Medial Discoid Meniscus in Children: A Multicenter Case Series of Clinical Features and Operative Results.

BACKGROUND: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature is limited to small case series. PURPOSE/HYPOTHESIS: Our purpose is to report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. We hypothesized that symptoms and signs, arthroscopic findings, surgical treatments, and outcomes are similar to those for symptomatic discoid lateral menisci. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review identified patients with a diagnosed discoid medial meniscus confirmed at surgery across 8 children's hospitals between January 2000 and June 2021. The literature on discoid lateral menisci was reviewed and summarized for comparison. RESULTS: A total of 21 patients (9 female, 12 male) with 22 discoid medial menisci were identified. The mean ± SD age at the time of diagnosis was 12.8 ± 3.8 years. The most common symptoms and signs were locking and/or clunking, present in 12 of 22 knees (55%), similar to that reported in patients with discoid lateral menisci. Twelve discoid medial menisci were complete (55%); 8, incomplete (36%); and 2, indeterminate (9%). Tears were present in 13 knees, most commonly horizontal cleavage (54%). Five discoid medial menisci were unstable (23%): 3 for posterior tears and 2 for rim insufficiency. All 22 knees underwent arthroscopic saucerization, and of the 13 torn menisci, 7 (54%) were repaired. The median follow-up was 24 months (range, 2-82 months). Four knees underwent reoperation. All knees that required reoperation had undergone repair for a posteriorly located tear. There was a significant association between operative repair and need for reoperation (P = .0048). High rates of peripheral instability were also noted in case series of patients with discoid lateral menisci. CONCLUSION: Patient presentations and treatments for those with discoid medial menisci were similar to those reported for patients with discoid lateral menisci. Knees with discoid medial menisci also demonstrated instability attributed to peripheral insufficiency and posterior tears. Tears were present in over half of knees with discoid medial menisci, and reoperation was more common in knees that underwent repair of tears than those without repair.

Athletes in medicine: A systematic review of performance of athletes in medicine.

INTRODUCTION: As interest in medicine grows, admissions committees must review an increasingly competitive pool of medical school and residency candidates. Nearly all admissions committees have moved towards a holistic review, which considers an applicant's experiences and attributes in addition to academic metrics. As such, identifying nonacademic predictors of success in medicine is necessary. Parallels between skills necessary to succeed in athletics and in medicine have been drawn, including teamwork, discipline and resiliency. This systematic review synthesises the current literature to evaluate the relationship between participation in athletics and performance in medicine. METHODS: The authors searched five databases to conduct a systematic review following PRISMA guidelines. Included studies assessed medical students, residents or attending physicians in the United States or Canada and used prior athletic participation as a predictor or explanatory variable. The review examined associations between prior athletic participation and outcomes in medical school, residency and/or as an attending physician. RESULTS: Eighteen studies evaluating medical students (78%), residents (28%) or attending physicians (6%) met inclusion criteria for this systematic review. Twelve (67%) studies specifically assessed participants based on skill level, and five (28%) studies specifically assessed participants based on type of athletic participation (team versus individual). Sixteen studies (89%) found that former athletes performed significantly better than their counterparts (p < 0.05). These studies found significant associations between prior athletic participation and better outcomes in multiple performance indicators, including exam scores, faculty ratings, surgical errors and burnout. CONCLUSIONS: Current literature, although limited, suggests that prior participation in athletics may be a predictor of success in medical school and residency. This was demonstrated through objective scoring methods, such as USMLE, and subjective outcomes, such as faculty ratings and burnout. Specifically, multiple studies indicate that former athletes demonstrated increased surgical skill proficiency and decreased burnout as medical students and residents.

Abbreviated Outpatient Upper Extremity Fracture Care to Avoid Clinic and Hospital Environmental Encounters During the COVID-19 Pandemic: A New Approach to Fracture Care?

