Publications by authors named "John D Kelly"

192 Publications

Evaluating Whole Genome Expression Differences in Idiopathic and Diabetic Adhesive Capsulitis.

J Shoulder Elbow Surg 2021 Aug 2. Epub 2021 Aug 2.

Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Medical Center, United States Department of Veterans Affairs, Philadelphia, PA, USA. Electronic address:

Background: Diabetic patients have a greater incidence of adhesive capsulitis (AC) and a more protracted disease course as compared to patients with idiopathic AC. The purpose of this study was to compare gene expression differences between AC with and without diabetes mellitus.

Methods: Shoulder capsule samples were prospectively obtained from diabetic or non-diabetic patients who presented with shoulder dysfunction and underwent arthroscopy (n=16). Shoulder samples of AC with and without diabetes (n=8) were compared to normal shoulder samples with and without diabetes as the control group (n=8). Shoulder capsule samples were subjected to whole transcriptome RNA-sequencing (RNA-seq) and differential expression analyzed with EdgeR. Only genes with a False Discovery Rate (FDR) less than 5% were included for further functional enrichment analysis.

Results: The sample population had a mean age of 47 years (range 24-62 years) and the mean HbA1C level for non-diabetic and diabetic patients was 5.18% and 8.71%, respectively. RNA-seq analysis revealed 66 genes were found to be differentially expressed between diabetic patients and non-diabetic patients with AC, while only 3 genes were differentially expressed when comparing control patients with and without diabetes. Furthermore, 286 genes were differentially expressed in idiopathic AC and 61 genes were differentially expressed in diabetic AC. On gene clustering analysis, idiopathic AC was enriched with multiple structural and muscle related pathways, such as muscle filament sliding, whereas diabetic AC included a greater number of hormonal and inflammatory signaling pathways, such as cellular response to corticotropin releasing factor.

Conclusions: Whole transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC to idiopathic AC, suggesting that these conditions are distinct clinical entities. The new genes expressed explain the differences in disease course and suggest new therapeutic targets which may lead to different treatment paradigms in these two subsets.
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http://dx.doi.org/10.1016/j.jse.2021.06.016DOI Listing
August 2021

Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training.

Eur Urol Open Sci 2020 Dec 6;22:23-33. Epub 2020 Nov 6.

Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.

Context: The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic.

Objective: To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training.

Evidence Acquisition: This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

Evidence Synthesis: There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90.

Conclusions: Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation.

Patient Summary: Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence.
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http://dx.doi.org/10.1016/j.euros.2020.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317899PMC
December 2020

The Comma Sign: An Anatomic Study.

Orthopedics 2021 Jul-Aug;44(4):e546-e548. Epub 2021 Jul 1.

The "comma sign" is a comma-shaped arc of tissue located at the superolateral edge of the subscapularis at its insertion on the humeral head. It consists of the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL). It was recently recognized as an important landmark to aid surgeons in identifying the edge of a torn subscapularis tendon. The exact proportion of CHL and SGHL has not been precisely defined. The goal of this study was to dissect and more accurately define the composition of the comma tissue and its exact relationship to the subscapularis tendon. A total of 8 fresh frozen cadaveric shoulder specimens (mean age, 74 years; 5 male, 3 female) were dissected via a wide deltopectoral approach. Anatomic landmarks were identified, and measurements were taken with a digital caliper. The midpoint width of the SGHL and CHL and the composite insertion width of the subscapularis were measured. Measurements were taken 3 times each and averaged to calculate mean width. Mean midpoint width of the SGHL, CHL, and composite insertion was 5.99 mm (range, 5.25-6.91 mm), 5.13 mm (range, 4.28-5.72 mm), and 9.93 mm (range, 6.69-12.05 mm), respectively. The comma sign consists of approximately half SGHL (54%) and half CHL (46%) at its insertion to the subscapularis tendon, with an approximate width of 1 cm. With the increase in arthroscopic subscapularis repairs, knowledge of these dimensions will aid surgeons in discerning the comma tissue from other capsular elements and ultimately help in surgical restoration of native anatomy. [. 2021;44(4):e546-e548.].
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http://dx.doi.org/10.3928/01477447-20210618-15DOI Listing
July 2021

Sports-related concussions in high school females: an epidemiologic analysis of twenty-year national trends.

Res Sports Med 2021 Jul 13:1-10. Epub 2021 Jul 13.

Professor of Clinical Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

The epidemiology of sports-related concussions (SRCs) and closed head injuries (CHIs) in high school females remains undefined at the national level, especially for unorganized sports and recreational activities. This study examines 1,176,092 national weighted estimates of SRCs or CHIs in female patients 14-18 years of age presenting to United States (US) emergency departments (EDs) between 2000 and 2019 in the National Electronic Injury Surveillance System (NEISS). The national weighted estimate of female patients in our study increased significantly (p < 0.001) between 2000 (9,835; 95% Confidence Interval [CI] 7,105-12,566) and 2019 (31,751; CI 26,392-37,110). The top five ranked sports and recreational activities most commonly associated with concussions and CHIs in female patients 14-18 years of age were: soccer (20.6%; CI 17.6%-23.6%); basketball (18.5%; CI 16.9%-20.1%); cheerleading (10.4%; CI 8.9%-11.9%); softball (10.1%; CI 9.0%-11.3%); volleyball (6.5%; CI 5.7%-7.2%). Simple univariate regression models showed that an increase of 10,000 annual female participants across all high school sports and recreational activities was associated with 308.7 (SE = 20.8, p < 0.001, R2 = 0.92) additional annual SRCs and CHIs presenting to US EDs. The promotion of concussion awareness and educational programs may help minimize SRCs and CHIs.
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http://dx.doi.org/10.1080/15438627.2021.1954514DOI Listing
July 2021

The Comma Sign: The Coracohumeral Ligament and Superior Glenohumeral Ligament Exhibit Similar Quantitative Characteristics With Terminal Confluence at the Subscapularis Insertion.

