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[Background]: Fibroblast growth factors (Fgfs) are required for survival and organ formation during embryogenesis. Fgfs often execute their functions redundantly. Previous analysis of Fgf3 mutants revealed effects on inner ear formation and embryonic survival with incomplete penetrance. [Results]: Here, we show that presence of a neomycin resistance gene (neo) replacing the Fgf3 coding region leads to reduced survival during embryogenesis and an increased penetrance of inner ear defects. Fgf3neo/neo mutants showed reduced expression of Fgf4, which is positioned in close proximity to the Fgf3 locus in the mouse genome. Conditional inactivation of Fgf4 during inner ear development on a Fgf3 null background using Fgf3/4 cis mice revealed a redundant requirement between these Fgfs during otic placode induction. In contrast, inactivation of Fgf3 and Fgf4 in the pharyngeal region where both Fgfs are also co-expressed using a Foxg1-Cre driver did not affect development of the pharyngeal arches. However, these mutants showed reduced perinatal survival. [Conclusions]: These results highlight the importance of Fgf signaling during development. In particular, different members of the Fgf family act redundantly to guarantee inner ear formation and embryonic survival., Consejería de Educación, Junta de Castilla y León, Grant/Award Number: CSI143P20; Programa Estratégico Instituto de Biología y Genética Molecular (IBGM), Escalera de Excelencia, Junta de Castilla y León, Grant/Award Numbers: CCVC8485, CLU-2019-02; MEC, Grant/Award Number: BFU2004-00860/BFI

Background Proximal humerus fractures (PHFx) are common orthopedic injuries among the elderly. Although nonoperative management remains the primary treatment modality, more than one-third of PHFx are now treated surgically. Over the past decade, reverse total shoulder arthroplasty (RTSA) has gained popularity as a treatment option for PHFx, both in elderly patients with complex fractures and patients younger than 65 years. While the age range of patients undergoing RTSA for PHFx has expanded, little is known about the impact of age on postoperative complications. The purpose of this study was to examine the relationship between age and 30-day complication rates following RTSA for PHFx. Methods The National Surgical Quality Improvement Program database was queried for patients who underwent RTSA for PHFx between 2006 and 2018. Patient demographic data, surgical characteristics, and adverse outcomes were extracted. Patients were divided into four cohorts by age ( 85 years), and univariate as well as multivariate analyses were performed. Results A total of 1099 patients were identified with a mean age of 72.7 years. Overall, 6.73% of patients experienced one or more complications. Mean operative duration decreased with age (135 minutes in the 85 years old cohort, P 85 years old cohort, P 85 years old cohorts. Age >75 years, preoperative dependent functional status, and ASA class 3 or 4 were found to be independent risk factors for perioperative blood transfusion. Age ≥65 years, female gender, congestive heart failure, preoperative dependent functional status, and ASA class 3 or 4 were found to be independent risk factors for non-home discharge. The rate of unplanned hospital readmission was highest in the >85 years old cohort (17.65%), though this difference did not reach statistical significance. Conclusions While RTSA appears to be a safe treatment option for PHFx in appropriately selected elderly patients, a longer hospitalization and more frequent non-home discharge should be anticipated. Additionally, elderly patients should be closely monitored for postoperative anemia. Level of evidence Level III; Retrospective Cohort Study

Recent efforts to contain health care costs and move toward value-based health care have intensified, with a continued focus on Medicare expenditures, especially for high-volume procedures. As total shoulder arthroplasty (TSA) volume continues to increase, especially within the Medicare population, it is important for orthopedic surgeons to understand recent trends in the allocation of health care expenditures and potential effects on reimbursements. The purpose of this study was to evaluate trends in annual Medicare utilization and provider reimbursement rates for shoulder arthroplasty procedures between 2012 and 2017.This study tracked annual Medicare claims and payments to shoulder arthroplasty surgeons via publicly available databases and aggregated data at the county level. Descriptive statistics were used to evaluate trends in procedure volume, utilization rate (per 10,000 Medicare beneficiaries), and reimbursement rate. We used adjusted multiple linear regression models to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percentage Medicare population, and race and ethnicity demographics) and procedure volume, utilization rate, and reimbursement rate.Between 2012 and 2017, there was an 81.3% increase in primary TSA volume and 55.5% increase in primary TSA utilization. The Midwest and South had higher utilization rates than the Northeast and West (P.001). TSA utilization rates in metropolitan areas were significantly higher than in rural areas (P.001). Utilization rates for primary TSA procedures also had a significant negative association with poverty rate (P.001). Regarding reimbursements, the Medicare payment per TSA case decreased from 2012 to 2017, with overall inflation-adjusted decreases of 7.1% and 11.8% for primary and revision cases, respectively. TSAs performed in metropolitan areas received significantly higher reimbursements per case than TSAs performed in rural areas ($1108.05 and $1066.40, respectively; P = .002). Furthermore, reimbursements per case were on average higher in the Northeast and West than in the South and Midwest (P.001).Our study confirms that although TSA volume and per capita utilization have increased dramatically since 2012, Medicare Part B reimbursements to surgeons have continued to fall even after the adoption of bundled-payment models for orthopedic procedures. Cost-containment efforts continue to focus on Medicare reimbursements to surgeons, although other expenditures such as hospital payments and operational and implant costs must also be evaluated as part of an overall transition to value-based health care.

Background: Total shoulder arthroplasty (TSA) is an increasingly common procedure. This study looked at trends in TSA using a nationwide registry, with a focus on patient demographics, comorbidities, and complications. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TSA from 2005 to 2018. Cohorts were created based on year of surgery: 2005-2010 (N = 1116), 2011-2014 (N = 5920), and 2015-2018 (N = 16,717). Patient demographics, comorbidities, operative time, hospital length of stay, discharge location, and complications within 30 days of surgery were compared between cohorts using bivariate and multivariate analysis. Results: Bivariate analysis revealed significantly more comorbidities among patients in the 2015-2018 cohort compared with the 2005-2010 cohort, specifically American Society of Anesthesiologist class III or IV (57.0% vs. 44.3%, P < .001), morbid obesity (10.8% vs. 7.8%, P < .001), diabetes (17.8% vs. 12.1%, P < .001), and chronic obstructive pulmonary disease (6.7% vs. 4.1%, P = .003). The use of regional anesthesia has decreased (5.6% in 2005-2010 vs. 2.8% in 2015-2018, P < .001), as has operative time (▵: −16 minutes, P < .001) and length of stay (▵: −0.6 days, P < .001). There were also significant decreased rates of perioperative blood transfusion (OR [odds ratio], 0.46), non-home discharge (OR, 0.79), urinary tract infection (OR, 0.47), and sepsis (OR, 0.17), (P < .001 for all comparisons) between the 2005-2010 and 2015-2018 cohorts. Conclusions: Between 2005 and 2018, patients undergoing TSA had increasingly more comorbidities but experienced lower rates of short-term complications, in the context of shorter hospitalizations and more frequent discharge to home.

Objectives: The significant psychological impact and prevalence of posttraumatic stress disorder (PTSD) have been thoroughly documented in multiple investigations of patients after anterior cruciate ligament ruptures, but this has not yet been assessed in patients after ulnar collateral ligament (UCL) rupture. Our hypothesis is that symptoms of PTSD are present among baseball players after UCL injury. Methods: Baseball players, from the high school to minor league baseball level who had suffered an acute UCL rupture were recruited at a tertiary care center. Patients completed the Horowitz Impact of Event Scale - Revised (IES-R) to analyze for PTSD symptomatology. Results: A total of 24 patients were enrolled. The mean patient age was 19.2 years (range 15-24 years). Twenty patients (83.3%) were pitchers; 12 pitched exclusively. Six patients surveyed played at the high school level (25%), 15 in college (62.5%), and 3 at the minor league level (12.5%). 100% of patients were male. Over 91% of patients experienced symptoms of intrusion, 87.5% displayed avoidance symptoms, and 79.2% had symptoms of hyperarousal. Twelve patients (50%) scored >24 on the IES-R (PTSD is a clinical concern). 6 patients (25%) reached the threshold for a probable diagnosis of PTSD (³33 on the IES-R). Conclusions: Following UCL rupture, athletes experience substantial emotional trauma, and a significant proportion of patients experience symptoms severe enough to warrant a diagnosis of PTSD.

