Search

Background: Published studies state that adherence to regular laboratory assessments for anti-arrhythmic drugs is as low as 20%. Monitoring adherence is important as other studies have shown that up to 93% of patients on amiodarone experience an adverse drug event leading to a potentially lethal event., Objective: To determine whether patients prescribed amiodarone or dofetilide are being monitored according to package labeling and guideline recommendations for adverse events., Methods: Patients prescribed amiodarone or dofetilide from a 2-year period were eligible for inclusion. Patients with ventricular arrhythmias, prescribed more than 1 anti-arrhythmic agent, or received anti-arrhythmic monitoring outside the health-care system were excluded. Adherence to monitoring parameters was assessed according to labeled recommendations and published guidelines. The primary objective was to determine the frequency of baseline and follow-up monitoring recommendations for patients receiving amiodarone or dofetilide. The secondary objective was to determine rates of adverse drug events., Results: One hundred patients were evaluated (amiodarone n = 50, dofetilide n = 50). Average rates of baseline and follow-up amiodarone monitoring parameters were 55% and 57%, respectively. Average rates of baseline and follow-up dofetilide monitoring were 99.6% and 85%, respectively. There was a statistically significant difference in abnormally elevated thyroid-stimulating hormone levels (8%-30%, P ≤ .005) after patients were prescribed amiodarone. Twelve percent of patients taking dofetilide had an increase in QTc interval by >15%., Conclusions: Amiodarone adverse event monitoring was lower than dofetilide in this cohort. Improving the monitoring of these agents may decrease morbidity risk in this population.

This article introduces changes occurring in the Veterans Health Administration (VHA) with respect to the delivery of acupuncture. The VHA has published a new occupation code and job qualification standard allowing licensed acupuncturists to practice at the VHA medical centers. This policy shift comes at a time of great need for complementary and integrative health (CIH) options for veterans as identified by the advancing research, policies, and legislation that support CIH. The VHA initiatives include fostering an understanding of the distinct profession of licensed acupuncturists, developing an appreciation of the emerging evidence for acupuncture, and creating the cultural shift to support a wider view of CIH services. Historically, acupuncture was provided in the VHA mostly by physician-acupuncturists and chiropractic acupuncturists. The publication of a qualification standard for licensed acupuncturists allows the VHA to increase its provider base and create cost savings for the delivery of acupuncture. This move requires overcoming barriers to the integration of licensed acupuncturists into the VHA system. The goal is to increase the utilization of acupuncture among veterans., Competing Interests: No competing financial interests exist.

The vitreous humor is a highly aqueous eye fluid interfacing with the retina and lens and providing shape. Its molecular composition provides a readout for the eye's physiological status. Changes in cellular metabolism underlie vitreoretinal pathologies, but despite routine surgical collection of vitreous, only limited reports of metabolism in the vitreous of human patients have been described. Vitreous samples from patients with rhegmatogenous retinal detachment ( n = 25) and proliferative diabetic retinopathy ( n = 9) were profiled along with control human vitreous samples ( n = 8) by untargeted mass-spectrometry-based metabolomics. Profound changes were observed in diabetic retinopathy vitreous, including altered glucose metabolism and activation of the pentose phosphate pathway, which provides reducing equivalents to counter oxidative stress. In addition, purine metabolism was altered in diabetic retinopathy, with decreased xanthine and elevated levels of related purines (inosine, hypoxanthine, urate, allantoate) generated in oxidant-producing reactions. In contrast, the vitreous metabolite profiles of retinal detachment patients were similar to controls. In total, our results suggest a rewiring of vitreous metabolism in diabetic retinopathy that underlies disease features such as oxidative stress and furthermore illustrates how the vitreous metabolic profile may be impacted by disease.

Facial reanimation provides patients affected by chronic facial paralysis a chance to regain basic human functions such as emotional expression, verbal communication, and oral competence for eating and swallowing, but there is still no consensus as to the best way to measure surgical outcomes. We performed a literature review to investigate the different functional outcomes that surgeons use to evaluate facial function after reanimation surgery, focusing on outcomes other than facial expressions such as speech, oral competence, and patient quality of life/satisfaction. A total of 37 articles were reviewed, with the majority reporting outcomes through subjective facial expression ratings and only 15 dealing with other functional outcomes. In particular, outcomes related to oral competence and speech were reported inconsistently. Facial reanimation patients would benefit from a unified movement to create and validate through consensus, an outcomes reporting system incorporating not only facial expression, but also oral competence, speech, and patient-reported quality of life, to enable global patient assessment., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

The delivery of a nerve insult (a "conditioning lesion") prior to a subsequent test lesion increases the number of regenerating axons and accelerates the speed of regeneration from the test site. A major barrier to clinical translation is the lack of an ethically acceptable and clinically feasible method of conditioning that does not further damage the nerve. Conditioning electrical stimulation (CES), a non-injurious intervention, has previously been shown to improve neurite outgrowth in vitro. In this study, we examined whether CES upregulates regeneration-associated gene (RAG) expression and promotes nerve regeneration in vivo, similar to a traditional nerve crush conditioning lesion (CCL). Adult rats were divided into four cohorts based on conditioning treatment to the common peroneal (fibular) nerve: i) CES (1h, 20Hz); ii) CCL (10s crush); iii) sham CES (1h, 0Hz); or iv) naïve (unconditioned). Immunofluorescence and qRT-PCR revealed significant RAG upregulation in the dorsal root ganglia of both CES and CCL animals, evident at 3-14days post-conditioning. To mimic a clinical microsurgical nerve repair, all cohorts underwent a common peroneal nerve cut and coaptation one week following conditioning. Both CES and CCL animals increased the length of nerve regeneration (3.8-fold) as well as the total number of regenerating axons (2.2-fold), compared to the sham and naïve-conditioned animals (p<0.001). These data support CES as a non-injurious conditioning paradigm that is comparable to a traditional CCL and is therefore a novel means to potentially enhance peripheral nerve repair in the clinical setting., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to use a physiological pressure transducer to measure real-time, continuous pressure changes in an ex vivo study model of porcine eyes to record the amount of force needed for scleral penetration and to measure acute intraocular pressure rise during intravitreal injections., Methods: A pressure transducer was inserted into the anterior chamber of 30 fresh porcine eyes, and intraocular pressure was measured 2 s prior to intravitreal injection until 2 s after. A force transducer plate was used to insert various gauge needles into the vitreous cavity and the amount of force in Newtons (N) required for scleral penetration was recorded., Results: For scleral perforation, 32- and 30-gauge needles required 0.44 N and 0.45 N, significantly less than larger gauge needles (P < 0.05). Similarly, 27- and 25-gauge needles required more force than smaller gauge needles but less than 19 gauge (P < 0.05). Intraocular pressure increased an average of 64.5 mmHg during intravitreal injection. Two seconds postinjection intraocular pressure readings showed a residual intraocular pressure increase of 11.1 mmHg from pre-injection baseline., Conclusion: Real-time continuous recordings of pressure reveal that an instantaneous intraocular pressure spike occurs during intravitreal injection and appears to be separate from the intraocular pressure spike that occurs during needle insertion. This pressure spike is transient and has not been captured by previous methods of intraocular pressure measurement, which rely on single time point measurements. The clinical significance of this brief intraocular pressure spike is unclear and warrants further investigation., (© 2017 Royal Australian and New Zealand College of Ophthalmologists.)