Arthrosc Sports Med Rehabil 2021 Jun 21;3(3):e645-e649. Epub 2021 Mar 21.

University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.

Purpose: The purpose of this morphologic cadaveric study was to quantitatively define the composition of the previously described comma tissue along with its relation to the subscapularis tendon insertion.

Methods: Fresh frozen cadaveric shoulder specimens were included for analysis. The coracohumeral ligament (CHL) was exposed at its origin along the base of the coracoid process and freed laterally along its course to the lesser tuberosity adjacent to the bicipital groove. The superior glenohumeral ligament (SGHL) was identified and traced along its course deep to the CHL within the rotator interval with insertion onto the superior aspect of the lesser tuberosity. The midpoint diameters of the SGHL and CHL and their composite insertional diameters on the subscapularis tendon insertion and lesser tuberosity were measured with digital calipers. The mean diameter was determined from 3 measurements taken of each ligament.

Results: Eight specimens were included. With the use of digital calipers, the mean midpoint diameters of the SGHL and CHL were identified as 5.99 mm (range, 5.25-6.91 mm) and 5.13 mm (range, 4.28-5.72 mm), respectively. The composite insertional diameter of the SGHL and CHL on both the lesser tuberosity and humeral insertion of the subscapularis tendon was 9.93 mm (range, 6.69-12.05 mm). At its insertion, the SGHL and CHL comprised 54% and 46% of the comma tissue, respectively. Additionally, all specimens were identified as showing a confluence of the SGHL and CHL composite insertion with the subscapularis tendon at the point of its humeral head insertion.

Conclusions: The comma tissue is a pivotal structure for the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of the midpoint diameter, insertional diameter, and composite distribution of the CHL and SGHL provided by this morphologic cadaveric analysis may aid surgeons in their efforts to restore the native anatomy.

Clinical Relevance: Subscapularis tendon tears have often been under-addressed during rotator cuff repair. The comma tissue has been described as an anatomic structure that can aid in the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of this important arthroscopic landmark may aid surgeons in their efforts to restore the native anatomy.
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http://dx.doi.org/10.1016/j.asmr.2020.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220576PMC
June 2021

Recovery of health-related quality of life in patients undergoing robot-assisted radical cystectomy with intracorporeal diversion.

BJU Int 2021 Jun 5. Epub 2021 Jun 5.

Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.

Objective: To report the health-related quality of life (HRQoL) after robot-assisted radical cystectomy and intracorporeal urinary diversion (iRARC), and to identify factors impacting on return to baseline.

Patients And Methods: Consecutive patients undergoing iRARC between January 2016 and December 2017 completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30-item core (EORTC-QLQ-C30) and EORTC-QLQ-Muscle-Invasive Bladder Cancer Module (EORTC-QLQ-BLM30) questionnaires before surgery and had a minimum of 12 months follow-up postoperatively.

Results: A total of 76 patients met the inclusion criteria at 12 months. Neobladder (NB) cases (n = 24) were younger (57.0 vs 71.0 years, P < 0.001) and fitter than ileal conduit (IC) cases (n = 52), and had higher physical (100.0 vs 93.3, P = 0.039) and sexual functioning (66.7 vs 50.0, P = 0.013) scores at baseline. Longitudinal analysis of the EORTC-QLQ-C30 showed that physical (NB: 93.3 vs 100.0, P = 0.020; IC: 80.0 vs 93.3, P < 0.001) and role functioning scores (NB: 83.3 vs 100.0, P = 0.010; IC: 83.3 vs 100.0, P = 0.017) decreased and fatigue score (NB: 22.2 vs 11.1, P = 0.026; IC: 33.3 vs 22.2, P = 0.008) increased at 3 months in both diversion groups. Scores returned to baseline at 6 months except physical functioning score in IC patients that remained below baseline until 12 months (86.7 vs 93.3, P = 0.012). The global HRQoL score did not show significant change postoperatively in both groups. A major 90-day Clavien-Dindo complication was a significant predictor (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.02-0.62; P = 0.012) of deteriorated global HRQoL score at 3 months, while occurrence of a late complication (OR 0.14, 95% CI 0.03-0.65; P = 0.013) was a predictor of deteriorated global HRQoL score at 12 months. Longitudinal analysis of the EORTC-QLQ-BLM30 showed that urinary problems (NB: 14.3 vs 38.3, P < 0.001; IC: 5.6 vs 19.1, P < 0.001) and future perspective (NB: 33.3 vs 44.4, P = 0.004; IC: 22.2 vs 44.4, P < 0.001) scores were better than baseline at 3 months. Sexual function deteriorated significantly at 3 months (NB: 8.3 vs 66.7, P < 0.001; IC: 4.2 vs 50.0, P < 0.001) and then showed improvement at 12 months but was still below baseline (NB: 33.3 vs 66.7, P = 0.001; IC: 25.0 vs 50.0, P < 0.001). Involvement in penile rehabilitation was shown to be a significant predictor (β 18.62, 95% CI 6.06-30.45; P = 0.005) of higher sexual function score at 12 months.

