectiveness of sequence analysis using single molecule Molecular Inversion Probes (smMIPs) in a cohort of patients diagnosed with Stargardt disease and other maculopathies. Methods: Here, we introduce a smMIPs panel that targets the exons and splice sites of all currently known genes associated with RP and LCA, the entire RPE65 gene, known causative deep-intronic variants leading to pseudo-exons, and part of the RP17 region associated with autosomal dominant RP, by using a total of 16,812 smMIPs. The RP-LCA smMIPs panel was used to screen 1,192 probands from an international cohort of predominantly RP and LCA cases. Results and discussion: After genetic analysis, a diagnostic yield of 56% was obtained which is on par with results from WES analysis. The effectiveness and the reduced costs compared to WES renders the RP-LCA smMIPs panel a competitive approach to provide IRD patients with a genetic diagnosis, especially in countries with restricted access to genetic testing.

Using single molecule Molecular Inversion Probes as a cost-effective, high-throughput sequencing approach to target all genes and loci associated with macular diseases.

Macular degenerations (MDs) are a subgroup of retinal disorders characterized by central vision loss. Knowledge is still lacking on the extent of genetic and nongenetic factors influencing inherited MD (iMD) and age-related MD (AMD) expression. Single molecule Molecular Inversion Probes (smMIPs) have proven effective in sequencing the ABCA4 gene in patients with Stargardt disease to identify associated coding and noncoding variation, however many MD patients still remain genetically unexplained. We hypothesized that the missing heritability of MDs may be revealed by smMIPs-based sequencing of all MD-associated genes and risk factors. Using 17,394 smMIPs, we sequenced the coding regions of 105 iMD and AMD-associated genes and noncoding or regulatory loci, known pseudo-exons, and the mitochondrial genome in two test cohorts that were previously screened for variants in ABCA4. Following detailed sequencing analysis of 110 probands, a diagnostic yield of 38% was observed. This established an ''MD-smMIPs panel," enabling a genotype-first approach in a high-throughput and cost-effective manner, whilst achieving uniform and high coverage across targets. Further analysis will identify known and novel variants in MD-associated genes to offer an accurate clinical diagnosis to patients. Furthermore, this will reveal new genetic associations for MD and potential genetic overlaps between iMD and AMD.

Biomechanical comparison of tuberosity-based proximal humeral locking plate compared to standard proximal humeral locking plate in varus cantilever bending.

PURPOSE: In a prior biomechanical study using a tuberosity-based proximal humeral locking plate (TBP) an improvement in greater tuberosity (GT) fixation strength with the TBP compared to a standard proximal humeral locking plate (PHLP) was demonstrated. The purpose of this study is to compare the TBP to the PHLP with a simulated calcar gap fracture under cyclic varus cantilever forces. METHODS: Seven matched pairs of cadaveric humeri were studied and 11A2.3 proximal humerus fractures were created by a 1 cm gap osteotomy at the surgical neck. Matched pairs were randomized for fixation using either a PHLP or a TBP. The proximal articular aspect of the humerus was potted and secured to the base of a load frame. The shaft was subjected to cyclic varus cantilever loading with a roller positioned 8 cm from the osteotomy. Change in vertical displacement of the diaphyseal fragment was monitored and digital images were obtained. Failure was defined as vertical displacement greater than 20 mm. Specimens not exhibiting failure over the course of 10,000 cycles were then loaded to 20 mm of vertical displacement. Reactant forces of the specimens at these displacements were recorded. RESULTS: Four/seven TBP specimens and four/seven PHLP specimens survived 10,000 cycles. The average cycles to failure for TBP specimens was 7325 cycles and 5715 cycles for PHLP specimens (p = 0.525). For the specimens that survived 10,000 cycles, the decrease in calcar gap was superior in the TBP specimens (p = 0.018). A similar trend was seen when these specimens were loaded to failure where the percent calcar gap recovery was higher for the TBP at 74.71 ± 10.07% versus 53.22 ± 30.35% for the PHLP (p = 0.072). In specimens that were loaded to failure after survival of 10,000 cycles the average stiffness of the TBP construct was 20.51 N/mm, and 11.74 N/mm for the PHLP construct (p = 0.024). CONCLUSION: In addition to superior GT fixation shown in a prior study, the TBP construct demonstrates significantly greater stiffness at the neck fracture compared to the PHLP, when loaded to failure. In addition, there was a trend towards less collapse in this calcar gap model.

