Citations

Background: Telemedicine is increasingly used to care for patients with movement disorders, but data regarding its global use are limited. Introduction: To obtain baseline international data about telemedicine use among movement disorder clinicians. Methods: An online survey was sent to all 6,056 Movement Disorder Society members in 2015. Scope, reimbursement, and perceived quality of telemedicine were assessed. Results: There were 549 respondents (9.1% overall response rate) from 83 countries. Most (85.8%) were physicians, and most (70.9%) worked in an academic or university practice. Half of respondents ( n = 287, from 57 countries) used telemedicine for clinical care; activities included e-mail (63.2%), video visits (follow-up [39.7%] and new [35.2%]), and video-based education (35.2%). One hundred five respondents personally conducted video visits, most frequently to outpatient clinics (53.5%), patient homes (30.8%), and hospital inpatients (30.3%). The most common challenges were a limited neurological examination (58.9%) and technological difficulties (53.3%), and the most common benefits were reduced travel time (92.9%) and patient costs (60.1%). The most frequent reimbursements were none (39.0%), public insurance (24.5%), and patient payment (9.3%). Half of respondents planned to use telemedicine in the future, and three-quarters were interested in telemedicine education. Conclusions: More than 250 respondents around the world engage in telemedicine for movement disorders; most perceived benefit for patients, despite challenges and reimbursement for clinicians. Formal instruction on telemedicine is highly desired. Although the survey response was low and possibly biased to over represent those with telemedicine experience, the study provides baseline data for future comparison and to improve telemedicine delivery.

Purpose: A biomechanical functional assessment was performed on a newly designed wrist hemiarthroplasty implant with aimed to identifying differences between the native wrist and wrist following the hemiarthroplasty procedure with [Formula: see text] and without a proximal row carpectomy (Hemi). Methods: Six cadaveric wrists were mounted on a custom testing fixture and underwent a series of functional tests to investigate differences in range of motion, muscles moment arms, and axis of rotation between the intact and post-operative wrists. The tested movements included manually-driven flexion-extension, radial-ulnar deviation, dart throwers motion, and circumduction. Results: The only significant change in range of motion was a decrease in flexion between the intact [Formula: see text] and both the Hemi [Formula: see text] and [Formula: see text] [Formula: see text] conditions. Minor differences in the mean position and variability of the axis of rotation’s piercing point were identified. A statistically significant decrease in the flexion moment arm of the flexor carpi radialis was identified between the intact ([Formula: see text][Formula: see text]mm) and [Formula: see text] ([Formula: see text][Formula: see text]mm) conditions. Statistically significant decreases were also identified in the radial deviation moment arms of the extensor carpi radialis brevis’ between the intact ([Formula: see text][Formula: see text]mm) and [Formula: see text] ([Formula: see text][Formula: see text]mm) conditions and the flexor carpi radialis’ between the intact ([Formula: see text][Formula: see text]mm) and Hemi ([Formula: see text][Formula: see text]mm) conditions as well as in the ulnar deviation moment arm of the extensor carpi ulnaris between the intact ([Formula: see text][Formula: see text]mm) and Hemi ([Formula: see text][Formula: see text]mm) conditions. Conclusions: While some statistically significant functional changes were identified between the native and hemiarthroplasty wrist, the findings suggest that post-operative function is equally acceptable in hemiarthroplasty with and without resection of the proximal carpal row.