BACKGROUND: To minimize in-person visits during the COVID-19 pandemic, a new fracture care protocol for children with complete and stable, nondisplaced or minimally displaced upper extremity (UE) fractures has been implemented. This protocol involves immobilization with a bivalved cast, which allows for home cast removal during a telemedicine visit, and no follow-up radiographs, thus eliminating the requirement for a return to clinic. The purpose of this study is to evaluate the outcomes and parent satisfaction of this new abbreviated fracture care protocol. METHODS: Between May 2020 and April 2021, during the COVID-19 pandemic, children with complete and stable, nondisplaced or minimally displaced UE fractures were treated with a bivalved cast and 1 follow-up telemedicine visit for home cast removal. A prospective longitudinal study of these patients was performed. The PROMIS Upper Extremity questionnaire was administered at enrollment and 3 months follow-up. Parents completed a satisfaction survey after home cast removal. Demographic data and information regarding complications were collected. A historical cohort of controls treated with standard cast in 2019 was used for comparison. RESULTS: A total of 56 patients with a mean age of 8±3 years (range 2 to 15) were prospectively enrolled in this study. Parent-reported PROMIS Upper Extremity scores showed a significant increase from 24.9 (95% confidence interval=20.8-29.1) at enrollment to 51.6 (95% confidence interval=50.8-52.5) at 3 months follow-up (P<0.001). Results of the satisfaction survey (n=39) showed all parents were either very satisfied (85%) or satisfied (15%). In addition, 10% of parents would have initially preferred to come into clinic for cast removal and 90% of parents would prefer this new treatment plan in the future. Patients in the abbreviated care cohort returned to clinic for a median 1 in-person visits, compared with 2 for historical controls (n=183, P<0.001). Abbreviated care patients received fewer (1.0) radiographs than controls (2.0, P<0.001). Complication rate did not differ between the groups (P=0.77). CONCLUSIONS: Complete and stable, nonminimally or minimally displaced UE fractures can be cared for safely and effectively in a single in-person visit, with a telemedicine cast removal visit. Parents are satisfied with this abbreviated protocol and prefer it to additional in-person visits. LEVEL OF EVIDENCE: Level III.

Nutritional Analysis of Foods and Beverages Posted in Social Media Accounts of Highly Followed Celebrities.

Importance: Celebrity social media posts engage millions of young followers daily, but the nutritional quality of foods and beverages in such posts, sponsored and unsponsored, is unknown. Objective: To quantify the nutritional quality of foods and beverages depicted in social media accounts of highly followed celebrities and assess whether nutritional quality is associated with post sponsorship, celebrity profession or gender, and followers' likes and comments. Design, Setting, and Participants: This cross-sectional study analyzed the content of food- and beverage-containing posts from Instagram (a photo- and video-sharing social media platform) accounts of 181 highly followed athletes, actors, actresses, television personalities, and music artists. Data were collected from May 2019 to March 2020. Main Outcomes and Measures: The nutritional quality of foods and beverages posted in celebrity social media accounts was rated using the Nutrient Profile Index (NPI) based on the sugar, sodium, energy, saturated fat, fiber, protein, and fruit and/or vegetable content per 100-g sample (a score of 0 indicated least healthy and 100, healthiest); foods with scores less than 64 and beverages with scores less than 70 were rated as "less healthy." Secondary outcomes were whether the nutritional quality of foods and beverages in social media posts was associated with post sponsorship, celebrity profession or gender, and followers' likes and comments. Mixed-effects regression models were used to estimate how outcomes differed across fixed effects. Results: The sample included social media accounts of 181 celebrities (66 actors, actresses, and television personalities [36.5%]; 64 music artists [35.4%]; and 51 athletes [28.2%]). A total of 102 celebrities (56.4%) were male, and the median age was 32 years (range, 17-73 years). Among 3065 social media posts containing 5180 total foods and beverages (2467 foods [47.6%]; 2713 beverages [52.4%]), snacks and sweets (920 [37.3%] of the foods) and alcoholic beverages (1375 [50.7%] of the beverages) were most common. Overall, 158 celebrity social media accounts (87.3%) earned a less healthy overall food nutrition score and 162 (89.5%) earned a less healthy overall beverage nutrition score, which would be unhealthy enough to fail legal youth advertising limits in the UK. For foods, social media posts with healthier nutrition scores were associated with significantly fewer likes (b, -0.003; 95% CI, -0.006 to 0.000; P = .04) and comments (b, -0.006; 95% CI, -0.009 to -0.003; P < .001) from followers. For beverages, nutrition scores were not significantly associated with likes (b, -0.010; 95% CI, -0.025 to 0.005; P = .18) or comments (b, -0.003; 95% CI, -0.022 to 0.016; P = .73). Only 147 food- or beverage-containing posts (4.8%) were sponsored by food- or beverage-relevant companies. Beverages in sponsored posts contained more than twice as much alcohol as those in nonsponsored posts (10.8 g [95% CI, 9.3 g to 12.3 g] per 100 g of beverage vs 5.3 g [95% CI, 4.7 g to 5.9 g] per 100 g of beverage). Conclusions and Relevance: In this cross-sectional study, most highly followed celebrity social media accounts depicted an unhealthy profile of foods and beverages, primarily in nonsponsored posts. These results suggest that influential depictions of unhealthy food and beverage consumption on social media may be a sociocultural problem that extends beyond advertisements and sponsorships, reinforcing unhealthy consumption norms.