Current Role of Reverse Total Shoulder Arthroplasty for Fractures of the Proximal Humerus.

LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Comparative effectiveness of treatment options for displaced midshaft clavicle fractures : a systematic review and network meta-analysis.

AIMS: The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures. METHODS: Initial search strategy incorporated MEDLINE, PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs). Four treatment arms were created: nonoperative (NO); intramedullary nailing (IMN); reconstruction plating (RP); and compression/pre-contoured plating (CP). A Bayesian NMA was conducted to compare all treatment options for outcomes of nonunion, malunion, and function using the Disabilities of the Arm Shoulder and Hand (DASH) and Constant-Murley Shoulder Outcome scores. RESULTS: In all, 19 RCTs consisting of 1,783 clavicle fractures were included in the NMA. All surgical options demonstrated a significantly lower odds ratio (OR) of nonunion in comparison to nonoperative management: CP versus NO (OR 0.08; 95% confidence interval (CI) 0.04 to 0.17); IMN versus NO (OR 0.07; 95% CI 0.02 to 0.19); RP versus NO (OR 0.07; 95% CI: 0.01 to 0.24). Compression plating was the only treatment to demonstrate significantly lower DASH scores relative to NO at six weeks (mean difference -10.97; 95% CI -20.69 to 1.47). CONCLUSION: Surgical fixation demonstrated a lower risk of nonunion compared to nonoperative management. Compression plating resulted in significantly less disability early after surgery compared to nonoperative management. These results demonstrate possible early improved functional outcomes with compression plating compared to nonoperative treatment. Surgical fixation of mid-shaft clavicle fractures with compression plating may result in quicker return to activity by rendering patients less disabled early after surgery. Cite this article: Bone Jt Open 2021;2(8):646-654.

Loan sharking: changing patterns in, and challenging perceptions of, an abuse of deprivation.

BACKGROUND: Illegal high interest lending or 'loan sharking' exploits the vulnerable and has profound negative impacts on individuals and communities. The 2008 UK financial crash and subsequent austerity programme coupled with changes in the consumer credit market have fuelled an increase in predatory lending. METHODS: The study is a descriptive analysis of demographic, financial, health and behavioural data on 753 victims (2011-2017). A review of the causative factors and potential political, economic and public health responses is analysed. RESULTS: Most victims were female but males were considerably more indebted. Illegal loans are largely taken out for routine living expenses and over 70% of victims reported other serious debts. Victims are disproportionately poor, unemployed and on benefits but fewer than half have had financial or benefits advice. Despite 90% reporting they would not borrow illegally again, 30% had previously done so from the same shark and over half considered them a friend. CONCLUSIONS: The increase in loan sharking has coincided with the withdrawal of traditional sub-prime lenders and local welfare assistance schemes, and the low penetration of Credit Unions in many areas. Conventional perceptions of loan sharks and their relationships with victims are largely incorrect. A range of coordinated financial, political and social interventions is required.

Analysis of Small Area Environmental, Socioeconomic and Health Data in Collaboration with Local Communities to Target and Evaluate 'Triple Win' Interventions in a Deprived Community in Birmingham UK.