Conclusion: While most functional domains and symptoms scales recover to or exceed baseline within 6 months of iRARC, physical function remains below baseline in IC patients up to 12 months. Global HRQoL is preserved for both types of urinary diversion; however, postoperative complications seem to be the main driving factor for global HRQoL. Sexual function is adversely affected after iRARC suggesting that structured rehabilitation of sexual function should be an integral part of the RC pathway.
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http://dx.doi.org/10.1111/bju.15505DOI Listing
June 2021

Your Best Life: Relationships-The Lifeblood of a Fulfilled Existence.

Authors:
John D Kelly

Clin Orthop Relat Res 2021 07;479(7):1438-1440

Professor of Clinical Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1097/CORR.0000000000001850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8208397PMC
July 2021

Cape-like Anomalous Confluence of the Long Head of the Biceps and Rotator Cuff in the Presence of a SLAP Tear: A Case Report.

JBJS Case Connect 2020 Oct-Dec;10(4):e2000151

1Penn Sports Medicine Center, University of Pennsylvania, Philadelphia, Pennsylvania.

Case: A 25-year-old woman sustained an acute tear of her superior anterior-posterior labrum with arthroscopic identification of an anomalous origin of the long head of the biceps arising exclusively from the supraspinatus tendon with no attachment to the supraglenoid tubercle or superior labrum.

Conclusion: This is the first report of a symptomatic superior labrum anterior-posterior tear in a patient with a rare anatomic confluence of the long head of the biceps to the supraspinatus. We recommend addressing the labral pathology with utilization of a standard technique because satisfactory results can be realized with isolated labral fixation to the glenoid, despite the absence of an attached biceps tendon.
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http://dx.doi.org/10.2106/JBJS.CC.20.00151DOI Listing
June 2021

Rock climbing confers distinct injury risk in pediatric versus adult populations: an analysis of twenty-year national trends.

Phys Sportsmed 2021 Jun 1:1-6. Epub 2021 Jun 1.

Department of Orthopaedic Surgery, Harvard Medical School and Boston Children's Hospital, Boston, USA.

: The sport of rock climbing has recently gained in popularity due in part to its adoption by noncompetitive athletes as a physical activity with a level of intensity that can be self-regulated. However, the epidemiology of rock climbing injuries is poorly described at the national level.: We report demographic and injury characteristics from 85,235 national weighted estimates of rock climbing injuries presenting to United States (US) emergency departments (EDs) between 2000 and 2019 in the National Electronic Injury Surveillance System, stratifying by whether patients were ≤18 years of age (A) or ≥19 years of age (B).: The national weighted estimate of patients presenting to US EDs with injuries associated with rock climbing rose significantly (p < 0.001) from 2000 (2,667, CI 1,777-3,557) to 2019 (7,087, CI 4,544-9,630). Patients ≤18 years of age were significantly less likely to be male (A: 56.3%, CI 52.0-60.6%; B: 64.7%; CI 60.4-69.0%; p = 0.003), sustain injuries on weekends (A: 29.8%, 24.5-35.1%; B: 64.7%, CI 60.4-69.0%; p = 0.002), or sustain injuries during summer seasons (A: 26.6%, CI 22.1-31.1%; B: 33.2%, CI 28.1-38.3%; p = 0.049). Multivariate logistic regression demonstrated that patients ≤18 years of age were significantly more likely to present to EDs with head and neck (OR: 1.52, CI 1.04-2.21; p = 0.032) or upper extremity (OR: 1.55; CI 1.24-1.93; p < 0.001) injuries associated with rock climbing.: We identified a significant increase in the annual estimated number of patients presenting to US EDs with rock climbing injuries compared to what has previously been reported. As the number of climbers continues to grow, standardized safety policies may be implemented that specifically target injury mechanisms and patterns unique to both adult and pediatric populations.
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http://dx.doi.org/10.1080/00913847.2021.1932631DOI Listing
June 2021

The Angular Relationships Between the Coracohumeral Ligament and Adjacent Shoulder Structures Are Variable.

Arthrosc Sports Med Rehabil 2021 Apr 24;3(2):e449-e453. Epub 2021 Feb 24.

University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.

Purpose: To describe the arthroscopic anatomy of the coracohumeral ligament (CHL) in relation to visible anatomic reference points to aid in the execution of a more effective arthroscopic medial-lateral rotator interval closure.

Methods: Detailed dissection to identify the CHL was performed in 4 shoulders from 2 fresh-frozen donor cadavers with a deltopectoral approach. The angular relationship between the CHL and the superior border of the subscapularis tendon was determined via gross dissection. Arthroscopic images were used to determine the angular position of the CHL in relation to both the glenoid articular surface and the intraarticular segment of the tendon of the long head of the biceps brachii (LHB).