Background: Machine learning has shown potential in accurately predicting outcomes after orthopedic surgery, thereby allowing for improved patient selection, risk stratification, and preoperative planning. This study sought to develop machine learning models to predict nonhome discharge after total shoulder arthroplasty (TSA). Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent elective TSA from 2012 to 2018. Boosted decision tree and artificial neural networks (ANN) machine learning models were developed to predict non-home discharge and 30-day postoperative complications. Model performance was measured using the area under the receiver operating characteristic curve (AUC) and overall accuracy (%). Multivariate binary logistic regression analyses were used to identify variables that were significantly associated with the predicted outcomes. Results: There were 21,544 elective TSA cases identified in the National Surgical Quality Improvement Program registry from 2012 to 2018 that met inclusion criteria. Multivariate logistic regression identified several variables associated with increased risk of nonhome discharge including female sex (odds ratio [OR] = 2.83; 95% confidence interval [CI] = 2.53-3.17; P

Background: Injury to the ulnar collateral ligament of the elbow is common among overhead throwing athletes and can result in significant functional limitations. While surgical reconstruction offers high rates of return to competition, there are no validated or universally accepted guidelines for determining when an athlete can safely resume play. Purpose: To assess the existing scientific literature for return-to-competition criteria utilized after ulnar collateral ligament reconstruction. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: The PubMed database was searched for clinical investigations of ulnar collateral ligament reconstruction in overhead throwing athletes published between January 2000 and June 2020. Only studies that had a minimum follow-up of 1 year and included at least 1 specific return-to-competition criterion were considered. Results: A total of 15 studies were included in the final analysis, encompassing 1156 patients with an average age of 20.7 years (SD, 2.0 years). Baseball players composed 96.3% of patients for whom sport was specified, and 92.4% of baseball players were pitchers. The most common return-to-competition criterion, identified in 87% of studies, was completion of a return-to-throwing program, which started on average 16.7 weeks (range, 12-18 weeks) after surgery. A return-to-mound program was utilized in 53% of studies, starting on average 7.4 months (range, 6-9 months) postoperatively. Minimum time from surgery was used in 73% studies, with players waiting 7 to 12 months (mean, 9.7; SD, 1.4 months) after surgery before return-to-competition consideration. The overall rate of return to competition at the preinjury level or higher was 85.7% (SD, 8.5%) at an average of 12.2 months (SD, 0.6 months). Conclusion: In general, we observed a paucity of literature describing the return-to-competition process after ulnar collateral ligament reconstruction in overhead throwing athletes. Only 3 explicit return-to-competition criteria were identified across all studies: completion of a return-to-throwing program, completion of a return-to-mound program for pitchers, and minimum time from surgery. Increased transparency regarding postoperative rehabilitation protocols and further research are necessary to identify and validate sport-specific return-to-competition criteria, which will ultimately help athletes return to play in a safe and timely fashion after ulnar collateral ligament reconstruction.

We report on the sixth case of an isolated pediatric transolecranon fracture‐dislocation, and the first case utilizing nonoperative management in a cast following closed reduction resulting in an excellent outcome. Our case provides support for nonoperative management of these rare injuries, especially when surgery is not practical or desirable.

Significance Pentosan polysulfate sodium (PPS) maculopathy is a clinical entity characterized by a pigmentary maculopathy in the setting of chronic exposure to PPS. Pentosan polysulfate sodium is indicated for discomfort related to interstitial cystitis/painful bladder syndrome. Given a reported interstitial cystitis/painful bladder syndrome prevalence up to 2%, recognition is critical to mitigate visual sequelae. Purpose We present an observational case report demonstrating typical findings of PPS maculopathy in a patient originally diagnosed with a pattern macular dystrophy. We demonstrate the importance of medical history, medication profile review, and multimodal imaging in the diagnosis and management. The patient provided written informed consent for medical information and images to be published. Case report A 55-year-old White woman presented with a painless, bilateral loss of vision and bilateral pigmentary maculopathy that was initially diagnosed as pattern macular dystrophy. Detailed review of medical history, medication profile, and subsequent studies, including optical coherence tomography, near-infrared reflectance imaging, fundus autofluorescence, fluorescein angiography, and genetic studies, ultimately led to the diagnosis of PPS maculopathy. Pentosan polysulfate sodium was discontinued, and ongoing surveillance with multimodal imaging was encouraged. Conclusions Because toxic maculopathies are an uncommon diagnosis, screening and recognition of PPS maculopathy are critical in the primary eye care setting. Discontinuation of the insulting agent may be necessary to prevent potentially severe and irreversible vision loss in the at-risk population.

Introduction Over the past two decades, various factors have led to fewer opportunities for hands-on learning in the operating room among orthopaedic surgery trainees. Innovative training platforms using anatomic models, cadaveric specimens, and augmented reality have been devised to address this deficiency in surgical training, but such training tools are often costly with limited accessibility. Cognitive training is a low-cost training technique that improves physical performance by refining the way in which information is mentally processed and has long been used by professional athletes and world-class musicians. More recently, cognitive training tools have been developed for several orthopaedic surgery procedures, but the overall utility of cognitive training in orthopaedic surgery remains unknown. Methods The purpose of this study was to review the existing literature regarding the use of cognitive training in orthopaedic surgery and to summarize the results of investigations comparing cognitive training tools with other methods of learning. To that effect, the PubMed and Embase databases were systematically reviewed for articles related to cognitive training in orthopaedic surgery. Results Eleven publications met the inclusion criteria, including six randomized controlled trials. Cognitive task analysis and mental rehearsal were the most common forms of cognitive training identified. All 11 publications supported the use of cognitive training in orthopaedic surgery training. In the six randomized controlled trials, the utilization of cognitive training was associated with notably improved surgical performance and increased knowledge compared with traditional methods of learning. Discussion Based on the limited evidence presented in this review, cognitive training represents a promising, low-cost adjunct to traditional orthopaedic surgery training. Further efforts should be directed at developing and evaluating additional cognitive training tools for orthopaedic surgery trainees.

To determine the association between surgical timing and short-term morbidity and mortality in elderly patients who sustain hip fractures using a national trauma database (OTA/AO 31A1-3, 31B1-3).Retrospective cohort study.Level I-IV trauma centers in the United States.All patients ≥65 years of age who underwent surgery for hip fracture from 2011 to 2013.Time to surgery of24, 24-48, and48 hours from admission.Primary outcome was mortality by hospital discharge. Secondary outcomes were complications of myocardial infarction, cardiac arrest, acute respiratory distress syndrome (ARDS), unplanned reintubation, pneumonia, stroke, severe sepsis, and intensive care unit length of stay.Twenty-seven thousand fifty-eight patients were included in the study. Relative to the24 hours cohort, patients in the48 hours cohort were at increased risk for mortality (OR 1.89, 95% CI 1.52-2.33, P0.001), ARDS (OR 2.57, 95% CI 1.94-3.39, P0.001 for ARDS), myocardial infarction (OR 2.19, 95% CI 1.64-2.94, P0.0001), pneumonia (OR 2.04, 95% CI 1.71-2.44, P0.001), severe sepsis (OR 2.34, 95% CI 1.52-3.58, P = 0.003), and intensive care unit stay (OR 2.48, 95% CI 2.25-2.74, P0.0001). A subgroup analysis showed that healthier patients (modified Charlson Comorbidity Index less than 5) who had surgery48 hours were not at increased risk of mortality.For elderly patients with hip fractures, delaying surgery for more than 48 hours may be associated with increased short-term morbidity and mortality. This association may be pronounced for patients with more medical comorbidities.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Despite the myriad of surgical procedures available for the treatment of a failed rotator cuff repair, significant overlap exists between complications associated with the various treatment options. Most complications can be classified into one of three categories: First, operative management of a failed rotator cuff repair can simply fail. Failure can be further characterized as mechanical, clinical, or the need for revision surgery. For instance, the retear rate after revision arthroscopic rotator cuff repair at 2 years is 40%, nearly double that of primary arthroscopic repair [ (Am J Sports Med. 2015;43(3):557–64)]. Second, complications can occur as a direct result of the surgical intervention. The major complications in this category include infection, nerve injury, and shoulder stiffness. Third, medical complications, such as venous thromboembolism, may arise as a secondary consequence of the surgical procedure. A few notable complications do not fit neatly into these categories but are worth mentioning. Allografts, xenografts, and synthetic materials used in augmentation of rotator cuff repairs, superior capsular reconstruction and subacromial balloon spacers can induce a foreign body response (J Shoulder Elbow Surg. 2018;27(9):1622–8; J Bone Joint Surg Am. 2006;88(6):1238–44; Int Orthop. 2015;39(12):2403–14; Subacromial “biodegradable spacer” in the management of irreparable rotator cuff tears: radiological findings, 2018, Vienna, Austria). Finally, reverse total shoulder arthroplasty for massive irreparable rotator cuff tears can lead to a number of unique complications including dislocation, intraoperative and postoperative fracture, and inferior scapular notching.

