Citations

Abstract Degeneration of the thymus and severe contraction of the T cell repertoire with aging suggest that immune homeostasis in old age could be mediated by distinct effectors. Therefore, receptors expressed on T cells as they undergo senescence in vitro, as well as those displayed by circulating T cells during normal chronologic aging, were examined. Monitoring of T cells driven to senescence showed de novo induction of CD56, the prototypic receptor of NK cells. Analysis of fresh T cells in peripheral blood showed an age-dependent induction of CD56. These unusual T cells expressed high levels of Bcl2, p16, and p53, and had limited, or completely lost, ability to undergo cell division, properties consistent with senescence. CD56 cross-linking without TCR ligation on CD56+ T cells resulted in extensive protein phosphorylation, NF-κB activation, and Bax down-regulation. CD56 cross-linking was also sufficient to drive production of various humoral factors. These data suggest that the immunologic environment in old age is functionally distinct, rather than being a dysfunctional version of that seen at a young age. CD56+ T cells are unique effectors capable of mediating TCR-independent immune cascades that could be harnessed to enhance protective immunity in the elderly.

ABSTRACT Children and adolescents who sustain a distal forearm fracture (DFF) owing to mild, but not moderate, trauma have reduced bone strength and cortical thinning at the distal radius and tibia. Whether these skeletal deficits track into adulthood is unknown. Therefore, we studied 75 women and 75 men (age range, 20 to 40 years) with a childhood (age <18 years) DFF and 150 sex-matched controls with no history of fracture using high-resolution peripheral quantitative computed tomography (HRpQCT) to examine bone strength (ie, failure load) by micro–finite element (µFE) analysis, as well as cortical and trabecular bone parameters at the distal radius and tibia. Level of trauma (mild versus moderate) was assigned using a validated classification scheme, blind to imaging results. When compared to sex-matched, nonfracture controls, women and men with a mild trauma childhood DFF (eg, fall from standing height) had significant reductions in failure load (p < 0.05) of the distal radius, whereas women and men with a moderate trauma childhood DFF (eg, fall while riding a bicycle) had values similar to controls. Consistent findings were observed at the distal tibia. Furthermore, women and men with a mild trauma childhood DFF had significant deficits in distal radius cortical area (p < 0.05), and significantly lower dual-energy X-ray absorptiometry (DXA)-derived bone density at the radius, hip, and total body regions compared to controls (all p < 0.05). By contrast, women and men with a moderate trauma childhood DFF had bone density, structure, and strength that did not differ significantly from controls. These findings in young adults are consistent with our observations in children/adolescents with DFF, and they suggest that a mild trauma childhood DFF may presage suboptimal peak bone density, structure, and strength in young adulthood. Children and adolescents who suffer mild trauma DFFs may need to be targeted for lifestyle interventions to help achieve improved skeletal health. © 2014 American Society for Bone and Mineral Research.

ABSTRACT We describe the first reported case of Ureaplasma parvum prosthetic joint infection (PJI) detected by PCR. Ureaplasma species do not possess a cell wall and are usually associated with colonization and infection of mucosal surfaces (not prosthetic material). U. parvum is a relatively new species name for certain serovars of Ureaplasma urealyticum , and PCR is useful for species determination. Our patient presented with late infection of his right total knee arthroplasty. Intraoperative fluid and tissue cultures and pre- and postoperative synovial fluid cultures were all negative. To discern the pathogen, we employed PCR coupled with electrospray ionization mass spectrometry (PCR/ESI-MS). Our patient's failure to respond to empirical antimicrobial treatment and our previous experience with PCR/ESI-MS in culture-negative cases of infection prompted us to use this approach over other diagnostic modalities. PCR/ESI-MS detected U. parvum in all samples. U. parvum -specific PCR testing was performed on all synovial fluid samples to confirm the U. parvum detection.

Background and Purpose— To address the increasing need to counsel patients about treatment indications for unruptured intracranial aneurysms (UIA), we endeavored to develop a consensus on assessment of UIAs among a group of specialists from diverse fields involved in research and treatment of UIAs. Methods— After composition of the research group, a Delphi consensus was initiated to identify and rate all features, which may be relevant to assess UIAs and their treatment by using ranking scales and analysis of inter-rater agreement (IRA) for each factor. IRA was categorized as very high, high, moderate, or low. Results— Ultimately, 39 specialists from 4 specialties agreed (high or very high IRAs) on the following key factors for or against UIA treatment decisions: (1) patient age, life expectancy, and comorbid diseases; (2) previous subarachnoid hemorrhage from a different aneurysm, family history for UIA or subarachnoid hemorrhage, nicotine use; (3) UIA size, location, and lobulation; (4) UIA growth or de novo formation on serial imaging; (5) clinical symptoms (cranial nerve deficit, mass effect, and thromboembolic events from UIAs); and (6) risk factors for UIA treatment (patient age and life expectancy, UIA size, and estimated risk of treatment). However, IRAs for features rated with low relevance were also generally low, which underlined the existing controversy about the natural history of UIAs. Conclusions— Our results highlight that neurovascular specialists currently consider many features as important when evaluating UIAs but also highlight that the appreciation of natural history of UIAs remains uncertain, even within a group of highly informed individuals.