Background: Upper trunk obstetric brachial plexus injury can cause profound shoulder and elbow dysfunction. Although neuroma excision with interpositional sural nerve grafting is the current gold standard, distal nerve transfers have a number of potential advantages. The goal of this study was to compare the clinical outcomes and health care costs between nerve grafting and distal nerve transfers in children with upper trunk obstetric brachial plexus injury., Methods: In this prospective cohort study, children who underwent triple nerve transfers were followed with the Active Movement Scale for 2 years. Their outcomes were compared to those of children who underwent nerve graft reconstruction. To assess health care use, a cost analysis was also performed., Results: Twelve patients who underwent nerve grafting were compared to 14 patients who underwent triple nerve transfers. Both groups had similar baseline characteristics and showed improved shoulder and elbow function following surgery. However, the nerve transfer group displayed significantly greater improvement in shoulder external rotation and forearm supination 2 years after surgery (p < 0.05). The operative time and length of hospital stay were significantly lower (p < 0.05), and the overall cost was approximately 50 percent less in the nerve transfer group., Conclusion: Triple nerve transfer for upper trunk obstetric brachial plexus injury is a feasible option, with better functional shoulder external rotation and forearm supination, faster recovery, and lower cost compared with traditional nerve graft reconstruction., Clinical Question/level of Evidence: Therapeutic, II.

Introduction: The current standard of treatment for glaucoma is trabeculectomy. The use of glaucoma drainage devices has increased in recent years since its efficacy and safety was established as it provides an alternative surgical option. A downfall of these devices is the lack of proper flow rate control. Areas covered: In this paper we describe a glaucoma drainage device regulator that has already been protoyped and undergone initial testing. It consists of an implantable device with a semipermeable membrane that is used during glaucoma surgery and can be opened with either thermal or photodisruptive laser to adjust the amount of flow precisely and non-invasively, addressing the current difficulties of glaucoma surgeries. A literature search was conducted using MEDLINE and manuscript references for studies published in English between 2000 and 2015 using the terms glaucoma, trabeculectomy and glaucoma drainage devices. Expert commentary: The GDDR device can decrease surgical risk and allow surgeons to post-operatively adjust flow as clinically needed using a non-invasive method. Further testing is planned to substantiate these initial results and evaluate the device's biocompatibility, tunability and efficacy.

Background/purpose: To report a case of simultaneous endophthalmitis and anterior segment ischemia (ASI) that occurred in a patient after strabismus surgery. This is the first known case of both complications occurring at the same time., Methods: Case report., Results: A 60-year-old woman presented with eye pain and loss of vision 6 days after uncomplicated strabismus surgery for thyroid eye disease. On examination, she had corneal edema, anterior segment fibrin, an atonic iris, and no view to the posterior segment. On fluorescein angiography of the anterior segment, a large portion of the iris was nonperfused. Posterior segment ultrasound showed dense vitritis and a choroidal abscess. Intraoperative cultures grew methicillin-resistant Staphylococcus aureus., Conclusions: Endophthalmitis and anterior segment ischemia are both exceedingly rare complications of strabismus surgery. It is possible that each one occurred independently, but more likely one process potentiated the other. One possible mechanism is inflammation-induced thrombosis.

PurposeWe report the in vivo testing of a large-lumen glaucoma drainage (LL-GDD) device equipped with a flow regulator. The device's membrane can be non-invasively opened with laser in the postoperative period to adjust aqueous flow and intraocular pressure.MethodsThe initial LL-GDD prototypes were constructed using 22 G silicone angiocatheters cut down to size. A 10 nm PVDF membrane was then affixed to the end using cyanoacrylate. The LL-GDD was tested first in a model eye equipped with ports for infusion and pressure measurement and in New Zealand rabbits.ResultsNew Zealand white satin cross rabbits were used, two eyes receiving the LL-GDD and the two fellow eyes serving as the control group with no intervention performed. After the procedure, the IOP in the LL-GGD surgical group dropped an average of 5.5 mm Hg (P=0.001), which was maintained until the membrane laser procedure at week 5 resulting in an average IOP reduction of 1.8 mm Hg. At week 7, the average IOP in the surgical group was 11 mm Hg compared with 18 mm Hg in the control group (P<0.001). A second laser procedure was done to completely open the membrane face, which resulted in an immediate drop in the average IOP of the surgical group by another 2.7 mm Hg, which was maintained until the study termination at day 55.ConclusionsThe large-lumen glaucoma drainage device demonstrated an ability both to prevent immediate postoperative hypotony and to allow progressively lower IOP on demand in this proof-of-concept study.

Purpose: To describe management of posteriorly retained iris expansion ring-a newly reported complication of phacoemulsification surgery in a patient with intact posterior capsule., Methods: Case report., Patients: A 64-year-old monocular patient with history of regressed proliferative diabetic retinopathy after pars plana vitrectomy, long-standing glaucoma, and cataract, undergoing phacoemulsification for cataract removal, complicated by posterior migration of the Malyugin ring through area of zonular dehiscence despite intact posterior capsule, which resulted in significant visual disturbance., Results: The intravitreal Malyugin ring was successfully removed by performing a standard 3-port 25-gauge vitrectomy and retrieving the mobilized ring into the barrel of the original injector device., Conclusion: A posteriorly retained iris expansion ring can be effectively extracted from the vitreous cavity with the original injector device, which allows for maximal control of the ring and minimal associated surgical trauma.