Background: Anterior cruciate ligament (ACL) reconstruction is the standard of care for patients after an ACL tear, as poor historical outcomes were observed after primary ACL repair. Certain subgroups of patients, however, have been shown to have outcomes equivalent to reconstruction after undergoing ACL repair and therefore may benefit from the potential advantages offered by avoiding reconstruction. It is important to accurately and consistently identify and indicate these candidates for ACL repair. Purpose/Hypothesis: The purpose of this study was to determine the inter- and intraobserver reliability of magnetic resonance imaging (MRI) evaluation for the reparability of ACL tears and to identify imaging factors that may lead to surgeon uncertainty or disagreement in decision making. Our hypothesis was that the orthopaedic surgeons surveyed would not be able to reliably agree on the reparability of an ACL using MRI scans alone. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: We administered 2 surveys to 6 fellowship-trained orthopaedic sports medicine surgeons. Each surgeon reviewed preoperative MRI scans for 20 patients and answered a series of questions, ultimately determining whether they would choose an ACL reconstruction or repair for the patient based on the imaging alone. The same survey was repeated 6 weeks later. Kappa values for inter- and intraobserver reliability of their decision making were then calculated. Results: The average kappa for interobserver reliability in the 2 surveys was 0.22, and the average kappa for intraobserver reliability was 0.34. Interobserver reliability among the surgeons in this group was poor to moderate; intraobserver reliability was slightly better. The choice for ACL repair was significantly correlated with proximal tear locations ( r = 0.854; P < .001), good-quality ACL tissue remnant ( r = 0.929; P < .001), and how many surgeons believed that the tear only involved a single bundle ( r = 0.590; P = .006). Conclusion: The surgeons surveyed in this study did not consistently agree on candidates for ACL repair using MRI alone.

During vertebrate development, the presomitic mesoderm (PSM) periodically segments into somites, which will form the segmented vertebral column and associated muscle, connective tissue, and dermis. The periodicity of somitogenesis is regulated by a segmentation clock of oscillating Notch activity. Here, we examined mouse mutants lacking onlyFgf4orFgf8, which we previously demonstrated act redundantly to prevent PSM differentiation.Fgf8is not required for somitogenesis, butFgf4mutants display a range of vertebral defects. We analyzedFgf4mutants by quantifying mRNAs fluorescently labeled by hybridization chain reaction within Imaris-based volumetric tissue subsets. These data indicate that FGF4 maintainsHes7levels and normal oscillatory patterns. To support our hypothesis that FGF4 regulates somitogenesis throughHes7, we demonstrate genetic synergy betweenHes7andFgf4, but not withFgf8. Our data indicate thatFgf4is potentially important in a spectrum of human Segmentation Defects of the Vertebrae caused by defective Notch oscillations.

Category: Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction occurring in patients with stage IIB Adult Acquired Flat Foot Deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus which is then filled with autograft, allograft, or a titanium wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes in the setting of stage IIB AAFD with the use of LCL. Methods: All patients who underwent LCL from October 2008 until October 2018 were retrospectively reviewed. Preoperative weight bearing radiographs, initial postoperative radiographs and 1-year weight bearing radiographs were reviewed. The following radiographic measurements were recorded: talonavicular uncoverage angle, incongruency angle, and calcaneal pitch. Results: A total of 44 patients were included in our study. The mean age of the cohort was 54 (range 18-74). The study cohort was divided into two groups. There were 17 (38.7%) patients that received a titanium wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (p=0.006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (p=0.013). There were no significant differences in post-operative talonavicular uncoverage angle, incongruency angle or calcaneal pitch at 6 months or 1 year. Conclusion: Adult acquired flat foot deformity is a difficult disorder to treat surgically. Lateral column lengthening is a common surgical procedure used to treat forefoot abduction that occurs. Our results show that at 6 months and 1 year no radiographic difference exists between autograft/allograft bone substitutes versus titanium wedge in LCL. Future research should evaluate the differences in patient reported outcomes between autograft/allograft versus titanium wedge bone substitutes. [Table: see text]

Little information is available on the functional activity of leukocytes after arthroplasty or the expansion of populations with immune suppressive properties during the acute post-operative period. Synovial fluid and matched pre- and post-surgical blood samples were collected from total hip and knee arthroplasty patients (THA and TKA, respectively) to examine the impact of surgery on peripheral blood leukocyte frequency, bactericidal activity, and inflammatory mediator expression. For spinal surgeries, inflammatory mediator production by peripheral blood mononuclear cells (PBMCs) pre- and post-surgery was examined. An expansion of immune suppressive granulocytic myeloid-derived suppressor cells (G-MDSCs) was observed following arthroplasty, which correlated with significantly increased serum interleukin-10 (IL-10) levels. Analysis of synovial fluid from THA and TKAs revealed reduced granulocyte colony-stimulating factor (G-CSF) and soluble CD40 ligand (sCD40L) and increased interleukin-6 (IL-6), monocyte chemoattractant protein 2 (CCL2) and Fms-like tyrosine kinase 3 ligand (Flt-3L) compared to pre- and post-surgical serum. For the spinal surgery cohort, stimulation of PBMCs isolated post-surgery with bacterial antigens produced significantly less pro-inflammatory (IL-1&alpha, IL-1&beta, interleukin-1 receptor antagonist (IL-1RA), IL-12p40, growth-related oncogene-&alpha, /GRO-&alpha, (CXCL1) and 6Ckine (CCL21)) and more anti-inflammatory/tissue repair mediators (IL-10, G-CSF and granulocyte-macrophage colony-stimulating factor (GM-CSF)) compared to PBMCs recovered before surgery. The observed bias towards systemic anti-inflammatory changes without concomitant increases in pro-inflammatory responses may influence susceptibility to infection following orthopaedic surgery in the context of underlying co-morbidities or risk factors.

Summary Introduction The UTD Classification System risk stratifies postnatal UTD into three groups: low risk (UTD P1), intermediate risk (UTD P2), and high risk (UTD P3). In the original consensus document, a functional scan is not recommended for UTD P1 and is left to the discretion of the clinician for UTD P2 and P3. Objective This study aims to understand which patients with postnatal urinary tract dilation would benefit from a functional study. We investigated how different elements of the UTD classification system predict differential renal function (DRF) and diuretic half-life (T½) on MAG3 scan in infants undergoing evaluation for prenatally detected UTD. Study design This is a multicenter retrospective chart review of infants 6 months of age or younger evaluated for prenatal UTD, correlating their first MAG3 scan and first postnatal renal ultrasound (RUS). Multivariable logistic regression was used to find UTD elements predictive of DRF 20 min. Results A total of 517 patients met study criteria. Median age at time of RUS and MAG3 renal scan was 48 days (IGR 31–81) and 63 days (IQR 45–98), respectively. DRF 20 min was found in 31% of kidneys with UTD P2 and 79% of kidneys with UTD P3. An abnormal ureter (OR 2.7, 95% CI 1.2–6.0) and parenchymal thinning (OR 16, 95% CI 5.8–41.4) were significant at predicting DRF 20 min, as did each cm increase in the anterior-posterior renal pelvic diameter (APRPD) (OR 4.8, 95% CI 3.0–7.7). Discussion The UTD system discriminates well and correlates with the likelihood of finding adverse features on diuretic renography. Patients in the UTD P3 high-risk category had a significantly higher incidence of decreased differential renal function and delayed drainage than those in UTD P1 and P2. Of the individual components of the UTD Classification system, the presence of parenchymal thinning was the most important factor in predicting both decreased differential renal function and delayed drainage. Conclusion Given the high incidence of poor function and delayed drainage seen in the UTD P3 group, we believe a functional study should be recommended in the evaluation of these patients. Our findings support leaving the performance of a functional study at the discretion of the physician for UTD P2. Download : Download high-res image (83KB) Download : Download full-size image Summary Figure . Percentage of patients with DRF 20 min across the different UTD Classification Risk Groups.