Results: Analysis of 4 cadaveric shoulders via gross dissection demonstrated the CHL to subtend a mean angle of 29° (range 16° to 39°) with respect to the superior border of the subscapularis tendon. Arthroscopic analysis of 4 cadaveric shoulders demonstrated the CHL to subtend a mean angle of 59° (range 38° to 77°) with respect to the glenoid articular surface. Additionally, arthroscopic analysis of 2 cadaveric shoulders demonstrated the CHL to subtend a mean angle of 29° (range 11° to 47°) with respect to the LHB tendon.

Conclusion: Although the position of the CHL in relation to the subscapularis tendon, glenoid articular surface, and LHB tendon demonstrates a moderate degree of anatomic variability, these structures provide valuable anatomic reference points for the identification of the course of this significant static shoulder stabilizer.

Clinical Relevance: Comprehensive understanding of the angular relationships between the CHL and adjacent shoulder structures may assist with the execution of a more effective arthroscopic rotator interval closure.
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http://dx.doi.org/10.1016/j.asmr.2020.10.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8129431PMC
April 2021

Ethical implications of AI in robotic surgical training: A Delphi consensus statement.

Eur Urol Focus 2021 Apr 30. Epub 2021 Apr 30.

Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London.

Context: As the role of AI in healthcare continues to expand there is increasing awareness of the potential pitfalls of AI and the need for guidance to avoid them.

Objectives: To provide ethical guidance on developing narrow AI applications for surgical training curricula. We define standardised approaches to developing AI driven applications in surgical training that address current recognised ethical implications of utilising AI on surgical data. We aim to describe an ethical approach based on the current evidence, understanding of AI and available technologies, by seeking consensus from an expert committee.

Evidence Acquisition: The project was carried out in 3 phases: (1) A steering group was formed to review the literature and summarize current evidence. (2) A larger expert panel convened and discussed the ethical implications of AI application based on the current evidence. A survey was created, with input from panel members. (3) Thirdly, panel-based consensus findings were determined using an online Delphi process to formulate guidance. 30 experts in AI implementation and/or training including clinicians, academics and industry contributed. The Delphi process underwent 3 rounds. Additions to the second and third-round surveys were formulated based on the answers and comments from previous rounds. Consensus opinion was defined as ≥ 80% agreement.

Evidence Synthesis: There was 100% response from all 3 rounds. The resulting formulated guidance showed good internal consistency, with a Cronbach alpha of >0.8. There was 100% consensus that there is currently a lack of guidance on the utilisation of AI in the setting of robotic surgical training. Consensus was reached in multiple areas, including: 1. Data protection and privacy; 2. Reproducibility and transparency; 3. Predictive analytics; 4. Inherent biases; 5. Areas of training most likely to benefit from AI.

Conclusions: Using the Delphi methodology, we achieved international consensus among experts to develop and reach content validation for guidance on ethical implications of AI in surgical training. Providing an ethical foundation for launching narrow AI applications in surgical training. This guidance will require further validation.

Patient Summary: As the role of AI in healthcare continues to expand there is increasing awareness of the potential pitfalls of AI and the need for guidance to avoid them.In this paper we provide guidance on ethical implications of AI in surgical training.
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http://dx.doi.org/10.1016/j.euf.2021.04.006DOI Listing
April 2021

Rising Trends in Wrestling-associated Injuries in Females Presenting to US Emergency Departments.

West J Emerg Med 2020 Dec 16;22(2):410-416. Epub 2020 Dec 16.

University of Pennsylvania, Perelman School of Medicine, Department of Orthopaedic Surgery, Philadelphia, Pennsylvania.

Introduction: Wrestling is one of the fastest-growing sports among females in the United States (US). However, female wrestling injuries remain poorly characterized. In this study we describe historical and projected national estimates of female wrestling injuries, and compare injury characteristics with those of male wrestlers.

Methods: We queried the National Electronic Injury Surveillance System (NEISS) database (2005-2019) to compare national weighted estimates and injury characteristics of male vs female wrestlers presenting to US emergency departments (ED) and projected annual female wrestling injuries expected by 2030.

Results: Our analyses demonstrated a significant (P < 0.001) increase in female wrestling injuries between 2005 (N = 1500; confidence interval [CI], 923 - 2,078) and 2019 (N = 3,404; CI 2,296 - 4,513). Linear regression (R2 = 0.69; P < 0.001) projected 4,558 (CI, 3104 - 6033) such injuries in 2030. Of female wrestling injuries 50.1% (CI, 44.1 - 56.2) occurred in patients 14-18 years of age. Compared with age-matched males, female wrestlers were significantly less likely to present with fractures (Female [F]: 10.6%; CI 7.5% - 13.7%; Male [M]: 15.7%; CI 14.7% - 16.7%; P = 0.003) or head/neck injuries (F: 18.5%; CI 13.2% - 23.9%; M: 24.6%; CI 23.2% - 26.0%; P = 0.018), and significantly more likely to present with strains/sprains (F: 48.8%; CI, 41.2% - 56.3%; M: 34.4%; CI 31.6% - 37.1%; P < 0.001).

Conclusion: Males and females possess distinctly unique physiology and anatomy, such as variances in ligamentous and muscular strength, which may help to explain differences in wrestling injury characteristics. Prompt management of injuries and specific training strategies aimed at prevention may help to reduce the projected increase of female wrestling-associated injuries as the popularity of the sport continues to rise.
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http://dx.doi.org/10.5811/westjem.2020.9.48490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972392PMC
December 2020

Osteosarcoma Mimicking Tenosynovial Giant Cell Tumor of the Hip in a Pediatric Patient: A Case Report.