The MESA (Multi-Ethnic Study of Atherosclerosis) was initiated to address unresolved questions about subclinical cardiovascular disease and its progression to clinically overt cardiovascular disease in a diverse population-based sample, incorporating emerging imaging technologies for better evaluation of subclinical disease and creating a population laboratory for future research. MESA's recruited (from 2000 to 2002) cohort comprised >6,000 adults from 4 racial/ethnic groups, ages 45 to 84 years, who were free of cardiovascular disease at baseline. Extensive cohort data have been collected over 5 exams (through 2011) with additional exam components added through extramurally funded ancillary study grants, and through regular phone follow-up contacts. Over 1,000 MESA papers have been published to date. Exam 6 will incorporate components that use novel wearable, imaging, and other technologies to address new research questions. MESA investigators have and continue to seek opportunities for collaboration with other researchers on a wide variety of topics to further expand the science of MESA., (Copyright © 2016 World Heart Federation (Geneva). All rights reserved.)

Reconstruction of the suprascapular nerve (SSN) after brachial plexus injury often involves nerve grafting or a nerve transfer. To restore shoulder abduction and external rotation, a branch of the spinal accessory nerve is commonly transferred to the SSN. To allow reinnervation of the SSN, any potential compression points should be released to prevent a possible double crush syndrome. For that reason, the authors perform a release of the superior transverse scapular ligament at the suprascapular notch in all patients undergoing reconstruction of the upper trunk of the brachial plexus. Performing the release through a standard anterior open supraclavicular approach to the brachial plexus avoids the need for an additional posterior incision or arthroscopic procedure., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background/aims: While the Endophthalmitis Vitrectomy Study (EVS) included only post-cataract surgery patients, the methods and data from that study are widely applied in the management of endophthalmitis of all types. We sought to examine how our experience with in-office vitreous aspiration differed from the EVS in two ways: first, by reviewing microbiological culture yields from vitreous aspirates obtained using 30-gauge needles versus 25-27-gauge needles and second, by reviewing culture yields in cases of endogenous versus non-endogenous endophthalmitis., Methods: Cases of endophthalmitis over a 14-year period were reviewed when vitreous tap was the initial diagnostic procedure. The data included infection source, needle size used to obtain a vitreous aspirate, organism cultured and rates of unsuccessful attempts at vitreous aspiration or dry taps., Results: 10 cases were endogenous endophthalmitis, while 36 cases were a mix of postoperative, post-traumatic, post-intravitreal injection and miscellaneous patients. A positive microbiological culture was obtained in 11/36 (31%) of vitreous taps using a 25-27-gauge needle and in 8/10 (80%) taps using a 30-gauge needle (p<0.01). A positive vitreous culture was obtained in 18/36 (50%) of all non-endogenous cases, while a positive result was obtained in 0/10 (0%) cases of endogenous endophthalmitis (p<0.01)., Conclusions: The use of a smaller needle in obtaining vitreous samples in endophthalmitis did not lower the microbiological yield. A positive microbiological yield was significantly less likely in cases of endogenous endophthalmitis compared with non-endogenous cases. Vitreous tap as a method for identifying the causative organism in endogenous endophthalmitis was of limited utility., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: AA amyloidosis due to subcutaneous injection of drugs of abuse has been described in the USA, but all the existing literature is from more than 20 years ago. There is more recent literature from Europe. We have observed a high incidence of AA amyloidosis in the county hospital in San Francisco., Design: Here, we describe 24 patients who had kidney biopsy-proven AA amyloidosis from our hospital from 1998 to 2013. All the patients were thought to have AA amyloidosis from skin popping of illicit drugs after having exhausted the intravenous route. These patients with biopsy-proven AA amyloidosis were analysed further., Results: All patients were found to have hepatitis C infection, hypertension was not common, most had advanced kidney failure, and acidosis was common as was tubulointerstitial involvement on the kidney biopsy. Other organ involvement included hepatomegaly and splenomegaly in a number of patients; direct myocardial involvement was not seen, but pulmonary hypertension, history of deep vein thrombosis and pulmonary embolism were common. The prognosis of these patients was poor. The mortality rate approached 50% 1 year after biopsy, and most of the patient needed dialysis shortly after diagnosis. Cessation of drug use seemed beneficial but rarely achievable., Conclusion: AA amyloidosis from skin popping is common in San Francisco. Most patients with renal involvement end up on dialysis, and mortality rates are exceedingly high., (© 2015 Asian Pacific Society of Nephrology.)

A brother and sister developed a previously undescribed constellation of autoimmune manifestations within their first year of life, with uncontrollable bullous pemphigoid, colitis, and proteinuria. The boy had hemophilia due to a factor VIII autoantibody and nephrotic syndrome. Both children required allogeneic hematopoietic cell transplantation (HCT), which resolved their autoimmunity. The early onset, severity, and distinctive findings suggested a single gene disorder underlying the phenotype. Whole-exome sequencing performed on five family members revealed the affected siblings to be compound heterozygous for two unique missense mutations in the 70-kD T cell receptor ζ-chain associated protein (ZAP-70). Healthy relatives were heterozygous mutation carriers. Although pre-HCT patient T cells were not available, mutation effects were determined using transfected cell lines and peripheral blood from carriers and controls. Mutation R192W in the C-SH2 domain exhibited reduced binding to phosphorylated ζ-chain, whereas mutation R360P in the N lobe of the catalytic domain disrupted an autoinhibitory mechanism, producing a weakly hyperactive ZAP-70 protein. Although human ZAP-70 deficiency can have dysregulated T cells, and autoreactive mouse thymocytes with weak Zap-70 signaling can escape tolerance, our patients' combination of hypomorphic and activating mutations suggested a new disease mechanism and produced previously undescribed human ZAP-70-associated autoimmune disease., (© 2016 Chan et al.)

The study aims to determine the progression of gyrate atrophy by measuring the area growth of chorioretinal atrophic lesions using ultra-wide-field images (UWFI). A retrospective, observational, and comparative study was conducted and UWFI (200°) were obtained from two patients with gyrate atrophy at baseline and follow-up. Measurements of atrophy were obtained for three types of lesions: Solitary atrophic lesions (SAL), De novo solitary lesions (DNSL), and peripapillary atrophy (PPA). Comparison of baseline and follow-up was done using t tests. Two patients with gyrate atrophy were included. Patient 1 presented 16 SAL, 5 DNSL, and PPA measured for both eyes (BE). Overall area growth (OAG) for SAL (expressed in decimals) presented a mean of 3.41, σ 3.07. DNSL area for BE presented a mean of 1586.08 P (2), σ 1069.55. OAG for PPA presented a mean of 1.21, σ 0.17. Patient 2 presented 5 SAL, no DNSL, and PPA was measured for BE. OAG for SAL presented a mean of 1.58, σ 1.05 (range 1.02-3.47). OAG for PPA presented a mean of 1.05, σ 0.001. Gyrate atrophy progression can be determined by measuring the changes in area using UWFI.