During vertebrate development, the presomitic mesoderm (PSM) is periodically segmented into somites, which will form the segmented vertebral column and associated muscle, connective tissue, and dermis. The periodicity of somitogenesis is regulated by a segmentation clock of oscillating Notch activity. Here, we examined mouse mutants lacking onlyFgf4orFgf8, which we previously demonstrated act redundantly to prevent PSM differentiation.Fgf8is not required for somitogenesis, butFgf4mutants display a range of vertebral defects. We analyzedFgf4mutants by quantifying mRNAs fluorescently labeled by hybridization chain reaction within Imaris-based volumetric tissue subsets. These data indicate that FGF4 controls Notch pathway oscillations through the transcriptional repressor, HES7. This hypothesis is supported by demonstrating a genetic synergy betweenHes7andFgf4, but not withFgf8. Thus,Fgf4is an essential Notch oscillation regulator and potentially important in a spectrum of human Segmentation Defects of the Vertebrae caused by defective Notch oscillations.

While much recent research has examined flamingo unipedal resting, as well as laterality in the resting behaviours of these birds, the phenomenon of unihemispheric sleep is not well documented in flamingos, and the potential relationship between unihemispheric sleep and these other aspects of flamingo resting behaviour has not been thoroughly explored. In the present report, unihemispheric sleep was studied in Caribbean Flamingos (Phoenicopterus ruber) (n=17) at the Philadelphia Zoo (Philadelphia, PA, USA). Specifically, we examined whether unihemispheric sleep, as measured by contralateral eye closure, is associated with unipedal resting and lateral behavioural side choice in resting Caribbean Flamingos. Results over three studies evidenced that Caribbean Flamingos do engage in unihemispheric sleep, and suggested that unihemispheric sleep is not related to unipedal resting or lateral neck-resting behaviour. Moreover, Harker and Harker's (2010) hypothesis that unipedal resting in flamingos is brought on by the impending onset of unihemispheric sleep was tested, with results failing to support this notion.

Background: Online video-sharing platforms such as YouTube have become popular sources of medical information for patients. However, concern exists regarding the quality of such non–peer reviewed content. In fact, a previous investigation found the majority of YouTube information related to femoroacetabular impingement (FAI) to be of poor quality. Purpose: To provide an updated assessment of the quality of FAI-related videos available on YouTube. Study Design: Cross-sectional study. Methods: The terms FAI, femoroacetabular impingement, and hip impingement were searched on YouTube, and exclusion criteria were applied to the first 100 results for each term. The diagnostic and treatment content of each video was graded and assigned a quality assessment rating based on a previously used rubric. Video characteristics (e.g. duration, views, “likes”) were compared using both quality assessment rating and video source. Results: A total of 142 videos were included in the final analysis. The most common video source was educational (48.6%), followed by physician-sponsored (30.3%). The majority of videos were graded as “somewhat useful” for both diagnostic and treatment content (59.4% and 61.6%, respectively); however, treatment content was rated “not useful” more often than diagnostic information (20.3% vs. 8.7%, respectively). Videos rated as “somewhat useful” received the most views per day on average, while educational videos were the most viewed by source (views and views per day). Educational videos had more views and likes on average than physician-sponsored videos ( P < .05), but all other comparisons of video characteristics by source were not significant. Video duration was the only characteristic found to vary significantly by quality assessment rating ( P < .001 for both diagnostic and treatment analyses), with higher-quality videos tending to be longer. Videos rated as “excellent” and “very useful” had mean durations >30 minutes but were viewed the least. Conclusion: The overall quality of FAI-related content on YouTube remains low. Clinicians should be familiar with medical information available to patients on the internet, as it can influence patients’ perspectives and shared decision-making processes. This review substantiates the need for more publicly available, high-quality video content regarding the diagnosis and treatment of FAI.

Background:Shoulder instability is a common and potentially debilitating injury among collision sport athletes that can lead to long-term damage of the glenohumeral joint. Limited data exist regarding instability among elite athletes in the National Football League (NFL).Purpose:To describe the epidemiology of shoulder instability in the NFL from 2012 through 2017.Study Design:Descriptive epidemiology study.Methods:The NFL’s injury database was reviewed for shoulder instability injuries resulting in missed time during the study inclusion dates. Injuries were classified by type and direction, as well as timing, setting, and mechanism. Median missed time was determined for the different types and directions of instability. Incidence rates for game-related injuries were calculated based on timing during the season and player position. Finally, the relationship between player position and instability direction was assessed.Results:During the 6-year study period, 355 players sustained 403 missed-time shoulder instability injuries. Most injuries occurred during games (65%) via a contact mechanism (85%). The overall incidence rate of game-related instability was 3.6 injuries per 100,000 player-plays and was highest during the preseason (4.9 per 100,000 player-plays). The defensive secondary position accounted for the most injuries, but quarterbacks had the highest incidence rate in games (5.5 per 100,000 player-plays). Excluding unspecified events (n = 128; 32%), 70% (n = 192) of injuries were subluxations and 30% (n = 83) were dislocations; 75% of dislocations were anterior, while subluxations were more evenly distributed between the anterior and posterior directions (45% vs 52%, respectively). Players missed substantially more time after dislocation compared with subluxation (median, 47 days vs 13 days, respectively). When instability direction was known, the majority of instability events among quarterbacks and offensive linemen were posterior (73% and 53%, respectively), while anterior instability was most common for all other positions.Conclusion:Shoulder instability is a common injury in the NFL and can result in considerable missed time. Dislocations occur less frequently than subluxations but lead to greater time lost. While most dislocations are anterior, more than half of subluxations are posterior, which is likely the result of repetitive microtrauma to the posterior capsulolabral complex sustained during sport-specific motions such as blocking. The risk of instability varies by player position, and position may also influence instability direction.

Osteophytes are a typical radiographic finding during osteoarthritis (OA). Osteophytes are thought to form in response to joint instability; however, the time course of osteophyte formation and joint stabilization following joint injury is not well understood. In this study, we investigated the time course of osteophyte formation and joint function following non-invasive knee injury in mice. We hypothesized that initial joint instability following knee injury would initiate osteophyte formation, which would in turn restabilize the joint and reduce range of motion (ROM). Mice were subjected to non-invasive anterior cruciate ligament (ACL) rupture. Anterior-posterior (AP) joint laxity, ROM, and chondro/osteophyte formation were measured immediately after injury, and 2, 4, 6, and 8 weeks post-injury. Chondrophyte areas at each time point were measured with histology, while mineralized osteophyte volume was determined using micro-computed tomography. Immediately after ACL rupture, AP joint laxity was increased twofold, while ROM was increased 11.7%. Chondrophytes appeared by 2 weeks post-injury, corresponding with a decrease in AP joint laxity and ROM. By 8 weeks post-injury, considerable osteophyte formation was observed around the joint, AP joint laxity returned to control levels, and joint ROM decreased to 61% of control values. These data support a role for chondro/osteophytes in joint restabilization after injury, and provide crucial insight into the time course and pathology of joint degeneration during OA development in the mouse. Statement of Clinical Significance: Results from this study increase understanding of conditions leading to osteophyte formation.© 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:466-473, 2017.

During vertebrate embryogenesis the interdigital mesenchyme is removed by programmed cell death (PCD), except in species with webbed limbs. Although bone morphogenetic proteins (BMPs) have long been known to be players in this process, it is unclear if they play a direct role in the interdigital mesenchyme or if they only act indirectly, by affecting fibroblast growth factor (FGF) signaling. A series of genetic studies have shown that BMPs act indirectly by regulating the withdrawal of FGF activity from the apical ectodermal ridge (AER); this FGF activity acts as a cell survival factor for the underlying mesenchyme. Other studies using exogenous factors to inhibit BMP activity in explanted mouse limbs suggest that BMPs do not act directly in the mesenchyme. To address the question of whether BMPs act directly, we used an interdigit-specific Cre line to inactivate several genes that encode components of the BMP signaling pathway, without perturbing the normal downregulation of AER-FGF activity. Of three Bmps expressed in the interdigital mesenchyme, Bmp7 is necessary for PCD, but Bmp2 and Bmp4 both have redundant roles, with Bmp2 being the more prominent player. Removing BMP signals to the interdigit by deleting the receptor gene, Bmpr1a, causes a loss of PCD and syndactyly, thereby unequivocally proving that BMPs are direct triggers of PCD in this tissue. We present a model in which two events must occur for normal interdigital PCD: the presence of a BMP death trigger and the absence of an FGF survival activity. We demonstrate that neither event is required for formation of the interdigital vasculature, which is necessary for PCD. However, both events converge on the production of reactive oxygen species that activate PCD.