JBJS Case Connect 2021 04 13;11(2). Epub 2021 Apr 13.

University of Pennsylvania, Philadelphia, Pennsylvania.

Case: A 17-year-old boy presented to the clinic complaining of right hip pain after soccer participation. Clinical findings and imaging studies led to the diagnoses of femoroacetabular impingement and diffuse tenosynovial giant cell tumor (TGCT). Comprehensive arthroscopic management and biopsy revealed a diagnosis of osteosarcoma. The patient subsequently underwent chemotherapy, surgical resection, and reconstruction.

Conclusion: Osteosarcoma of the proximal femur may mimic TGCT on imaging studies because osteosarcoma may show changes suggestive of inflammation. We recommend heightened clinical awareness and a comprehensive differential workup in the management of presumed TGCT about the hip in the pediatric patient population.
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http://dx.doi.org/10.2106/JBJS.CC.20.00650DOI Listing
April 2021

Comparison between partial and full coverage repair in massive rotator cuff tears. A minimum five year follow-up.

Orthop Traumatol Surg Res 2021 06 30;107(4):102911. Epub 2021 Mar 30.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, U.S.A.

Background: Massive rotator cuff surgical management can be challenging. Controversy exists in the literature regarding the potential benefit of full head coverage for arthroscopic rotator cuff repair. The purpose of this study was to compare re-tear rate and clinical outcome of arthroscopic repair of massive rotator cuff tears in relation to the achievement of full humeral head footprint coverage or not. Hypothesis We hypothesized that there will be no difference in re-tear rate and clinical outcomes between full and partial coverage rotator cuff repairs.

Patients And Methods: A retrospective analysis of all adult patients with a massive rotator cuff tear who underwent arthroscopic repair with a minimum five years follow-up was performed. Outcomes analyzed included re-tear rate, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and the Penn Shoulder Score. Correlation and subgroup analyses were performed in order to evaluate whether age, symptom duration, tear size, coverage percentage, and fatty infiltration had any effect in outcome.

Results: The average ASES score was 76.3±25.2, and average Penn Shoulder Score was 75.8±23.1 at 7.9 years mean follow-up in 27 patients analyzed. Re-tear rate was similar between full and partial footprint coverage repair with 2 versus 4 failures, respectively (p=0.64). ASES and Penn Shoulder scores were 84.2 and 83.7 for full rotator cuff repair versus 70.6 and 71.1, for partial coverage repair (p=0.20 and p=0.22, respectively). The percentage of head coverage and the tear size were both found to be significantly correlated with outcome, with coefficient of determination R of 0.40 and 0.217, respectively, while a global fatty degeneration index GFDI <1.5 was associated with improved functional outcome.

Discussion: No difference in failure rate and functional outcome was detected between full and partial coverage rotator cuff repair. The size of the tear and fatty infiltration were inversely correlated with functional score while the percentage of coverage achieved was positively correlated with favorable outcome.

Level Of Evidence: III; retrospective comparative study.
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http://dx.doi.org/10.1016/j.otsr.2021.102911DOI Listing
June 2021

Is delay to radical cystectomy following BCG failure oncologically safe?

Nat Rev Urol 2021 Jun;18(6):323-324

Division of Surgery and Interventional Science, University College London, London, UK.

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http://dx.doi.org/10.1038/s41585-021-00457-1DOI Listing
June 2021

Return-to-Play and Competitive Outcomes After Ulnar Collateral Ligament Reconstruction Among Baseball Players: A Systematic Review.

Orthop J Sports Med 2020 Dec 28;8(12):2325967120966310. Epub 2020 Dec 28.

Penn Throwing Clinic, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Ulnar collateral ligament (UCL) reconstruction (UCLR) is very common in baseball. However, no review has compared the return-to-play (RTP) and in-game performance statistics of pitchers after primary and revision UCLR as well as of position players after UCLR.

Purpose: To review, synthesize, and evaluate the published literature on outcomes after UCLR in baseball players to determine RTP and competitive outcomes among various populations of baseball players.

Study Design: Systematic review; Level of evidence, 4.

Methods: A literature search including studies between 1980 and November 4, 2019, was conducted for articles that included the following terms: ulnar collateral ligament, elbow, medial collateral ligament, Tommy John surgery, throwing athletes, baseball pitchers, biomechanics, and performance. To be included, studies must have evaluated baseball players at any level who underwent UCLR (primary or revision) and assessed RTP and/or competitive outcomes.

Results: A total of 29 studies with relatively high methodological quality met the inclusion criteria. After primary UCLR, Major League Baseball (MLB) pitchers returned to play in 80% to 97% of cases in approximately 12 months; however, return to the same level of play (RTSP) was less frequent and took longer, with 67% to 87% of MLB pitchers returning in about 15 months. RTP rates for MLB pitchers after revision UCLR were slightly lower, ranging from 77% to 85%, while RTSP rates ranged from 55% to 78%. RTP rates for catchers (59%-80%) were generally lower than RTP rates for infielders (76%) and outfielders (89%). All studies found a decrease in pitching workloads after UCLR. Fastball usage may also decrease after UCLR. Changes in earned run average and walks plus hits per inning pitched were inconclusive.