Background: Joint incongruity in posteromedial rotatory instability (PMRI) has been theorized to determine early articular degenerative changes. Our hypothesis was that the articular contact area and contact pressure differ significantly between an intact elbow and an elbow affected by PMRI. Methods: Seven cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and allow passive elbow flexion (0° to 90°). The mean contact area and contact pressure data were collected and processed using the Tekscan sensor and software. After testing the intact specimen (intact elbow), a PMRI injury was simulated (PMRI elbow) and the specimen was tested again. Results: The PMRI elbows were characterized by initial joint subluxation and significantly elevated articular contact pressure. Both worsened, corresponding with a reduction in contact area, as the elbow was flexed from 0° until the joint subluxation and incongruity spontaneously reduced (at a mean [and standard error] of 60° ± 5° of flexion), at which point the mean contact pressure decreased from 870 ± 50 kPa (pre-reduction) to 440 ± 40 kPa (post-reduction) (p < 0.001) and the mean contact area increased from 80 ± 8 mm 2 to 150 ± 58 mm 2 (p < 0.001). This reduction of the subluxation was also followed by a shift of the contact area from the coronoid fracture edge toward the lower portion of the coronoid. At the flexion angle at which the PMRI elbows reduced, both the contact area and the contact pressure of the intact elbows differed significantly from those of the PMRI elbows, both before and after the elbow reduction (p < 0.001). Conclusions: The reduction in contact area and increased contact pressures due to joint subluxation and incongruity could explain the progressive arthritis seen in some elbows affected by PMRI. Clinical Relevance: This biomechanical study suggests that the early degenerative changes associated with PMRI reported in the literature could be subsequent to joint incongruity and an increase in contact pressure between the coronoid fracture surface and the trochlea.

Axial carpal injuries are rare entities where a traumatic force transmits through the intermetacarpal space, dissociating the carpometacarpal joint and disrupting the distal carpal row in an axial radial or axial ulnar pattern via true axial force or compressive crush mechanism. Differences in outcomes remain unclear with regard to the specific type of axial carpal injury pattern. A retrospective case series identified 37 wrists (in 37 patients) over 25 years who presented to a Level 1 trauma centre, with 20 wrists experiencing an axial radial injury and 17 wrists experiencing an axial ulnar injury. Of all the variables evaluated, only axial radial injuries were identified as predictors of poor outcome as defined by Mayo Wrist scores with univariate analysis demonstrating 6 times increased risk and multivariate analysis demonstrating 15 times increased risk of a poor outcome compared with axial ulnar injuries. This knowledge will provide prognostic information to surgeons managing patients with these severe injuries. Level of evidence: IV

SummaryBackgroundAlthough obesity affects approximately one in five youths, only a fraction is treated in pediatric weight management clinics. Characteristics distinguishing youth with obesity who seek weight management treatment from those who do not are largely unknown. Yet identification of specific health characteristics which differentiate treatment‐seeking from non‐treatment seeking youth with obesity may shed light on underlying motivations for pursuing treatment.ObjectivesCompare the cardiometabolic profiles of an obesity treatment‐seeking sample of youth to a population‐based sample of youth with obesity, while controlling for body mass index (BMI).MethodsThis cross‐sectional study included participants, ages 12–17 years, with obesity from the Pediatric Obesity and Weight Evaluation Registry (POWER) and National Health and Nutrition Examination Survey, representing the treatment‐seeking and population samples, respectively. Mean differences were calculated for systolic and diastolic blood pressure percentiles, total cholesterol, low‐density and high‐density lipoprotein‐cholesterol, triglycerides, fasting glucose, glycated hemoglobin and alanine aminotransferase, while adjusting for age, sex, race/ethnicity, insurance status, and multiple of the 95th BMI percentile.ResultsThe POWER and National Health and Nutrition Examination Survey cohorts included 1,823 and 617 participants, respectively. The POWER cohort had higher systolic blood pressure percentile (mean difference 17.4, 95% confidence interval [14.6, 20.1], p < 0.001), diastolic blood pressure percentile (21.8 [19, 24.5], p < 0.001), triglycerides (42.3 [28, 56.5], p < 0.001) and alanine aminotransferase (7.5 [5.1, 9.8], p < 0.001) and lower fasting glucose (−6.9 [−8.2, −5.6], p < 0.001) and high‐density lipoprotein‐cholesterol (−2.3 [−3.8, −0.9], p < 0.002). There were no differences in total cholesterol or low‐density lipoprotein‐cholesterol or clinical differences in glycated hemoglobin.ConclusionFor a given BMI, obesity treatment‐seeking youth are more adversely affected by cardiometabolic risk factors than the general population of youth with obesity. This suggests that treatment‐seeking youth may represent a distinct group that is at particularly high risk for the development of future cardiometabolic disease.