Development of osteoarthritis commonly involves degeneration of epiphyseal trabecular bone. In previous studies, we observed 30-44% loss of epiphyseal trabecular bone (BV/TV) from the distal femur within 1 week following non-invasive knee injury in mice. Mechanical unloading (disuse) may contribute to this bone loss; however, it is unclear to what extent the injured limb is unloaded following injury, and whether disuse can fully account for the observed magnitude of bone loss. In this study, we investigated the contribution of mechanical unloading to trabecular bone changes observed following non-invasive knee injury in mice (female C57BL/6N). We investigated changes in gait during treadmill walking, and changes in voluntary activity level using Open Field analysis at 4, 14, 28, and 42 days post-injury. We also quantified epiphyseal trabecular bone using μCT and weighed lower-limb muscles to quantify atrophy following knee injury in both ground control and hindlimb unloaded (HLU) mice. Gait analysis revealed a slightly altered stride pattern in the injured limb, with a decreased stance phase and increased swing phase. However, Open Field analysis revealed no differences in voluntary movement between injured and sham mice at any time point. Both knee injury and HLU resulted in comparable magnitudes of trabecular bone loss; however, HLU resulted in considerably more muscle loss than knee injury, suggesting another mechanism contributing to bone loss following injury. Altogether, these data suggest that mechanical unloading likely contributes to trabecular bone loss following non-invasive knee injury, but the magnitude of this bone loss cannot be fully explained by disuse. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1680-1687, 2016.

Purpose The incidence of retinopathy of prematurity (ROP) has increased continuously in recent years. However, the therapeutic effects of current treatments still remain undesired. This study aims to investigate the role of C-CBL in retinal angiogenesis in ROP and its potential as a therapeutic target. Methods Mouse retina microvascular endothelial cells (mRMECs) and induced experimental ROP/ oxygen-induced retinopathy (OIR) mice were employed to investigate the role of C-CBL in angiogenesis with combined molecular and cellular approaches, and histopathology methods. OIR mouse pups at postnatal day 12 (P12) were either injected intravitreally with adenovirus overexpressing c-Cbl or c-Cbl siRNA. Retinal neovascularization and avascular status were evaluated by retinal immunofluorescence (IF) staining, whole-mounts and hematoxylin and eosin (H&E) staining. Results C-CBL inhibits neovascularization by negatively regulating JAK2/STAT3/VEGF signaling axis in a ubiquitination-dependent manner. Knockdown of c-Cbl by siRNA reduced ubiquitin-mediated JAK2 degradation and increased levels of p-JAK2, p-STAT3, VEGF, and neovascularization in mRMECs, which can be reversed by JAK2 inhibitor treatment. While knockdown of c-Cbl significantly increased neovascular (NV) zone in the retinas, c-Cbl overexpression inhibited neovascularization in the retinal tissues in OIR mice. Conclusion We found that C-CBL is required for anti-neovascularization process in ROP development by inhibiting JAK2/STAT3-dependent angiogenesis. Thus, our finding strongly suggest that C-CBL may be a potential novel therapeutic target for treating ROP.

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of hip disorders, including neonatal instability, acetabular dysplasia, hip subluxation, and frank dislocation of the hip. It is a common disorder, with a reported incidence of between 0.1% and >10% of live births. Coordinated, interdisciplinary care is important to achieving successful outcomes. This starts with accurate assessment of risk factors in the prenatal period, thorough clinical examination by the primary care provider at all well-child visits, and early referral to a pediatric orthopaedic surgeon for prompt diagnosis and treatment. Early diagnosis and prompt treatment is critical for an excellent outcome. Ongoing, open communication between clinicians is essential for the effective coordination of care. Treatment options vary depending on the age of presentation. A Pavlik harness (dynamic hip abduction orthosis) is used for children up to 6 months of age. A more rigid abduction orthosis may be used if treatment with a Pavlik harness is unsuccessful, with a closed reduction and spica cast being the next step if needed for children up to 18 months of age. Finally, open reduction with possible concomitant femoral and/or pelvic osteotomies is the surgical option in an older child, when necessary. In general, the later the child is diagnosed with and treated for DDH, the greater the risk of a nonoptimal outcome. Depending on the severity of the condition, children with DDH may need to be followed closely until skeletal maturity so as not to miss the diagnosis of asymptomatic residual hip dysplasia, which can predispose patients to early hip arthritis.

Embryonic morphogenesis of a complex organism requires proper regulation of patterning and directional growth. The Planar Cell Polarity (PCP) signaling is emerging as a critical evolutionarily conserved mechanism whereby directional information is conveyed. PCP is thought to be established by global cues, and recent studies have revealed an instructive role of Wnt signaling gradient in epithelia tissues of both invertebrates and vertebrates. However, it remains unclear whether Wnt/PCP signaling is coordinately regulated with embryonic patterning during morphogenesis. Here in the mammalian developing limbs, we find that the AER-derived Fgfs required for limb patterning regulates PCP along the proximal-distal axis in a Wnt5a-dependent manner. We demonstrate with genetic evidence that Wnt5a gradient acts as a global cue that is instructive in establishing PCP in the limb mesenchyme, while Wnt5a also plays a permissive role to allow Fgf signaling to orient PCP. Our results indicate that limb morphogenesis is critically regulated by coordination of directional growth and patterning through integrating Wnt5a and Fgf signaling in PCP regulation.

Treatment options for patients with brain metastases (BMs) have limited efficacy and the mortality rate is virtually 100%. Targeted therapy is critically under-utilized, and our understanding of mechanisms underpinning metastatic outgrowth in the brain is limited. To address these deficiencies, we investigated the genomic and transcriptomic landscapes of 36 BMs from breast, lung, melanoma and oesophageal cancers, using DNA copy-number analysis and exome- and RNA-sequencing. The key findings were as follows. (a) Identification of novel candidates with possible roles in BM development, including the significantly mutated genes DSC2, ST7, PIK3R1 and SMC5, and the DNA repair, ERBB-HER signalling, axon guidance and protein kinase-A signalling pathways. (b) Mutational signature analysis was applied to successfully identify the primary cancer type for two BMs with unknown origins. (c) Actionable genomic alterations were identified in 31/36 BMs (86%); in one case we retrospectively identified ERBB2 amplification representing apparent HER2 status conversion, then confirmed progressive enrichment for HER2-positivity across four consecutive metastatic deposits by IHC and SISH, resulting in the deployment of HER2-targeted therapy for the patient. (d) In the ERBB/HER pathway, ERBB2 expression correlated with ERBB3 (r(2) = 0.496; p < 0.0001) and HER3 and HER4 were frequently activated in an independent cohort of 167 archival BM from seven primary cancer types: 57.6% and 52.6% of cases were phospho-HER3(Y1222) or phospho-HER4(Y1162) membrane-positive, respectively. The HER3 ligands NRG1/2 were barely detectable by RNAseq, with NRG1 (8p12) genomic loss in 63.6% breast cancer-BMs, suggesting a microenvironmental source of ligand. In summary, this is the first study to characterize the genomic landscapes of BM. The data revealed novel candidates, potential clinical applications for genomic profiling of resectable BMs, and highlighted the possibility of therapeutically targeting HER3, which is broadly over-expressed and activated in BMs, independent of primary site and systemic therapy.