Conclusion: Pitchers returned to play after UCLR in approximately 12 months and generally took longer to return to their same level of play. Pitchers also returned to play less frequently after revision UCLR. After both primary and revision UCLR, professional pitchers experienced decreased workloads and potentially decreased fastball usage as well. Catchers may RTP after UCLR less frequently than pitchers, infielders, and outfielders possibly because of the frequency of throwing in the position. These results will help guide clinical decision making and patient education when treating UCL tears in baseball players.
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http://dx.doi.org/10.1177/2325967120966310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905078PMC
December 2020

Your Best Life: In Times of Crisis, Small Victories Matter.

Authors:
John D Kelly

Clin Orthop Relat Res 2021 05;479(5):901-903

J. D. Kelly IV, Professor of Clinical Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1097/CORR.0000000000001711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052069PMC
May 2021

Characterization and Biomarker Analyses of Post-COVID-19 Complications and Neurological Manifestations.

Cells 2021 02 13;10(2). Epub 2021 Feb 13.

Department of Laboratory Medicine, San Francisco VA Health Care System, San Francisco, CA 94121, USA.

As the SARS-CoV-2 pandemic continues, reports have demonstrated neurologic sequelae following COVID-19 recovery. Mechanisms to explain long-term neurological sequelae are unknown and need to be identified. Plasma from 24 individuals recovering from COVID-19 at 1 to 3 months after initial infection were collected for cytokine and antibody levels and neuronal-enriched extracellular vesicle (nEV) protein cargo analyses. Plasma cytokine IL-4 was increased in all COVID-19 participants. Volunteers with self-reported neurological problems (nCoV, = 8) had a positive correlation of IL6 with age or severity of the sequalae, at least one co-morbidity and increased SARS-CoV-2 antibody compared to those COVID-19 individuals without neurological issues (CoV, = 16). Protein markers of neuronal dysfunction including amyloid beta, neurofilament light, neurogranin, total tau, and p-T181-tau were all significantly increased in the nEVs of all participants recovering from COVID-19 compared to historic controls. This study suggests ongoing peripheral and neuroinflammation after COVID-19 infection that may influence neurological sequelae by altering nEV proteins. Individuals recovering from COVID-19 may have occult neural damage while those with demonstrative neurological symptoms additionally had more severe infection. Longitudinal studies to monitor plasma biomarkers and nEV cargo are warranted to assess persistent neurodegeneration and systemic effects.
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http://dx.doi.org/10.3390/cells10020386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7918597PMC
February 2021

Major Urological Cancer Surgery for Patients is Safe and Surgical Training Should Be Encouraged During the COVID-19 Pandemic: A Multicentre Analysis of 30-day Outcomes.

Eur Urol Open Sci 2021 Mar 9;25:39-43. Epub 2021 Jan 9.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.

COVID-19 has resulted in the deferral of major surgery for genitourinary (GU) cancers with the exception of cancers with a high risk of progression. We report outcomes for major GU cancer operations, namely radical prostatectomy (RP), radical cystectomy (RC), radical nephrectomy (RN), partial nephrectomy (PN), and nephroureterectomy performed at 13 major GU cancer centres across the UK between March 1 and May 5, 2020. A total of 598 such operations were performed. Four patients (0.7%) developed COVID-19 postoperatively. There was no COVID-19-related mortality at 30 d. A minimally invasive approach was used in 499 cases (83.4%). A total of 228 cases (38.1%) were described as training procedures. Training case status was not associated with a higher American Society of Anesthesiologists (ASA) score ( =  0.194) or hospital length of stay (LOS;  >  0.05 for all operation types). The risk of contracting COVID-19 was not associated with longer hospital LOS ( =  0.146), training case status ( =  0.588), higher ASA score ( =  0.295), or type of hospital site ( =  0.303). Our results suggest that major surgery for urological cancers remains safe and training should be encouraged during the ongoing COVID-19 pandemic provided appropriate countermeasures are taken. These real-life data are important for policy-makers and clinicians when counselling patients during the current pandemic.

Patient Summary: We collected outcome data for major operations for prostate, bladder, and kidney cancers during the COVID-19 pandemic. These surgeries remain safe and training should be encouraged during the ongoing pandemic provided appropriate countermeasures are taken. Our real-life results are important for policy-makers and clinicians when counselling patients during the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.euros.2021.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796655PMC
March 2021

Evaluation of the New American Urological Association Guidelines Risk Classification for Hematuria.

J Urol 2021 May 24;205(5):1387-1393. Epub 2020 Dec 24.

Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.

Purpose: Microhematuria is a prevalent condition and the American Urological Association has developed a new risk-stratified approach for the evaluation of patients with microhematuria. Our objective was to provide the first evaluation of this important guideline.

Materials And Methods: This multinational cohort study combines contemporary patients from 5 clinical trials and 2 prospective registries who underwent urological evaluation for hematuria. Patients were stratified into American Urological Association risk strata (low, intermediate or high risk) based on sex, age, degree of hematuria, and smoking history. The primary end point was the incidence of bladder cancer within each risk stratum.