Five-star prices, appealing healthy item descriptions? Expensive restaurants' descriptive menu language.

Objective: Prior research shows that America's top-selling inexpensive casual dining restaurants use less appealing language to describe healthy menu items than standard items. This may suggest to diners that healthy options are less tasty and enjoyable. The present research asked whether expensive restaurants also use less appealing language to describe healthy items, or whether healthy items are described with equally appealing language as standard items in high status dining contexts. Method: Using Yelp, the name and description of every food item were recorded from the menus of 160 top-rated expensive restaurants across 8 U.S. cities (Nitems = 3,295; Nwords = 32,516). Healthy menu items were defined as salads and side vegetables, and standard items as all other dishes (excluding desserts), with high interrater reliability (K = .89). Descriptive words were categorized into 22 predefined themes, and log likelihood analyses compared normalized theme frequencies from standard item and healthy item descriptions. Results: Healthy items were described with 4.8-times fewer American region words, 2.7-times fewer exciting words, 1.4-times fewer tasty words, and significantly fewer portion size, spicy, artisanal, and foreign region words. Unlike inexpensive restaurants, however, expensive restaurants did not use any health-focused themes to promote healthy items and used several appealing themes more frequently in healthy item descriptions. Conclusions: Like inexpensive restaurants, expensive American restaurants described healthy items as less appealing and less authentically American than standard foods, but to a lesser extent. Implications for ordering behavior and solutions for improving the appeal of healthy menu items are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Naïve human pluripotent stem cells respond to Wnt, Nodal and LIF signalling to produce expandable naïve extra-embryonic endoderm.

Embryonic stem cells (ESCs) exist in at least two states that transcriptionally resemble different stages of embryonic development. Naïve ESCs resemble peri-implantation stages and primed ESCs the pre-gastrulation epiblast. In mouse, primed ESCs give rise to definitive endoderm in response to the pathways downstream of Nodal and Wnt signalling. However, when these pathways are activated in naïve ESCs, they differentiate to a cell type resembling early primitive endoderm (PrE), the blastocyst-stage progenitor of the extra-embryonic endoderm. Here, we apply this context dependency to human ESCs, showing that activation of Nodal and Wnt signalling drives the differentiation of naïve pluripotent cells toward extra-embryonic PrE, or hypoblast, and these can be expanded as an in vitro model for naïve extra-embryonic endoderm (nEnd). Consistent with observations made in mouse, human PrE differentiation is dependent on FGF signalling in vitro, and we show that, by inhibiting FGF receptor signalling, we can simplify naïve pluripotent culture conditions, such that the inhibitor requirements closer resemble those used in mouse. The expandable nEnd cultures reported here represent stable extra-embryonic endoderm, or human hypoblast, cell lines.This article has an associated 'The people behind the papers' interview.

Insulin fine-tunes self-renewal pathways governing naive pluripotency and extra-embryonic endoderm.

Signalling downstream of Activin/Nodal (ActA) and Wnt can induce endoderm differentiation and also support self-renewal in pluripotent cells. Here we find that these apparently contradictory activities are fine-tuned by insulin. In the absence of insulin, the combination of these cytokines supports endoderm in a context-dependent manner. When applied to naive pluripotent cells that resemble peri-implantation embryos, ActA and Wnt induce extra-embryonic primitive endoderm (PrE), whereas when applied to primed pluripotent epiblast stem cells (EpiSC), these cytokines induce gastrulation-stage embryonic definitive endoderm. In naive embryonic stem cell culture, we find that insulin complements LIF signalling to support self-renewal; however, when it is removed, LIF, ActA and Wnt signalling not only induce PrE differentiation, but also support its expansion. Self-renewal of these PrE cultures is robust and, on the basis of gene expression, these cells resemble early blastocyst-stage PrE, a naive endoderm state able to make both visceral and parietal endoderm.

Transcriptional regulation of Hhex in hematopoiesis and hematopoietic stem cell ontogeny.