We evaluated patient knowledge, attitudes, and beliefs regarding changes present with the Affordable Care Act (ACA). HIV-infected adults attending an academic medical center HIV clinic in Omaha, Nebraska were asked to complete a self-administered survey between November 2013 and March 2014. Information collected included demographics, knowledge regarding healthcare reform policies, as well as attitudes and beliefs regarding the potential impact of the ACA on patient access to healthcare. Basic descriptive statistics were used to assess demographic characteristics of respondents and outcomes of interest. Chi-square tests were used for comparisons of interest among participants; some trends were evaluated with Cochran-Armitage trend tests. Four hundred and six patients completed the questionnaire. Of the respondents 90% were between the ages of 27 and 64, 61% were white, 27% had no health insurance, and 21% reported that they felt they had or will eventually benefit from the ACA. The proportion who responded "I don't know" to this question decreased over the study period (p=0.036). Overall, 57% reported they do not believe that they are informed enough to make decisions about the ACA. In answering four knowledge-based questions, only 3% answered all of them correctly. Knowledge about the ACA was significantly associated with perception of benefit (p=0.018). HIV-infected patients are not well informed about the ACA and few perceive that they will benefit from healthcare reform. Targeted education and outreach are necessary to reduce the knowledge gap for this population that stands to benefit greatly from the ACA.

Background Baptisia is commonly found in residential gardens as an ornamental plant, in municipal "rain gardens" for water control, as well as in native and restored prairie habitat. Cytisine, an alkaloid with nicotinic acetylcholine receptor agonist properties, is a component of Baptisia . Case Report Two patients poisoned after simultaneously ingesting Baptisia plant material are presented. In addition to findings of generalized nicotinic agonist toxicity, including generalized weakness and gastrointestinal symptoms, profound ataxia was present in both, consistent with recently described nicotinic subunit activity in the cerebellum. Why Should an Emergency Physician Be Aware of This? Baptisia , a native prairie plant commonly found in restored prairie habitats and public spaces, has striking "look-alike" characteristics, in its immature state, to asparagus. As future exposures by foraging citizens will be likely, awareness of this relationship and the toxic manifestations of cytisine will be useful.

Tendons are ineffective at repairing sub-rupture fatigue injuries. Accordingly, we evaluated whether an exercise protocol that we have previously found to decrease structural damage kinks in fatigue damaged tendons, leads to improvement in mechanical properties. We hypothesized that exercise that promotes repair of fatigue damage will decrease apoptosis and increase the population of myofibroblasts. Rat patellar tendons underwent in vivo fatigue loading for 500 or 7200 cycles. Animals resumed cage activity for 2-weeks, then either remained cage active or began treadmill running until sacrifice at 4- or 10-weeks post-fatigue loading. Exercise following fatigue damage increased the stiffness back towards naïve levels, decreased apoptosis and increased the population of myofibroblasts. Next, proteins associated with inhibition of apoptosis (Collagen VI) or activation of myofibroblast (pSmad 2/3, fibrillin, integrin subunits αV and α5) were evaluated. Data suggests that collagen VI may not be integral to inhibition of apoptosis in this context. Exercise increased pSmad 2/3 and fibrillin in the insertion region for the 7200-cycles group. In addition, exercise decreased integrin αV and increased integrin α5 in fatigue damaged tendons. Data suggests that a decrease in apoptosis and an increase in population of myofibroblasts may be integral to remodeling of fatigue damaged tendons.

Background The alignment of the lower extremity has important implications in the development of knee arthritis. The effect of incremental rotations of the limb on common parameters of alignment has not been studied. The purpose of the study was to (1) determine the standardized neutral position measurements of alignment and (2) determine the effect of rotation on commonly used measurements of alignment. Methods Eighty-seven full length CT angiography studies (49 males and 38 females, average age 66 years old) were included. Three-dimensional models were created using a rendering software program and placed on a virtual plane. An image of the extremity was obtained. Thirty scans were randomly selected, and those models were rotated in 3° intervals around the longitudinal axis and additional images were obtained. Results In the neutral position, the mechanical lateral distal femoral articular angle (mLDFA) was 85.6 ± 2.3°, medial proximal tibial angle (MPTA) was 86.1 ± 2.8°, and mechanical tibiofemoral angle (mTFA) was −0.7 ± 3.1°. Females had a more valgus alignment with a mTFA of 0.5 ± 2.9° while males had a more varus alignment with a mTFA of −1.7 ± 2.9°. The anatomic tibiofemoral angle (aTFA) was 4.8 ± 2.6°, the anatomic lateral distal femoral angle (aLDFA) measured 80.2 ± 2.2°, and the anatomical-mechanical angle (AMA) was 5.4 ± 0.7°. The prevalence of constitutional varus was 18%. The effect of rotation on the rotated scans led to statistically significant differences relative to the 0° measurement for all measurements. These effects may be small, and their clinical importance is unknown. Conclusions This study provides new information on standardized measures of lower extremity alignment and the relationship between discreet axial rotations of the entire lower extremity and these parameters.

Pancreatic cancer is molecularly diverse, with few effective therapies. Increased mutation burden and defective DNA repair are associated with response to immune checkpoint inhibitors in several other cancer types. We interrogated 385 pancreatic cancer genomes to define hypermutation and its causes. Mutational signatures inferring defects in DNA repair were enriched in those with the highest mutation burdens. Mismatch repair deficiency was identified in 1% of tumors harboring different mechanisms of somatic inactivation of MLH1 and MSH2. Defining mutation load in individual pancreatic cancers and the optimal assay for patient selection may inform clinical trial design for immunotherapy in pancreatic cancer.

Summary Objective Joint injuries initiate a surge of inflammatory cytokines and proteases that contribute to cartilage and subchondral bone degeneration. Detecting these early processes in animal models of post-traumatic osteoarthritis (PTOA) typically involves ex vivo analysis of blood serum or synovial fluid biomarkers, or histological analysis of the joint. In this study, we used in vivo fluorescence reflectance imaging (FRI) to quantify protease, matrix metalloproteinase (MMP), and Cathepsin K activity in mice following anterior cruciate ligament (ACL) rupture. We hypothesized that these processes would be elevated at early time points following joint injury, but would return to control levels at later time points. Design Mice were injured via tibial compression overload, and FRI was performed at time points from 1 to 56 days after injury using commercially available activatable fluorescent tracers to quantify protease, MMP, and cathepsin K activity in injured vs uninjured knees. PTOA was assessed at 56 days post-injury using micro-computed tomography and whole-joint histology. Results Protease activity, MMP activity, and cathepsin K activity were all significantly increased in injured knees relative to uninjured knees at all time points, peaking at 1–7 days post-injury, then decreasing at later time points while still remaining elevated relative to controls. Conclusions This study establishes FRI as a reliable method for in vivo quantification of early biological processes in a translatable mouse model of PTOA, and provides crucial information about the time course of inflammation and biological activity following joint injury. These data may inform future studies aimed at targeting these early processes to inhibit PTOA development.

Post-traumatic osteoarthritis (PTOA) is a common long-term consequence of joint injuries such as anterior cruciate ligament (ACL) rupture. In this study we used a tibial compression overload mouse model to compare knee injury induced at low speed (1 mm/s), which creates an avulsion fracture, to injury induced at high speed (500 mm/s), which induces midsubstance tear of the ACL. Mice were sacrificed at 0 days, 10 days, 12 weeks, or 16 weeks post-injury, and joints were analyzed with micro-computed tomography, whole joint histology, and biomechanical laxity testing. Knee injury with both injury modes caused considerable trabecular bone loss by 10 days post-injury, with the Low Speed Injury group (avulsion) exhibiting a greater amount of bone loss than the High Speed Injury group (midsubstance tear). Immediately after injury, both injury modes resulted in greater than 2-fold increases in total AP joint laxity relative to control knees. By 12 and 16 weeks post-injury, total AP laxity was restored to uninjured control values, possibly due to knee stabilization via osteophyte formation. This model presents an opportunity to explore fundamental questions regarding the role of bone turnover in PTOA, and the findings of this study support a biomechanical mechanism of osteophyte formation following injury.