Results: A total of 15,779 patients were included in the analysis. Overall, 727 patients (4.6%) were classified as low risk, 1,863 patients (11.8%) were classified as intermediate risk, and 13,189 patients (83.6%) were classified as high risk. The predominance of high risk patients was consistent across all cohorts. A total of 857 bladder cancers were diagnosed with a bladder cancer incidence of 5.4%. Bladder cancer was more prevalent in men, smokers, older patients and patients with gross hematuria. The cancer incidence for low, intermediate and high risk groups was 0.4% (3 patients), 1.0% (18 patients) and 6.3% (836 patients), respectively.

Conclusions: The new risk stratification system separates hematuria patients into clinically meaningful categories with differing likelihoods of bladder cancer that would justify evaluating the low, intermediate and high risk groups with incremental intensity. Furthermore, it provides the relative incidence of bladder cancer in each risk group which should facilitate patient counseling regarding the risks and benefits of evaluation for bladder cancer.
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http://dx.doi.org/10.1097/JU.0000000000001550DOI Listing
May 2021

Two Secreted Proteoglycans, Activators of Urothelial Cell-Cell Adhesion, Negatively Contribute to Bladder Cancer Initiation and Progression.

Cancers (Basel) 2020 Nov 13;12(11). Epub 2020 Nov 13.

UCL Institute of Ophthalmology, University College London, 11-43 Bath Street, London EC1V 9EL, UK.

Osteomodulin (OMD) and proline/arginine-rich end leucine repeat protein (PRELP) are secreted extracellular matrix proteins belonging to the small leucine-rich proteoglycans family. We found that OMD and PRELP were specifically expressed in umbrella cells in bladder epithelia, and their expression levels were dramatically downregulated in all bladder cancers from very early stages and various epithelial cancers. Our in vitro studies including gene expression profiling using bladder cancer cell lines revealed that OMD or PRELP application suppressed the cancer progression by inhibiting TGF-β and EGF pathways, which reversed epithelial-mesenchymal transition (EMT), activated cell-cell adhesion, and inhibited various oncogenic pathways. Furthermore, the overexpression of OMD in bladder cancer cells strongly inhibited the anchorage-independent growth and tumorigenicity in mouse xenograft studies. On the other hand, we found that in the bladder epithelia, the knockout mice of OMD and/or PRELP gene caused partial EMT and a loss of tight junctions of the umbrella cells and resulted in formation of a bladder carcinoma in situ-like structure by spontaneous breakdowns of the umbrella cell layer. Furthermore, the ontological analysis of the expression profiling of an OMD knockout mouse bladder demonstrated very high similarity with those obtained from human bladder cancers. Our data indicate that OMD and PRELP are endogenous inhibitors of cancer initiation and progression by controlling EMT. OMD and/or PRELP may have potential for the treatment of bladder cancer.
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http://dx.doi.org/10.3390/cancers12113362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7697838PMC
November 2020

Evolving robotic surgery training and improving patient safety, with the integration of novel technologies.

World J Urol 2021 Aug 6;39(8):2883-2893. Epub 2020 Nov 6.

Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.

Introduction: Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.

Methods: A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.

Results: Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.

Conclusions: Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the 'continuum of training' by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.
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http://dx.doi.org/10.1007/s00345-020-03467-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8405494PMC
August 2021

The Role of Remplissage in the Setting of Shoulder Instability.

Sports Med Arthrosc Rev 2020 Dec;28(4):140-145

University of Penn, Perelman School of Medicine, Philadelphia, PA.

Recurrent anterior shoulder instability is a multifactorial problem for which many solutions exist. Often, the bony surface area of the humeral head and the glenoid needs to be addressed surgically. For large, engaging humeral head defects associated with <25% glenoid bone loss, a remplissage procedure can effectively "fill in" the humeral defect with minimal postoperative morbidity. Remplissage is an effective biological solution that should be considered any time there is a humeral head defect which is contributing to glenohumeral instability.
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http://dx.doi.org/10.1097/JSA.0000000000000289DOI Listing
December 2020

A cohort study of 30 day mortality after NON-EMERGENCY surgery in a COVID-19 cold site.

Int J Surg 2020 Dec 24;84:57-65. Epub 2020 Oct 24.

Department of Urology, University College London Hospital NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK.

Background: Two million non-emergency surgeries are being cancelled globally every week due to the COVID-19 pandemic, which will have a major impact on patients and healthcare systems.

Methods: During the peak of the pandemic in the United Kingdom, we set up a multicentre cancer network amongst 14 National Health Service institutions, performing urological, thoracic, gynaecological and general surgical urgent and cancer operations at a central COVID-19 cold site. This is a cohort study of 500 consecutive patients undergoing surgery in this network. The primary outcome was 30-day mortality from COVID-19. Secondary outcomes included all-cause mortality and post-operative complications at 30-days.

Results: 500 patients underwent surgery with median age 62.5 (IQR 51-71). 65% were male, 60% had a known diagnosis of cancer and 61% of surgeries were considered complex or major. No patient died from COVID-19 at 30-days. 30-day all-cause mortality was 3/500 (1%). 10 (2%) patients were diagnosed with COVID-19, 4 (1%) with confirmed laboratory diagnosis and 6 (1%) with probable COVID-19. 33/500 (7%) of patients developed Clavien-Dindo grade 3 or higher complications, with 1/33 (3%) occurring in a patient with COVID-19.