Purpose: We introduce a new method to observe the morphologic features of the vitreous with spectral-domain optical coherence tomography (SD-OCT) by evaluating and describing the posterior vitreous structure of various selected cases using enhanced high-density (HD) line mode., Methods: This is a descriptive case series of SD-OCT images with enhanced HD line at Denver Health Medical Center, University of Colorado School of Medicine, in 2014. The medical records with ocular images for these patients were analyzed., Results: Enhanced HD line in vitreoretinal mode with SD-OCT offered wide images with well-visible vitreoretinal interface. The posterior precortical vitreous pocket (PPVP), often mistaken as a posterior vitreous detachment on standard retina-based cross line mode, was easily identified. Vitreomacular adhesion and traction, absence or presence of connecting channels between PPVP and Cloquet's canal, liquefied vitreous lacuna, and emulsified silicone oil droplet-layer could be observed., Conclusions: SD-OCT using enhanced HD line in vitreoretinal mode enables clear visualization of the posterior vitreous structure and often reclassifies patients previously thought to have a posterior vitreous detachment.

Unlabelled: We describe a surgical technique for scleral fixation of a posterior chamber intraocular lens (PC IOL) using a 24-gauge injectable polypropylene suture delivery system. A 3-piece PC IOL is inserted into the anterior chamber of the eye. Two sclerotomies are made 1.5 mm posterior to the limbus using a microvitreoretinal blade. The 24-gauge injector delivers a preformed suture loop into the eye with the double-armed needles still external to the eye. Each polypropylene IOL haptic is directed through the loop using microforceps. The suture loop is tightened around the haptic, and the attached needles are used to fixate the IOL to the sclera and close the sclerotomies simultaneously. This technique has been used in an ex vivo porcine eye and in an aphakic patient. In the latter, the IOL was quickly fixated to the sclera and maintained a stable position postoperatively., Financial Disclosure: Dr. Olson has a patent pending for the device described in this article. No other author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Protein disulfide isomerase (PDI) family members regulate protein folding and calcium homeostasis in the endoplasmic reticulum (ER). The PDI family member anterior gradient (AGR) 3 is expressed in the airway, but the localization, regulation, and function of AGR3 are poorly understood. Here we report that AGR3, unlike its closest homolog AGR2, is restricted to ciliated cells in the airway epithelium and is not induced by ER stress. Mice lacking AGR3 are viable and develop ciliated cells with normal-appearing cilia. However, ciliary beat frequency was lower in airways from AGR3-deficient mice compared with control mice (20% lower in the absence of stimulation and 35% lower after ATP stimulation). AGR3 deficiency had no detectable effects on ciliary beat frequency (CBF) when airways were perfused with a calcium-free solution, suggesting that AGR3 is required for calcium-mediated regulation of ciliary function. Decreased CBF was associated with impaired mucociliary clearance in AGR3-deficient airways. We conclude that AGR3 is a specialized member of the PDI family that plays an unexpected role in the regulation of CBF and mucociliary clearance in the airway.

Glaucoma, the second most common cause of blindness in the world, is a multifactorial disease with several risk factors, of which intraocular pressure (IOP) is a primary contributing factor. Filtration surgery is one of the most effective means to significantly lower IOP compared to medical or laser treatments, and it is typically reserved for advanced disease. However, there are high rates of postoperative complications associated with the procedure, often from over- or under-filtration. To address these problems, the glaucoma drainage device regulator (GDDR) implant was developed to allow post-operative control of aqueous flow and IOP. The device, a tube with a nanopore membrane, is placed beneath the scleral flap. Postoperatively, the membrane surface can be ruptured with a laser to augment flow through the system. This feature allows adjustable control of aqueous flow and diminishes the risk of hypotony in the early postoperative period.

Delayed graft function (DGF) is a frequent complication of renal transplantation, particularly in the setting of transplantation of kidneys derived from deceased donors and expanded-criteria donors. DGF results from tubular epithelial cell injury and has immediate and long term consequences. These include requirement for post-transplantation dialysis, increased incidence of acute rejection, and poorer long-term outcomes. DGF represents one of the clearest clinical examples of renal acute ischemia/reperfusion injury. Experimental studies have demonstrated that ischemia/reperfusion injury induces the synthesis of the full length secreted isoform of matrix metalloproteinase-2 (FL-MMP-2), as well as an intracellular N-terminal truncated MMP-2 isoform (NTT-MMP-2) that initiates an innate immune response. We hypothesized that the two MMP-2 isoforms mediate tubular epithelial cell injury in DGF. Archival renal biopsy sections from 10 protocol biopsy controls and 41 cases with a clinical diagnosis of DGF were analyzed for the extent of tubular injury, expression of the FL-MMP-2 and NTT-MMP-2 isoforms by immunohistochemistry (IHC), in situ hybridization, and qPCR to determine isoform abundance. Differences in transcript abundance were related to tubular injury score. Markers of MMP-2-mediated injury included TUNEL staining and assessment of peritubular capillary density. There was a clear relationship between tubular epithelial cell expression of both FL-MMP-2 and NTT-MMP-2 IHC with the extent of tubular injury. The MMP-2 isoforms were detected in the same tubular segments and were present at sites of tubular injury. qPCR demonstrated highly significant increases in both the FL-MMP-2 and NTT-MMP-2 transcripts. Statistical analysis revealed highly significant associations between FL-MMP-2 and NTT-MMP-2 transcript abundance and the extent of tubular injury, with NTT-MMP-2 having the strongest association. We conclude that two distinct MMP-2 isoforms are associated with tubular injury in DGF and offer novel therapeutic targets for the prevention of this disorder.