Hematopoietic stem cells (HSCs) emerge during development via an endothelial-to-hematopoietic transition from hemogenic endothelium of the dorsal aorta (DA). Using in situ hybridization and analysis of a knock-in RedStar reporter, we show that the transcriptional regulator Hhex is expressed in endothelium of the dorsal aorta (DA) and in clusters of putative HSCs as they are specified during murine development. We exploited this observation, using the Hhex locus to define cis regulatory elements, enhancers and interacting transcription factors that are both necessary and sufficient to support gene expression in the emerging HSC. We identify an evolutionarily conserved non-coding region (ECR) in the Hhex locus with the capacity to bind the hematopoietic-affiliated transcriptional regulators Gata2, SCL, Fli1, Pu.1 and Ets1/2. This region is sufficient to drive the expression of a transgenic GFP reporter in the DA endothelium and intra-aortic hematopoietic clusters. GFP-positive AGM cells co-expressed HSC-associated markers c-Kit, CD34, VE-Cadherin, and CD45, and were capable of multipotential differentiation and long term engraftment when transplanted into myelo-ablated recipients. The Hhex ECR was also sufficient to drive expression at additional blood sites including the yolk sac blood islands, fetal liver, vitelline and umbilical arteries and the adult bone marrow, suggesting a common mechanism for Hhex regulation throughout ontogenesis of the blood system. To explore the physiological requirement for the Hhex ECR region during hematoendothelial development, we deleted the ECR element from the endogenous locus in the context of a targeted Hhex-RedStar reporter allele. Results indicate a specific requirement for the ECR in blood-associated Hhex expression during development and further demonstrate a requirement for this region in the adult HSC compartment. Taken together, our results identified the ECR region as an enhancer both necessary and sufficient for gene expression in HSC development and homeostasis. The Hhex ECR thus appears to be a core node for the convergence of the transcription factor network that governs the emergence of HSCs.

Tissue-specific transcriptomics and proteomics of a filarial nematode and its Wolbachia endosymbiont.

BACKGROUND: Filarial nematodes cause debilitating human diseases. While treatable, recent evidence suggests drug resistance is developing, necessitating the development of novel targets and new treatment options. Although transcriptomic and proteomic studies around the nematode life cycle have greatly enhanced our knowledge, whole organism approaches have not provided spatial resolution of gene expression, which can be gained by examining individual tissues. Generally, due to their small size, tissue dissection of human-infecting filarial nematodes remains extremely challenging. However, canine heartworm disease is caused by a closely related and much larger filarial nematode, Dirofilaria immitis. As with many other filarial nematodes, D. immitis contains Wolbachia, an obligate bacterial endosymbiont present in the hypodermis and developing oocytes within the uterus. Here, we describe the first concurrent tissue-specific transcriptomic and proteomic profiling of a filarial nematode (D. immitis) and its Wolbachia (wDi) in order to better understand tissue functions and identify tissue-specific antigens that may be used for the development of new diagnostic and therapeutic tools. METHODS: Adult D. immitis worms were dissected into female body wall (FBW), female uterus (FU), female intestine (FI), female head (FH), male body wall (MBW), male testis (MT), male intestine (MI), male head (MH) and 10.1186/s12864-015-2083-2 male spicule (MS) and used to prepare transcriptomic and proteomic libraries. RESULTS: Transcriptomic and proteomic analysis of several D. immitis tissues identified many biological functions enriched within certain tissues. Hierarchical clustering of the D. immitis tissue transcriptomes, along with the recently published whole-worm adult male and female D. immitis transcriptomes, revealed that the whole-worm transcriptome is typically dominated by transcripts originating from reproductive tissue. The uterus appeared to have the most variable transcriptome, possibly due to age. Although many functions are shared between the reproductive tissues, the most significant differences in gene expression were observed between the uterus and testis. Interestingly, wDi gene expression in the male and female body wall is fairly similar, yet slightly different to that of Wolbachia gene expression in the uterus. Proteomic methods verified 32 % of the predicted D. immitis proteome, including over 700 hypothetical proteins of D. immitis. Of note, hypothetical proteins were among some of the most abundant Wolbachia proteins identified, which may fulfill some important yet still uncharacterized biological function. CONCLUSIONS: The spatial resolution gained from this parallel transcriptomic and proteomic analysis adds to our understanding of filarial biology and serves as a resource with which to develop future therapeutic strategies against filarial nematodes and their Wolbachia endosymbionts.