Conclusion: It is safe to continue cancer and urgent surgery during the COVID-19 pandemic with appropriate service reconfiguration.
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http://dx.doi.org/10.1016/j.ijsu.2020.10.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7584883PMC
December 2020

Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group.

BJU Int 2021 05 5;127(5):585-595. Epub 2020 Nov 5.

Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.

Objectives: To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians.

Patients And Methods: We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien-Dindo grading) and mortality rate. Cancer-specific mortality (CSM) and other-cause mortality (OCM) after surgery were calculated using the non-parametric Aalen-Johansen estimator.

Results: A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30- and 90-day rate for high-grade (Clavien-Dindo grades III-V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre- and postoperative variables, age ≥80 years was not an independent predictor of high-grade complications (odds ratio 0.6, 95% confidence interval 0.3-1.1; P = 0.12). The non-cancer-related 90-day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12-month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001).

Conclusions: The minimally invasive approach to RARC with ICUD for bladder cancer in well-selected elderly patients (aged ≥80 years) achieved a tolerable high-grade complication rate; the 90-day postoperative mortality rate was driven by cancer progression and the non-cancer-related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer-related vs treatment-related risks and benefits.
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http://dx.doi.org/10.1111/bju.15274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246851PMC
May 2021

Your Best Life: Sidelined During COVID-19-Coming Back to Work a Better Person and Surgeon.

Authors:
John D Kelly

Clin Orthop Relat Res 2020 11;478(11):2434-2435

J. D. Kelly IV, Professor of Clinical Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1097/CORR.0000000000001515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572004PMC
November 2020

Wrestling-related concussions and closed head injuries predominantly occur in high school age athletes.

J Sports Med Phys Fitness 2021 Mar 3;61(3):407-412. Epub 2020 Sep 3.

Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.

Background: Sports-related concussions (SRC) and closed head injuries (CHI) have recently garnered national attention given mounting concern for long-term neurological sequelae resulting from repetitive head trauma. Despite historically dangerous techniques in wrestling that involve impacts to the head, there is a paucity of epidemiologic data in regard to wrestling-related concussions (WRCs) in the United States (USA).

Methods: The National Electronic Injury Surveillance System (NEISS) database was queried (2000-2018) to report national estimates and demographic characteristics of patients 6-25 years of age presenting to US emergency departments (EDs) with WRCs and CHIs.

Results: The average annual number of patients presenting to US EDs with WRCs or CHIs was 3465 (95% confidence interval [CI]: 2489-4441). Over one-third of patients were between 15 (17.7%; 95% CI: 15.8%-19.7%) and 16 (17.0%; 95% CI: 14.9%-19.1%) years of age, which comprised the peak age groups during which such head injuries were sustained. The vast majority of patients were male (96.3%; 95% CI: 94.8%-97.7%). Lastly, 6.2% (95% CI: 4.3-8.2%) of patients did not present to the ED on the same day that the injury was sustained.

Conclusions: Due to the unique nature and culture of the sport, wrestlers may be more likely to attribute SRC or CHI symptoms to normal training-related fatigue, which can lead to underreporting or delayed diagnosis. It is therefore imperative that appropriate safety initiatives and concussion awareness campaigns be implemented in youth wrestling to decrease the incidence of SRCs at local and national levels.
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http://dx.doi.org/10.23736/S0022-4707.20.11194-0DOI Listing
March 2021

Co-targeting PIM and PI3K/mTOR using multikinase inhibitor AUM302 and a combination of AZD-1208 and BEZ235 in prostate cancer.

Sci Rep 2020 09 1;10(1):14380. Epub 2020 Sep 1.

Molecular Diagnostics and Therapeutics Group, University College London, London, UK.

PIM and PI3K/mTOR pathways are often dysregulated in prostate cancer, and may lead to decreased survival, increased metastasis and invasion. The pathways are heavily interconnected and act on a variety of common effectors that can lead to the development of resistance to drug inhibitors. Most current treatments exhibit issues with toxicity and resistance. We investigated the novel multikinase PIM/PI3K/mTOR inhibitor, AUM302, versus a combination of the PIM inhibitor, AZD-1208, and the PI3K/mTOR inhibitor BEZ235 (Dactolisib) to determine their impact on mRNA and phosphoprotein expression, as well as their functional efficacy. We have determined that around 20% of prostate cancer patients overexpress the direct targets of these drugs, and this cohort are more likely to have a high Gleason grade tumour (≥ Gleason 8). A co-targeted inhibition approach offered broader inhibition of genes and phosphoproteins in the PI3K/mTOR pathway, when compared to single kinase inhibition. The preclinical inhibitor AUM302, used at a lower dose, elicited a comparable or superior functional outcome compared with combined AZD-1208 + BEZ235, which have been investigated in clinical trials, and could help to reduce treatment toxicity in future trials. We believe that a co-targeting approach is a viable therapeutic strategy that should be developed further in pre-clinical studies.
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http://dx.doi.org/10.1038/s41598-020-71263-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463239PMC
September 2020

Your Best Life: Overcoming Approval Addiction.

Authors:
John D Kelly

Clin Orthop Relat Res 2020 08;478(8):1733-1734

J. D. Kelly, IV, Professor of Clinical Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1097/CORR.0000000000001265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371090PMC
August 2020
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