Objective: Brief postsurgical electrical stimulation (ES) has been shown to enhance peripheral nerve regeneration in animal models following axotomy and crush injury. However, whether this treatment is beneficial in humans with sensory nerve injury has not been tested. The goal of this study was to test the hypothesis that ES would enhance sensory nerve regeneration following digital nerve transection compared to surgery alone., Methods: Patients with complete digital nerve transection underwent epineurial nerve repair. After coaptation of the severed nerve ends, fine wire electrodes were implanted before skin closure. Postoperatively, patients were randomized to receiving either 1 hour of 20Hz continuous ES or sham stimulation in a double-blinded manner. Patients were followed monthly for 6 months by a blinded evaluator to monitor physiological recovery of spatial discrimination, pressure threshold, and quantitative small fiber sensory testing. Functional disability was measured using the Disability of Arm, Shoulder, and Hand questionnaire., Results: A total of 36 patients were recruited, with 18 in each group. Those in the ES group showed consistently greater improvements in all sensory modalities by 5 to 6 months postoperatively compared to the controls. Although there was a trend of greater functional improvements in the ES group, it was not statistically significant (p > 0.01)., Interpretation: Postsurgical ES enhanced sensory reinnervation in patients who sustained complete digital nerve transection. The conferred benefits apply to a wide range of sensory functions., (© 2015 American Neurological Association.)

A male with sickle SC disease presented at age 8 years with proliferative sickle cell retinopathy (PSCR) and bilateral vitreous hemorrhage which spontaneously resolved, then recurred at 13 years of age. Despite conventional therapy with repeated pan-retinal photocoagulation and pars plana vitrectomy, he developed progressive PSCR and recurrent vitreous hemorrhage over the next 30 months. We describe the successful use of chronic red cell exchange transfusion (RCE) to preserve his vision and stabilize the retinopathy., (© 2015 Wiley Periodicals, Inc.)

Purpose: To propose a model that measures the effect of intravitreal bevacizumab (IVB) on relatively healthy retina. The purpose is to analyze the remote effect of a branch retinal vein occlusion in the healthy retina, to determine the response it may have to IVB, and to determine if IVB has an atrophic effect on the healthy retina., Methods: Retrospective, longitudinal comparative analysis of patients with branch retinal vein occlusion treated with IVB. Eyes were divided into experimental (branch retinal vein occlusion eye) and control (contralateral eye) groups. Each eye was analyzed for thickness and area. Thickness measurements were performed for total retinal thickness, inner retina thickness, and outer retina thickness. Area was measured for photoreceptors, choroid, and total retina., Results: Eighteen eyes of 9 patients. For thickness analysis, 1,050 scans were studied, and 126 measurements were performed on 42 scans for area analysis. No difference was observed for thickness, except for inner retina thickness. No difference was observed for area. No difference was observed when analyzing a cumulative exposure to IVB., Conclusion: There is no evidence to suggest an atrophic effect caused by IVB when analyzing thickness or area in this experiment. This model could be used to analyze the long-term safety of IVB in larger studies.

Purpose: To purpose if this study was to determine whether the horizontal rectus muscle tendons (HRMTs) can be observed using anterior segment optical coherence tomography (AS-OCT) and to determine the repeatability of its measurements. Also, this study aimed to observe and measure the different external ocular structures at the level of the horizontal rectus muscle (HRM) insertion., Methods: This was a retrospective, observational, descriptive and comparative study. Images were obtained utilizing the RTVue 100 CAM system. Eyes were analyzed at the three and nine o'clock position. Scans were performed for three different locations: the limbus, the ciliary body and the equator. All scans were analyzed by two graders, separately and blinded. Measurements were performed for: HRMT length; HRM thickness; conjunctival epithelium thickness; conjunctiva and Tenon's capsule thickness; scleral thickness; and external ocular thickness., Results: Results were obtained from twenty eyes of ten volunteers. The conjunctival epithelium thickness was 52.33 μm, the total conjunctiva/Tenon's capsule thickness was 313.54 μm, the medial rectus (MR) thickness was 136.63 μm and the lateral rectus (LR) thickness was 181.65 μm. The MR tendon length was 1,426.88 μm, the LR tendon length was 1,433.65 μm, the scleral thickness was 489.91 μm and the total external ocular structure thickness was 785.17 μm. Intra-observer reproducibility (intraclass correlation coefficient [ICC]) for tendon length was 0.993 for grader #1, 0.989 for grader #2; the muscle thickness ICC was 0.990 for grader #1 and 0.981 for grader #2. The inter-observer reproducibility ICC for tendon length was 0.557; the ICC for muscle thickness was 0.834., Conclusions: It is possible to visualize and measure HRMTs using AS-OCT. Measurements of the HRM, as well as the surrounding external ocular tissues, can be achieved.

This paper uses computer modeling to estimate the progressive decline in oxygenation that occurs in the human diabetic retina after years of slowly progressive ischemic insult. An established model combines diffusion, saturable consumption, and blood capillary sources to determine the oxygen distribution across the retina. Incorporating long-term degradation of blood supply from the retinal capillaries into the model yields insight into the effects of progressive ischemia associated with prolonged hyperglycemia, suggesting time-scales over which therapeutic mitigation could have beneficial effect. A new extension of the model for oxygen distribution introduces a feedback mechanism for vasodilation and its potential to prolong healthy retinal function., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The mechanisms behind the association of atrial fibrillation (AF) and dementia are unknown. One possibility is that exposure to chronic microembolism or microbleeds results in repetitive cerebral injury that is manifest by cognitive decline., Objective: The purpose of this study was to test the hypothesis that AF patients with a low percentage of time in the therapeutic range (TTR) are at higher risk for dementia due to under- or overanticoagulation., Methods: Patients anticoagulated with warfarin (target international normalized ratio [INR] 2-3), managed by the Intermountain Healthcare Clinical Pharmacist Anticoagulation Service with no history of dementia or stroke/transient ischemic attack, were included in the study. The primary outcome was dementia incidence defined by ICD-9 codes. Percent time in TTR was calculated using the method of linear interpolation and stratified as >75%, 51%-75%, 26%-50%, and ≤25%. Multivariable Cox hazard regression was used to determine dementia incidence by percentage categories of TTR., Results: A total of 2605 patients (age 73.7 ± 10.8 years, 1408 [54.0%] male) were studied. The CHADS2 score distribution was 0: 216 (8.3%); 1: 579 (22.2%); 2: 859(33.0%); 3: 708 (27.2%); and ≥4: 243 (9.3%). The percent TTR averaged 63.1 ± 21.3, with percent INR <2.0: 25.6% ± 17.9% and percent INR >3.0: 16.2% ± 13.6%. Dementia was diagnosed in 109 patients (4.2%) (senile: 37 [1.4%]; vascular: 8 [0.3%]; Alzheimer: 64 (2.5%]). After adjustment, decreasing categories of percent TTR were associated with increased dementia risk (vs >75%): <25%: hazard ratio (HR) 5.34, P < .0001; 26%-50%: HR 4.10, P < .0001; and 51%-75%: HR = 2.57, P = .001., Conclusion: Quality of anticoagulation management represented as percent TTR among AF patients without dementia was associated with dementia incidence. These data support the possibility of chronic cerebral injury as a mechanism that underlies the association of AF and dementia., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the capabilities of a new glaucoma drainage device regulator in controlling fluid flow as well as to demonstrate that this effect may be titratable by noninvasive means., Methods: A rigid eye model with two main ports was used. On the first port, we placed a saline solution column. On the second, we placed a glaucoma shunt. We then measured the flow and flow rate through the system. After placing the regulator device on the tip of the tube, we measured again with the intact membrane and with the membrane open 50% and 100%. For the ex vivo testing we used a similar setting, using a cadaveric porcine eye, we measured again the flow and flow rate. However, this time we opened the membrane gradually using laser shots. A one-way analysis of variance and a Fisher's Least Significant Difference test were used for statistical significance. We also calculated the correlation between the numbers of laser shots applied and the main outcomes., Results: The flow through the system with the glaucoma drainage device regulator (membrane intact and 50% open) was statistically lower than with the membrane open 100% and without device ( P < 0.05). The flow was successfully controlled by the number of laser shots applied, and showed a positive correlation (+ 0.9). The flow rate was almost doubled every 10 shots and statistically lower than without device at all time ( P < 0.05)., Conclusions: The glaucoma drainage device regulator can be controlled noninvasively with laser, and allows titratable control of aqueous flow., Translational Relevance: Initial results and evidence from this experiment will justify the initiation of in vivo animal trials with the glaucoma drainage device regulator; which brings us closer to possible human trials and the chance to significantly improve the existing technology to treat glaucoma surgically.