This study sought to examine the relationship between weather and aggression in Caribbean flamingos by utilising a novel observation method. Previous research has shown evidence of increased levels of aggression during periods of warmer weather in a wide range of species including humans. We observed the captive flock of Caribbean flamingos at the Smithsonian National Zoological Park (Washington, DC, USA) by means of a web cam, and correlated the observed instances of aggression with eight different weather variables gathered via www.weather.com . Results evidenced significant positive correlations between aggression and several variables including: temperature [ r (38) = 0.31, P = 0.048], “feels like” [ r (38) = 0.31, P = 0.049], and UV-index [ r (38) = 0.35, P = 0.025]; and a multiple linear regression (stepwise) suggested that UV-index is a significant predictor of aggressive instances, thus highlighting the relationship between such environmental factors and flamingo aggression. Evidence has been found of a relationships between UV light and aggression in other species, and the results of the present study suggest a similar relationship in flamingos. Employing webcams may allow researchers to obtain larger samples to be included in the study of aggression or to examine this and other behaviors in a wider variety of captive animals.

a b s t r a c t The use of tracking devices (e.g., VHF radio collars, GPS collars, ear transmitters) enables researchers to assess activity budgets, species-specific movement patterns, effects of envi- ronmental enrichment, and exercise levels in zoo animals. The fundamental assumption in these studies of tagged animals is that attachable tracking devices have negligible effects on the animals' behavior. The present study examined solitary and social behavior rates, as well as overall activity budgets, in eight African elephants living at the San Diego Zoo Safari Park, Escondido, CA, USA. Each elephant was trained over several months to wear leather collars affixed with GPS units encased in watertight plastic containers. Behavioral data col- lected while the GPS collars were worn (16 daylight hours, 16 night hours) were compared to behavioral data when the GPS collars were not worn (16 daylight hours, 16 night hours) throughout June and July 2010. No significant differences (P < 0.05) in behavior rates or average percent of observation time the subjects were recorded in particular states were found. During the morning hours, while the collars were both worn and not worn, feeding was the most common behavior state (M = 44.7 ± 3.8%, M = 49.3 ± 15.3%), followed by res- ting (M = 35.5 ± 10%, M = 37.3 ± 12%) and walking (M = 10 ± 3.1%, M = 8.7 ± 1.9%). During the evening hours, feeding remained the most common behavior state for both worn and not worn conditions (M = 66.1 ± 12.3%, M = 63.3 ± 13.7%), followed by resting (M = 17.6 ± 7.7%, M = 19.4 ± 9.5%), and sleeping (M = 8.1 ± 8.9%, M = 7.8 ± 8.1%). This distribution of daily behavior state is similar to previous activity budgets examined in other zoo elephant herds. These results suggest that, with adequate training, GPS collars may have minimal impact on the behavior of zoo elephants.

Much controversy surrounds the welfare of elephants within zoological institutions. Among the many concerns are lack of exercise and the prevention of sedentary health and welfare issues due to smaller exhibits in comparison to the home-range sizes for elephants in Africa and Asia. While many scientists have used GPS to examine distances travelled by wild elephants, there is currently little information on distance travelled by elephants within zoological institutions. In the wild, it is necessary to chemically immobilise elephants using a dart gun in order to put on or take off collars which are used to acquire GPS data. Within a zoological institution, elephants can be trained to wear a collar with a GPS device but this training can be time consuming and also dangerous depending on the level of expertise of animal care staff. However, training an elephant within a zoological institution to wear an anklet outfitted with a GPS device can be much safer and less time consuming. The purpose of the current research was to validate methods for examining the walking rates of elephants in a zoological facility. This included testing GPS units, examining walking rates of eight elephants at the San Diego Zoo Safari Park using collars and conducting trials on a subset of elephants wearing both a collar and anklet outfitted with GPS devices to determine reliability. The average distance travelled by eight African elephants (Loxodonta africana) within a 24-h period was 8.65 (± 0.64) km which corresponds to a rate of 0.360 (± 0.033) kph. Trials comparing anklets to collars were found to be highly reliable except on days when weather conditions were overcast or there was rainfall at the park. The methods used for the current study can be utilised in future studies to examine walking rates as a component of animal welfare for elephants or other large mammals within zoological institutions.

Pancreatic cancer is a highly lethal malignancy with few effective therapies. We performed exome sequencing and copy number analysis to define genomic aberrations in a prospectively accrued clinical cohort (n = 142) of early (stage I and II) sporadic pancreatic ductal adenocarcinoma. Detailed analysis of 99 informative tumours identified substantial heterogeneity with 2,016 non-silent mutations and 1,628 copy-number variations. We define 16 significantly mutated genes, reaffirming known mutations (KRAS, TP53, CDKN2A, SMAD4, MLL3, TGFBR2, ARID1A and SF3B1), and uncover novel mutated genes including additional genes involved in chromatin modification (EPC1 and ARID2), DNA damage repair (ATM) and other mechanisms (ZIM2, MAP2K4, NALCN, SLC16A4 and MAGEA6). Integrative analysis with in vitro functional data and animal models provided supportive evidence for potential roles for these genetic aberrations in carcinogenesis. Pathway-based analysis of recurrently mutated genes recapitulated clustering in core signalling pathways in pancreatic ductal adenocarcinoma, and identified new mutated genes in each pathway. We also identified frequent and diverse somatic aberrations in genes described traditionally as embryonic regulators of axon guidance, particularly SLIT/ROBO signalling, which was also evident in murine Sleeping Beauty transposon-mediated somatic mutagenesis models of pancreatic cancer, providing further supportive evidence for the potential involvement of axon guidance genes in pancreatic carcinogenesis.

Fracture healing involves rapid stem and progenitor cell migration, homing, and differentiation. SDF-1 (CXCL12) is considered a master regulator of CXCR4-positive stem and progenitor cell trafficking to sites of ischemic (hypoxic) injury and regulates their subsequent differentiation into mature reparative cells. In this study, we investigated the role of SDF-1/CXCR4 signaling in fracture healing where vascular disruption results in hypoxia and SDF-1 expression. Mice were injected with AMD3100, a CXCR4 antagonist, or vehicle twice daily until euthanasia with the intent to impair stem cell homing to the fracture site and/or their differentiation. Fracture healing was evaluated using micro-computed tomography, histology, quantitative PCR, and mechanical testing. AMD3100 administration resulted in a significantly reduced hyaline cartilage volume (day 14), callus volume (day 42) and mineralized bone volume (day 42) and reduced expression of genes associated with endochondral ossification including collagen Type 1 alpha 1, collagen Type 2 alpha 1, vascular endothelial growth factor, Annexin A5, nitric oxide synthase 2, and mechanistic target of rapamycin. Our data suggest that the SDF-1/CXCR4 signaling plays a central role in bone healing possibly by regulating the recruitment and/or differentiation of stem and progenitor cells.

Morphogenesis of mammalian facial processes requires coordination of cellular proliferation, migration, and apoptosis to develop intricate features. Cleft lip and/or palate (CL/P), the most frequent human craniofacial birth defect, can be caused by perturbation of any of these programs. Mutations of WNT, P63, and IRF6 yield CL/P in humans and mice; however, how these genes are regulated remains elusive. We generated mouse lines lacking Pbx genes in cephalic ectoderm and demonstrated that they exhibit fully penetrant CL/P and perturbed Wnt signalling. We also characterized a midfacial regulatory element that Pbx proteins bind in order to control the expression of Wnt9b-Wnt3, which in turn regulate p63. Altogether, we establish a Pbx-dependent Wnt-p63-Irf6 regulatory module in midfacial ectoderm that is conserved within mammals. Dysregulation of this network leads to localized suppression of midfacial apoptosis and CL/P. Ectopic Wnt ectodermal expression in Pbx mutants rescues the clefting, opening avenues for tissue repair.

Aortic arch malformations are common congenital disorders that are frequently of unknown etiology. To gain insight into the factors that guide branchial aortic arch development, we examined the process by which these vessels assemble in wild type zebrafish embryos and in kurzschluss(tr12) (kus(tr12)) mutants. In wild type embryos, each branchial aortic arch first appears as an island of angioblasts in the lateral pharyngeal mesoderm, then elaborates by angiogenesis to connect to the lateral dorsal aorta and ventral aorta. In kus(tr12) mutants, angioblast formation and initial sprouting are normal, but aortic arches 5 and 6 fail to form a lumenized connection to the lateral dorsal aorta. Blood enters these blind-ending vessels from the ventral aorta, distending the arteries and precipitating fusion with an adjacent vein. This arteriovenous malformation (AVM), which shunts nearly all blood directly back to the heart, is not exclusively genetically programmed, as its formation correlates with blood flow and aortic arch enlargement. By positional cloning, we have identified a nonsense mutation in unc45a in kus(tr12) mutants. Our results are the first to ascribe a role for Unc45a, a putative myosin chaperone, in vertebrate development, and identify a novel mechanism by which an AVM can form.