Objective: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. Design: Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. Setting: ICUs. Patients: Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo ( n = 45 and n = 60, respectively). Interventions: IV angiotensin II or placebo. Measurements and Main Results: Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo ( p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo ( p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo ( p = 0.001), respectively. Conclusions: In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.

IntroductionIn prior small animal studies, we maintained vascularized bone allotransplant viability without long‐term immunotherapy. Instead, an autogenous neoangiogenic circulation is created from implanted vessels, sufficient to maintain bone viability with only 2 weeks immunosupression. Blood flow is maintained despite rejection of the allogeneic vascular pedicle thereafter. We have previously described a large animal (swine) pre‐clinical model, reconstructing tibial defects with vascularized tibial allotransplants. In this manuscript, autologous angiogenesis is evaluated in this model and correlated with bone viability.Materials and methodsAllogeneic tibial segments were transplanted across a major swine leukocyte antigen mismatch. Microvascular repair of the bone VCA pedicle was combined with intraosseous implantation of an autogenous arteriovenous (AV) bundle. The bundle was ligated in group 1 (n = 4), and allowed to perfuse in group 2 (n = 4). Three‐drug immunotherapy was given for 2 weeks. At 16 weeks micro‐CT angiography quantified neoangiogenic vessel volume. Bone viability, rejection grade, and bone healing were analyzed.ResultsA substantial neoangiogenic circulation developed from the implanted AV‐bundle in group 2, with vessel density superior to ligated AV‐bundle controls (0.11 ± 0.05 vs. 0.01 ± 0.01, P = .029). Bone allotransplant viability was also significantly enhanced by neoangiogenesis (78.7 ± 4.4% vs. 27.7 ± 5.8%, P = .028) with higher bone healing scores (21.4 ± 2.9 vs. 12.5 ± 3.7, P = .029). Ligated control tibias demonstrated disorganized bone morphology and higher local inflammation (P = .143).ConclusionImplantation of autogenous AV bundles into vascularized bone allotransplants resulted in the rapid formation of a neoangiogenic autogenous blood supply in a swine tibia model that maintained bone viability, improved bone healing, and minimized rejection.

703 Background: Clinical and pathologic factors alone have limited prognostic ability in patients with metastatic clear cell renal cell carcinoma (ccRCC). We sought to determine if tissue biomarkers, along with our previously reported clinical metastases score, can be used to predict cancer specific survival (CSS) in patients with metastatic ccRCC. Methods: Patients with metastatic ccRCC who underwent nephrectomy between 1990-2004 were identified using the Mayo Clinic Nephrectomy Registry. Sections from paraffin-embedded primary tumor tissue blocks were used for immunohistochemistry staining for PD-1, B7-H1 (PD-L1), B7-H3, Bim (downstream pro-apoptotic signaling molecule in PD-1 pathway), CA-IX, IMP3, Ki67, and survivin. CSS was the primary outcome. Biomarkers that were significantly associated with CSS after adjusting for the metastases score were used to develop a biomarker-specific multivariable model using a bootstrap resampling approach and forward selection. Predictive ability was summarized using a bootstrap-corrected c-index. Results: The cohort included 602 patients, 192 (32%) with metastases at diagnosis and 410 (68%) who developed metastases after nephrectomy. Median follow-up among survivors was 9.6 years (IQR 4.2,12.8) and 504 patients died of RCC. Bim, IMP3, Ki67, and survivin expression were significantly associated with CSS after adjusting for the metastases score and were used to develop a biomarker-specific model. High Bim (HR 1.44; 95%CI 1.16-1.78; p < 0.001), high survivin (HR 1.35; 95%CI 1.08-1.68; p = 0.008), and the metastases score (HR 1.13 per one point; 95%CI 1.10-1.16; p < 0.001) were retained as independent predictors in the final multivariable model (c-index 0.69). Conclusions: We created a prognostic model combining the clinical metastases score and two primary tissue expression biomarkers, Bim and survivin, for patients with metastatic RCC who underwent nephrectomy. External validation will be required prior to clinical use.