Context: There is high demand for local-level population health data. A national system of state and local data collection would help improve both population health and health care delivery. The primary source of state-level population health data for adults is the Behavioral Risk Factor Surveillance System. However, many states need data on children and adolescents, racial and ethnic subpopulations, consistent estimates for localities, or more in-depth information on key topics than the Behavioral Risk Factor Surveillance System provides. Eleven state health surveys (SHSs) have emerged in an effort to address these gaps., Design: Semistructured telephone interviews were conducted in 2009 with representatives of 9 SHSs. The interviews were recorded, and data were transcribed, organized, and analyzed according to the query structure. This analysis identified (1) the core elements of SHS that have been successful in meeting needs for local data and (2) the processes and strategies used by state officials in creating these surveys., Results: Key findings include the following: (1) SHSs provide concrete data on local health issues that meet the needs of policy makers who wish to adopt evidence-based public health policies; (2) data from SHSs allow researchers to identify issues, apply for grants, and evaluate, assess, and track health indicators; (3) a "champion" is required to build the case for a survey and push through barriers to obtain funding and stakeholder buy-in; and (4) SHSs face challenges such as inconsistent funding and lack of uniform standards., Conclusion: Opportunities to support SHSs include (1) identifying sustained funding sources; (2) providing technical assistance and facilitating training to foster best practices, quality standards, and comparability across states; and (3) supporting an organization for SHS researchers to share resources, information, and experiences.

We present a case study of a novel variation of the targeted sensory reinnervation technique that provides additional control over sensory restoration after transhumeral amputation. The use of intraoperative somatosensory evoked potentials on individual fascicles of the median and ulnar nerves allowed us to specifically target sensory fascicles to reroute to target cutaneous nerves at a distance away from anticipated motor sites in a transhumeral amputee. This resulted in restored hand maps of the median and ulnar nerve in discrete spatially separated areas. In addition, the subject was able to use native and reinnervated muscle sites to control a robotic arm while simultaneously sensing touch and force feedback from the robotic gripper in a physiologically correct manner. This proof of principle study is the first to demonstrate the ability to have simultaneous dual flow of information (motor and sensory) within the residual limb. In working towards clinical deployment of a sensory integrated prosthetic device, this surgical method addresses the important issue of restoring a usable access point to provide natural hand sensation after upper limb amputation.

Purpose: To address the most dynamic and current issues concerning human genetics, risk factors, pharmacoeconomics, and prevention regarding age-related macular degeneration., Methods: An online review of the database Pubmed and Ovid was performed, searching for the key words: age-related macular degeneration, AMD, pharmacoeconomics, risk factors, VEGF, prevention, genetics and their compound phrases. The search was limited to articles published since 1985 to date. All returned articles were carefully screened and their references were manually reviewed for additional relevant data. The webpage www.clinicaltrials.gov was also accessed in search of relevant research trials., Results: A total of 366 articles were reviewed, including 64 additional articles extracted from the references and 25 webpages and online databases from different institutions. At the end, only 244 references were included in this review., Conclusion: Age-related macular degeneration is a complex multifactorial disease that has an uneven manifestation around the world but with one common denominator, it is increasing and spreading. The economic burden that this disease poses in developed nations will increase in the coming years. Effective preventive therapies need to be developed in the near future.

Background and Objective: During vitrectomy in phakic patients, lens damage can occur while shaving the peripheral vitreous. Modifying the vitrector with a slight bend can diminish this risk., Materials and Methods: To assess whether the bent vitrector performs to standard, the cutting and aspiration functionality of a straight and bent cutter was tested on both the vitreous from an enucleated porcine eye and balanced salt solution. Data were analyzed using a paired two-tailed t-test for comparison of two small sample means., Results: The average time for removal of vitreous was 19.32 seconds with the straight cutter and 19.26 seconds for the bent cutter. There was no statistically significant difference between the removal rates (P = .87). The average time for aspiration of balanced salt solution was 14.3 seconds with the straight tip and 14.16 seconds with the bent tip. There was no statistically significant difference between the aspiration rates (P = .55)., Conclusion: Both unmodified and bent vitrectors demonstrate an equally efficient rate of removal of vitreous and balanced salt solution in vitro., (Copyright 2014, SLACK Incorporated.)

Traumatic brachial plexus root avulsions are devastating injuries, and are complex and challenging to reconstruct. Double free muscle transfer using the gracilis muscles is a potentially effective method of restoring upper extremity function. The authors report on the first two patients treated using this technique in Canada. Both sustained traumatic brachial plexus root avulsion injuries resulting in a flail arm. In the first step of this two-stage procedure, a gracilis muscle was transferred to restore elbow flexion, and wrist and digit extension. Months later, the transfer of the second gracilis muscle was performed to enhance elbow flexion and to enable wrist and digit flexion. Postoperatively, both patients achieved Medical Research Council grade 4 elbow flexion, functional handgrip and were able to return to gainful employment. Patient satisfaction was high and active range of motion improved substantially. The authors' experience supports the use of this technique following severe brachial plexus injury.