Background: The current systems of healthcare delivery in the United States suffer from problems that often leave patients with inadequate quality of care. In their report entitled “Crossing the Quality Chasm,” the Institute of Medicine (IOM) identified reasons for poor and/or inconsistent quality of healthcare delivery and provided recommendations to improve it. The purpose of this review is to describe features of an innovative web-based program called the Thyroid Cancer Care Collaborative (TCCC) and see how it addresses IOM recommendations to improve the quality of healthcare delivery. Summary: The TCCC addresses the three actionable IOM recommendations directed at healthcare organizations and clinicians to redesign the care process. It does so by exploiting information technology (IT) in ways suggested by the IOM, and it fits within a set of 10 rules provided by the IOM. Some features of the TCCC include: (i) automated disease staging based on three validated scoring systems; (ii) highly illustrated educational videos on all aspects of thyroid cancer care; (iii) personalized clinical decision-making modules for clinicians and physicians; (iv) portability of data to share among treating physicians; (v) virtual tumor boards, “ask the expert,” and frequently asked questions modules; (vi) physician workflow integration; and (vii) data for comprehensive analysis to answer difficult questions in thyroid cancer management. Conclusion: The TCCC has the potential to improve thyroid cancer care delivery and offers several benefits to patients, clinicians, and researchers. The TCCC is a valuable example of how IOM initiatives can improve the healthcare system.

AbstractPurposeCurrently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2‐year follow‐up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).MethodsThe records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan–Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2‐year follow‐up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.ResultsFifty‐nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow‐up of 5 (range 2–14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6–60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.ConclusionsIsolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.Level of evidenceRetrospective case series, Level IV.

Abstract Purpose Intra‐articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients. Methods At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre‐injection, during post‐injection anaesthetic phase, and at 14 days post‐injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected. Results Fifty‐four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre‐injection NRS score was 7.0 (range 2.5–10.0), post‐injection anaesthetic phase was 1.0 (range 0.0–5.0), and 14 day post‐injection was 5.0 (range 0.0–10.0). As a group, NRS scores significantly diminished from post‐injection anaesthetic phase to 14 days post‐injection ( p < 0.001). At 14 days post‐injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations. Conclusion In patients with symptomatic FAI and labral tear, intra‐articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic‐only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool. Level of evidence Therapeutic case series, Level IV.

AbstractBackgroundWell‐differentiated thyroid cancer (WDTC) recurs in up to 30% of patients. Guidelines from the American Thyroid Association (ATA) and the National Comprehensive Cancer Network (NCCN) provide valuable parameters for the management of recurrent disease, but fail to guide the clinician as to the multitude of factors that should be taken into account. The Thyroid Cancer Care Collaborative (TCCC) is a web‐based repository of a patient's clinical information. Ten clinical decision‐making modules (CDMMs) process this information and display individualized treatment recommendations.MethodsWe conducted a review of the literature and analysis of the management of patients with recurrent/persistent WDTC.ResultsSurgery remains the most common treatment in recurrent/persistent WDTC and can be performed with limited morbidity in experienced hands. However, careful observation may be the recommended course in select patients. Reoperation yields biochemical remission rates between 21% and 66%. There is a reported 1.2% incidence of permanent unexpected nerve paralysis and a 3.5% incidence of permanent hypoparathyroidism. External beam radiotherapy and percutaneous ethanol ablation have been reported as therapeutic alternatives. Radioactive iodine as a primary therapy has been reported previously for metastatic lymph nodes, but is currently advocated by the ATA as an adjuvant to surgery.ConclusionThe management of recurrent lymph nodes is a multifactorial decision and is best determined by a multidisciplinary team. The CDMMs allow for easy adoption of contemporary knowledge, making this information accessible to both patient and clinician. © 2014 Wiley Periodicals, Inc. Head Neck 37: 605–614, 2015