Previous research has suggested that the duration of stressful video material is estimated to be longer than one containing less stressful material. The current study sought to examine what effects viewing news coverage of the September 11th 2001 terrorist attacks might have on estimated duration of exposure. 16 participants were recruited from Saint Joseph's College of Maine psychology courses and viewed two 3-min. video clips. One clip contained coverage of the 9–11 terrorist attacks; the other, a nonstressful control, was taken from a familiar segment of The Wizard of Oz. Participants estimated the length of the clip and rated stress experienced while viewing the clip. Analysis showed the September 11th footage was rated as more stressful and was estimated as longer than the control clip.

To develop and validate a translatable and reproducible rodent critical-sized defect (CSD) model and to determine the optimal dose of recombinant human bone morphogenetic protein (BMP)-7 required to consistently heal the CSD in the new model.Rats with 6-mm CSDs stabilized with a commercial radiolucent plate and screws with angular stability were randomly assigned to 4 treatment groups with varied doses of recombinant human BMP-7 (25, 50, 75, and 100 μg) on absorbable collagen sponge and a single control group (absorbable collagen sponge alone). Bone formation was evaluated by radiographs, micro-computed tomography, histology, and biomechanics.All the rats treated with 100 μg of BMP-7 with CSDs were united by 4 weeks and all 75- and 50-μg-group rats united by 6 weeks. None of the animals in the 25-μg BMP-7 group or the control group were healed at the time of killing. Bone volume, bone mineral density, the ratio of bone volume to total volume, stiffness, and ultimate load to failure were maximal in the 50-μg group. Total callus volume progressively increased with increasing BMP dose. Histologic analysis demonstrated increased callus width with increasing BMP-7 doses above 50 μg, but the bone seemed structurally abnormal.There was a 100% union rate in the 50-, 75-, and 100-μg BMP-7-treated groups. None of the control or 25-μg-dose rats united. The biomechanical data demonstrated that 50 μg of BMP-7 produced the highest mechanical strength in the bone regenerate. These data also suggest that administration of BMP-7 above 50 μg does not improve bone regeneration and actually seems to produce lower quality bone with diminished biomechanical properties.

During vertebrate axis extension, adjacent tissue layers undergo profound morphological changes: within the neuroepithelium, neural tube closure and neural crest formation are occurring, while within the paraxial mesoderm somites are segmenting from the presomitic mesoderm (PSM). Little is known about the signals between these tissues that regulate their coordinated morphogenesis. Here, we analyze the posterior axis truncation of mouse Fgf3 null homozygotes and demonstrate that the earliest role of PSM-derived FGF3 is to regulate BMP signals in the adjacent neuroepithelium. FGF3 loss causes elevated BMP signals leading to increased neuroepithelium proliferation, delay in neural tube closure and premature neural crest specification. We demonstrate that elevated BMP4 depletes PSM progenitors in vitro, phenocopying the Fgf3 mutant, suggesting that excessive BMP signals cause the Fgf3 axis defect. To test this in vivo we increased BMP signaling in Fgf3 mutants by removing one copy of Noggin, which encodes a BMP antagonist. In such mutants, all parameters of the Fgf3 phenotype were exacerbated: neural tube closure delay, premature neural crest specification, and premature axis termination. Conversely, genetically decreasing BMP signaling in Fgf3 mutants, via loss of BMP receptor activity, alleviates morphological defects. Aberrant apoptosis is observed in the Fgf3 mutant tailbud. However, we demonstrate that cell death does not cause the Fgf3 phenotype: blocking apoptosis via deletion of pro-apoptotic genes surprisingly increases all Fgf3 defects including causing spina bifida. We demonstrate that this counterintuitive consequence of blocking apoptosis is caused by the increased survival of BMP-producing cells in the neuroepithelium. Thus, we show that FGF3 in the caudal vertebrate embryo regulates BMP signaling in the neuroepithelium, which in turn regulates neural tube closure, neural crest specification and axis termination. Uncovering this FGF3-BMP signaling axis is a major advance toward understanding how these tissue layers interact during axis extension with important implications in human disease., This work was supported by the Center for Cancer Research of the Intramural Research Program of the National Institutes of Health through the National Cancer Institute.

Integrated genomic analysis of 456 pancreatic ductal adenocarcinomas identified 32 recurrently mutated genes that aggregate into 10 pathways: KRAS, TGF-β, WNT, NOTCH, ROBO/SLIT signalling, G1/S transition, SWI-SNF, chromatin modification, DNA repair and RNA processing. Expression analysis defined 4 subtypes: (1) squamous; (2) pancreatic progenitor; (3) immunogenic; and (4) aberrantly differentiated endocrine exocrine (ADEX) that correlate with histopathological characteristics. Squamous tumours are enriched for TP53 and KDM6A mutations, upregulation of the TP63∆N transcriptional network, hypermethylation of pancreatic endodermal cell-fate determining genes and have a poor prognosis. Pancreatic progenitor tumours preferentially express genes involved in early pancreatic development (FOXA2/3, PDX1 and MNX1). ADEX tumours displayed upregulation of genes that regulate networks involved in KRAS activation, exocrine (NR5A2 and RBPJL), and endocrine differentiation (NEUROD1 and NKX2-2). Immunogenic tumours contained upregulated immune networks including pathways involved in acquired immune suppression. These data infer differences in the molecular evolution of pancreatic cancer subtypes and identify opportunities for therapeutic development.

The effect of chronic water deprivation on metabolic rate and long-trace taste-aversion conditioning was examined in Wistar-derived rats. Subjects were either maintained on a water deprivation regimen or allowed free access to water for a seven-week period prior to conditioning. At conditioning, rats were presented a saccharin CS followed 0-, 45-, 90-, or 180-min later by an i.p. injection of LiCl. Additionally, pseudo-conditioned groups were presented the CS followed immediately by an injection of physiological saline. Heightened oxygen consumption in deprived subjects suggested that chronic water deprivation increased metabolic rate. While no differences in the amount of saccharin intake were observed at conditioning, percent preference for saccharin scores during a 24-h two-bottle water/saccharin test revealed that non-chronically deprived rats supported conditioning at longer CS-US intervals than did chronically water-deprived rats. Results are interpreted in terms of a time-contraction effect stemming from an alteration of an internal metabolic count-down timer.

Patients with high-grade serous ovarian cancer (HGSC) have experienced little improvement in overall survival, and standard treatment has not advanced beyond platinum-based combination chemotherapy, during the past 30 years. To understand the drivers of clinical phenotypes better, here we use whole-genome sequencing of tumour and germline DNA samples from 92 patients with primary refractory, resistant, sensitive and matched acquired resistant disease. We show that gene breakage commonly inactivates the tumour suppressors RB1, NF1, RAD51B and PTEN in HGSC, and contributes to acquired chemotherapy resistance. CCNE1 amplification was common in primary resistant and refractory disease. We observed several molecular events associated with acquired resistance, including multiple independent reversions of germline BRCA1 or BRCA2 mutations in individual patients, loss of BRCA1 promoter methylation, an alteration in molecular subtype, and recurrent promoter fusion associated with overexpression of the drug efflux pump MDR1.

Sperm competition is widespread, resulting in sexual selection when the gametes of two or more males compete for access to a given set of ova. This study shows, for the first time, that sexual selection has influenced the evolution of the mammalian vas deferens – that is, the muscular duct which rapidly transports spermatozoa from the cauda epididymis to the ampulla during sexual activity. Morphometric studies of 103 species, representing 70 genera of mammals, show that the vas deferens is on average 33% shorter and its muscular walls are 45% thicker, in those forms where sperm competition pressures are greatest. The outer and inner longitudinal muscle layers of the vas are thickened under these conditions, whereas the central, circular muscle layer is significantly reduced. Thus, mammals that have multiple partner mating systems, and large testes in relation to body weight, have shorter and more muscular vasa deferentia than mammals where single partner mating systems, and smaller relative testes sizes, are the norm. These differences are statistically significant after application of procedures to correct for possible phylogenetic biases in the data set. Sperm competition has played an important role in the evolution of the mammalian vasa deferentia, favouring muscular specializations that enhance sperm transport.