The hand is an integral component of the human body, with an incredible spectrum of functionality. In addition to possessing gross and fine motor capabilities essential for physical survival, the hand is fundamental to social conventions, enabling greeting, grooming, artistic expression and syntactical communication. The loss of one or both hands is, thus, a devastating experience, requiring significant psychological support and physical rehabilitation. The majority of hand amputations occur in working-age males, most commonly as a result of work-related trauma or as casualties sustained during combat. For millennia, humans have used state-of-the-art technology to design clever devices to facilitate the reintegration of hand amputees into society. The present article provides a historical overview of the progress in replacing a missing hand, from early iron hands intended primarily for use in battle, to today's standard body-powered and myoelectric prostheses, to revolutionary advancements in the restoration of sensorimotor control with targeted reinnervation and hand transplantation.

Background: Medication non-adherence is a complex phenomenon that requires tailored interventions to improve it. A new self-reported measure of medication non-adherence was previously reported based on the commonly reported reasons underlying non-adherence with the intention to match the items in the scale with tailored interventions., Objective: The objectives were to revise the original Medication Adherence Reasons Scale (MAR-Scale) based on expert opinion and cognitive interviewing, and establish the psychometric properties of the revised scale., Methods: A cross-sectional design was used in cholesterol lowering and asthma maintenance medications in collaboration with an integrated medical center in the Mountain West. In the first phase, the original MAR-Scale was revised based on expert opinion and cognitive interviewing. In the second phase, the revised MAR-Scale was tested for psychometric properties in a random sample of 350 subjects on each medication., Results: Revisions based on expert opinion included asking a global question about adherence in the past 7 days, simplifying the items and converting them into first person sentences, objective anchoring of the scale, and expanding the 'forgetfulness' item. Cognitive interviewing added one additional item to the survey. The revised MAR- Scale identified 50% of the cholesterol lowering respondents and 68% of the asthma maintenance respondents as non-adherents. An exploratory factor analysis identified four domains in the scale, with Cronbach's alpha ranging from 0.848-0.953 in cholesterol lowering and 0.827-0.891 in asthma maintenance medications. The scale also exhibited significant correlations with few other self-reported measures, consistent with hypotheses. A key limitation of the study was the moderate response rate to the survey for both medications., Conclusion: The revised MAR-Scale demonstrates better psychometric properties than the original.

Background: Current surgical management of obstetrical brachial plexus injury is primary reconstruction with sural nerve grafts. Recently, the nerve-to-nerve transfer technique has been used to treat brachial plexus injury in adults, affording the benefit of distal coaptations that minimize regenerative distance. The purpose of this study was to test the hypothesis that nerve transfers are effective in reconstructing isolated upper trunk obstetrical brachial plexus injuries., Methods: Ten patients aged 10 to 18 months were treated with three nerve transfers: spinal accessory nerve to the suprascapular nerve for shoulder abduction and external rotation; a radial to axillary nerve for shoulder abduction; and ulnar or median nerve transfer to the musculocutaneous nerve for elbow flexion. Patients were assessed preoperatively and postoperatively using the Active Movement Scale. All patients were followed regularly for up to 2 years., Results: Improvement in elbow and shoulder function was observed between 6 and 24 months. By 6 months, all patients passed the cookie test. At 24 months, shoulder abduction improved from 3.7 ± 0.6 to 5.0 ± 0.5, shoulder external rotation from 1.8 ± 0.4 to 4.3 ± 0.6, shoulder flexion from 3.7 ± 0.5 to 5.4 ± 0.5, elbow flexion from 3.7 ± 0.6 to 6.3 ± 0.2, and forearm supination from 2.1 ± 0.4 to 5.9 ± 0.2. There was no clinically appreciable donor-site morbidity., Conclusions: Nerve transfers reduced operative times compared with traditional nerve grafting procedures. Those patients showed significant gains in Active Movement Scale score by 24 months postoperatively, comparable to results achieved by nerve grafting. These findings support nerve transfers as a potential alternative treatment option for upper trunk obstetrical brachial plexus injuries., Clinical Question/level of Evidence: Therapeutic, IV.

Soluble epoxide hydrolase (sEH) catalyzes the conversion of epoxyeicosatrienoic acids into less active eicosanoids, and inhibitors of sEH have anti-inflammatory and antiapoptotic properties. Based on previous observations that sEH inhibition attenuates cisplatin-induced nephrotoxicity by modulating nuclear factor-κB signaling, we hypothesized that this strategy would also attenuate cisplatin-induced renal apoptosis. Inhibition of sEH with AR9273 [1-adamantan-1-yl-3-(1-methylsulfonyl-piperidin-4-yl-urea)] reduced cisplatin-induced apoptosis through mechanisms involving mitochondrial apoptotic pathways and by reducing reactive oxygen species. Renal mitochondrial Bax induction following cisplatin treatment was significantly decreased by treatment of mice with AR9273 and these antiapoptotic effects involved p38 mitogen-activated protein kinase signaling. Similar mechanisms contributed to reduced apoptosis in Ephx2(-/-) mice treated with cisplatin. Moreover, in pig kidney proximal tubule cells, cisplatin-induced mitochondrial trafficking of Bax and cytochrome c, caspase-3 activation, and oxidative stress are significantly attenuated in the presence of epoxyeicosatrienoic acids (EETs). Collectively, these in vivo and in vitro studies demonstrate a role for EETs in limiting cisplatin-induced renal apoptosis. Inhibition of sEH represents a novel therapeutic strategy for protection against cisplatin-induced renal damage.

Background and Objective: To describe a suction-based grasping tool for the surgical removal of irregular-shaped and nonferromagnetic intraocular foreign bodies., Materials and Methods: A surgical tool with suction capabilities, consisting of a stainless steel shaft with a plastic handle and a customizable and interchangeable suction tip, was designed in order to better engage and manipulate irregular-shaped in-traocular foreign bodies of various sizes and physical properties. The maximal suction force and surgical capabilities were assessed in the laboratory and on a cadaveric eye vitrectomy model., Results: The suction force of the water-tight seal between the intraocular foreign body and the suction tip was estimated to be approximately 40 MN. During an open-sky vitrectomy in a porcine model, the device was successful in engaging and firmly securing foreign bodies of different sizes and shapes., Conclusion: The suction-based grasping tool enables removal of irregular-shaped and nonferromagnetic foreign bodies., (Copyright 2013, SLACK Incorporated.)