The contemporary environment is a complex of interactions between physical, biological and socioeconomic systems with major impacts on public health. It is well understood that deprived communities are more exposed to negative environmental and social factors, more susceptible to the effects of those exposures, more excluded from access to positive factors, less able to change their circumstances and consequently experience worse health, economic and social outcomes compared to the more affluent. Welsh House Farm estate in Birmingham is one of the most deprived areas in Europe. An alliance between a local charity, City Council Public Health and a University in collaboration with the local community has accessed, analysed and mapped a range of health, social and economic factors at small area level, identifying areas where the community experience is unacceptably worse than other parts of Birmingham and therefore requiring targeted interventions. We make specific recommendations for coordinated action addressing the living, moving and consuming domains of residents' lives and have also identified positive aspects of life on the estate to celebrate. This pilot demonstrates the utility and cost-effectiveness of local collaboration to identify and target health, environmental and social inequalities informed by local concerns.

Wider horizons, wiser choices: horizon scanning for public health protection and improvement.

Background: Systematic continuous thinking about the future helps organizations, professions and communities to both prepare for, and shape, the future. This becomes ever more critical given the accelerating rate at which new data emerge, and in some cases uncertainties around their reliability and interpretation. Businesses with the capability to filter and analyse vast volumes of data to create knowledge and insights requiring action have a competitive advantage. Similarly Government and the public sector, including public health can be more effective and efficient through the early identification of emerging issues (both threats and opportunities). Methods: Horizon scanning approaches, and the use of resulting intelligence related to health protection and improvement were reviewed. Results: Public health horizon scanning systems have to date focussed on health technologies and infectious diseases. While these have been successful there is a major gap in terms of non-infectious hazards and health improvement. Conclusion: Any system to meet this need must recognize the changed environment for delivering front line public health services and the critical role of local authorities and the local democratic process. This presents opportunities and challenges and this paper explores those dynamics describing an existing environment and health horizon scanning system which could readily and rapidly be re-engineered to provide a national service.

Living in a 'fat swamp': exposure to multiple sources of accessible, cheap, energy-dense fast foods in a deprived community.

This study assesses the levels of fats, including trans-fatty acids, and salt in common takeaway fast foods in a deprived urban municipality in the West Midlands, England, and implications in the context of the spatial distribution of fast food takeaways. The results of the compositional analysis of over 250 take-out foods were compared with established and derived standards. About 70% of products exceeded the recommendation that a meal should contain less than 30% of a Guideline Daily Amount (GDA). More than half of them exceeded 50% GDA for at least one metric, including 81% of all analyses for SFA. And 17% of samples exceeded the GDA for SFA, including each of two meals that contained about twice the GDA. Over 30% samples exceeded the children's GDA for total fat or SFA. 27% of salt analyses exceeded the GDA. People in Sandwell are exposed to large portion sizes and high levels of fats and salt in takeaway foods, with levels in some foods having increased since 2010. Given this population's limited options to break out of a highly compromising environment of living simultaneously in a 'swamp' of unhealthy, readily accessible and cheap takeaways, and a 'desert' of healthy options, an immediate and innovative package of interventions is required.

Next-generation carrier screening.

PURPOSE: Carrier screening for recessive Mendelian disorders traditionally employs focused genotyping to interrogate limited sets of mutations most prevalent in specific ethnic groups. We sought to develop a next-generation DNA sequencing-based workflow to enable analysis of a more comprehensive set of disease-causing mutations. METHODS: We utilized molecular inversion probes to capture the protein-coding regions of 15 genes from genomic DNA isolated from whole blood and sequenced those regions using the Illumina HiSeq 2000 (Illumina, San Diego, CA). To assess the quality of the resulting data, we measured both the fraction of the targeted region yielding high-quality genotype calls, and the sensitivity and specificity of those calls by comparison with conventional Sanger sequencing across hundreds of samples. Finally, to improve the overall accuracy for detecting insertions and deletions, we introduce a novel assembly-based approach that substantially increases sensitivity without reducing specificity. RESULTS: We generated high-quality sequence for at least 99.8% of targeted base pairs in samples derived from blood and achieved high concordance with Sanger sequencing (sensitivity >99.9%, specificity >99.999%). Our novel algorithm is capable of detecting insertions and deletions inaccessible by current methods. CONCLUSION: Our next-generation DNA sequencing-based approach yields the accuracy and completeness necessary for a carrier screening test.