Purpose: To describe a novel surgical technique and novel surgical instrumentation for fixating an extraocular drainage device used for glaucoma-filtering surgery., Materials and Methods: The technique was performed in a laboratory setting using ex-vivo porcine eyes. We describe the surgical technique of using injectable, 25-gauge shape-memory clip system to fixate an Ahmed drainage device., Results: The use of an injectable, shape-memory alloy clip provides the advantages of rapid, easy deployment and decreased risk of late suture failure. Importantly, the injectable, shape-memory clips can be used in surgical situations where suturing is difficult and time intensive, such as those encountered during glaucoma drainage device placement., Conclusions: The use of an injectable, shape-memory alloy clip is a promising new surgical tool and technique for fixating an extraocular drainage device used for glaucoma surgery.

Paracentral occlusive retinopathy is an uncommon manifestation of sickle cell disease. If macular ischemia is not reversed, permanent vision loss can result. The authors report the successful use of exchange transfusion to treat unilateral paracentral occlusive retinopathy secondary to sickle cell disease in a 23-year-old man with hemoglobin SS disease. Initial presentation demonstrated arteriolar occlusion, perivenous hemorrhages, vessel tortuosity, and areas of retinal ischemia. Visual acuity was count fingers, and the patient noted a paracentral scotoma. Following transfusion, there was restoration of arteriolar flow as documented with fluorescein angiogram, and visual acuity returned to 20/20., (Copyright 2013, SLACK Incorporated.)

Objectives: To identify and compare key features of independent comprehensive state health surveys (SHS) with those of the Behavioral Risk Factor Surveillance System (BRFSS) for addressing the need for statewide and local population health data., Methods: We developed inclusion criteria, systematically collected information about federal and SHS that met these criteria, and obtained supplemental information from SHS leaders., Results: We identified comprehensive independent SHS in 11 states and BRFSS surveys in all 50 states. The independent SHS meet important statewide and local data needs, filling 3 key health data gaps in the BRFSS: lack of adequate data on special populations such as children, lack of data on specific localities, and limited depth and scope of health topics surveyed on key issues such as health insurance coverage. Unlike BRFSS, independent SHS have limited comparability with each other., Conclusions: The BRFSS and independent SHS each meet some key state and local data needs but result in data gaps and inefficient use of resources. Surveys could more effectively and efficiently meet future needs for comparable data to monitor health care reform and address health disparities if they were coordinated across states and at the national, state, and local levels.

Purpose: To address the most dynamic and current issues concerning today's treatment options and promising research efforts regarding treatment for age-related macular degeneration. This review is aimed to serve as a practical reference for more in-depth reviews on the subject., Methods: An online review of the database PubMed and Ovid were performed, searching for the key words age-related macular degeneration, AMD, VEGF, treatment, PDT, steroids, bevacizumab, ranibizumab, VEGF-trap, radiation, combined therapy, as well as their compound phrases. The search was limited to articles published since 1985. All returned articles were carefully screened, and their references were manually reviewed for additional relevant data. The web page www.clinicaltrials.gov was also accessed in search of relevant research trials., Results: A total of 363 articles were reviewed, including 64 additional articles extracted from the references. At the end, only 160 references were included in this review., Conclusion: Treatment for age-related macular degeneration is a very dynamic research field. While current treatments are mainly aimed at blocking vascular endothelial growth factor, future treatments seek to prevent vision loss because of scarring. Promising efforts have been made to address the dry form of the disease, which has lacked effective treatment.

Background: To evaluate and compare the perfluorocarbon liquid, silicone oil, and viscoelastic against standard saline, in their ability to dampen the impact force of a foreign body, dropped within the eye. In an experimental surgical model in where cohesive and adhesive forces of the substances are not enough to float heavy-than-water foreign bodies., Methods: A model of ophthalmic surgery was constructed. A BB pellet was dropped from 24 mm onto a force transducer through four different fluids: balanced salt solution, perfluoro-n-octane, viscoelastic, and silicone oil. The impact energy (force) for each case was measured and recorded by the force transducer. The mean force of impact for each fluid was compared using the Student t-test., Results: Silicone oil resulted in the lowest force of impact. Both silicone oil and viscoelastic dampened the impact an order of magnitude more than perfluoro-n-octane and balanced salt solution., Conclusions: Silicone oil and viscoelastic cushioned the force from a dropped BB. They may be useful adjuncts to prevent iatrogenic retinal injury during vitrectomy for intraocular foreign body removal., (© 2012 The Authors. Clinical and Experimental Ophthalmology © 2012 Royal Australian and New Zealand College of Ophthalmologists.)

Background: Children with obstetrical brachial plexus injury often develop an internal rotation and adduction contracture about the shoulder as a secondary deformity, resulting in an inability to externally rotate and abduct the shoulder. The Hoffer procedure is evaluated for its potential benefit in improving shoulder abduction and external rotation and its impact on activities of daily living., Methods: This is a retrospective review of patients treated in brachial plexus injury clinic who underwent tendon transfer procedures about the shoulder. Preoperative and postoperative active movement and active range of motion were measured and recorded using the Mallet scale and the Active Movement Scale., Results: Twenty patients were included in the study. Average age at time of surgery was 6.35 years. Thirteen patients had primary brachial plexus reconstructive surgery and four patients had concomitant wrist extension tendon transfer procedures. All patients had full passive range of motion preoperatively. The average follow-up period was 25.45 months. Average differences in pre-Hoffer and post-Hoffer Mallet scale scores are as follows: active abduction, 1.20; external rotation, 1.35; hand-to-neck, 1.25; hand-to-back, 0.75; hand-to-mouth, 0.65; and aggregate score, 5.20 (p<0.001 for all). Average differences in relevant pre-Hoffer and post-Hoffer Active Movement Scale scores are as follows: shoulder abduction, 2.10; shoulder external rotation, 4.25; and shoulder internal rotation, -0.80. All patients maintained full range of motion passively; thus, no functional loss was experienced. These results showed very high statistical significance (p<0.001 for all) and clinical significance. Younger patients (≤6 years) and those with better preoperative shoulder flexion and shoulder internal rotation yielded better postoperative results., Conclusions: The Hoffer procedure provides clinically and statistically significant improvement in external rotation and abduction while preserving functional internal rotation range in the child with obstetrical brachial plexus palsy and secondary shoulder deformity., Clinical Question/level of Evidence: Therapeutic, IV.