Progress monitoring and feedback delivered in routine psychiatric care: Beneficial but not reaching those thought to need it most.

Objective: The study evaluated the use and effectiveness of a progress monitoring system routinely operational in a private mental health care setting. Method: In a nonrandomized trial in which 778 consecutively admitted patients underwent a 2-week cognitive behavioral therapy intervention, the effectiveness of therapists choosing to use progress monitoring feedback to frame therapist-patient discussions about individuals' progress was evaluated. Results: Patients engaged in discussions involving progress monitoring feedback during the intervention achieved a more consistent recovery rate. Furthermore, individuals that were not-on-track to achieve a positive outcome experienced a boost to recovery immediately after receiving feedback. However, evidence suggested that therapists were not using progress monitoring to primarily focus additional resources on not-on-track patients. Conclusion: Progress monitoring feedback benefited patient recovery. However, guidelines could improve the system by directing therapists to use feedback primarily with patients not on course for a positive therapeutic outcome.

Tensioned Wire-Assisted Intramedullary Nail Treatment of Proximal Tibia Shaft Fractures: A Technical Trick.

Proximal tibia shaft fractures are often challenging to manage because of their intrinsic tendency toward valgus and apex anterior deformity. In recent years, intramedullary nailing (IMN) has become more frequently used to treat these injuries, allowing for biologic advantages such as load-sharing, immediate weight-bearing, and avoidance of disruption of periosteal blood supply. Several adjunctive techniques, such as semiextended positioning, blocking screws, and external fixation, have been developed to assist with fracture reduction during IMN. We describe a new adjunctive reduction technique-tensioned wire-assisted IMN-for the treatment of proximal tibia shaft fractures. We have found that tensioned wire assistance facilitates fracture reduction during IMN, does not interfere with intraoperative image intensification, and is compatible with both standard nailing instrumentation and additional adjunctive techniques. We present tensioned wire nailing as a technical trick for anatomic and stable reduction of proximal tibia fractures and compare a cohort of proximal tibia shaft fractures managed with and without tensioned wire assistance.

Lexical knowledge boosts statistically-driven speech segmentation.

The hypothesis that known words can serve as anchors for discovering new words in connected speech has computational and empirical support. However, evidence for how the bootstrapping effect of known words interacts with other mechanisms of lexical acquisition, such as statistical learning, is incomplete. In 3 experiments, we investigated the consequences of introducing a known word in an artificial language with no segmentation cues other than cross-syllable transitional probabilities. We started with an artificial language containing 4 trisyllabic novel words and observed standard above-chance performance in a subsequent recognition memory task. We then replaced 1 of the 4 novel words with a real word (tomorrow) and noted improved segmentation of the other 3 novel words. This improvement was maintained when the real word was a different length to the novel words (philosophy), ruling out an explanation based on metrical expectation. The improvement was also maintained when the word was added to the 4 original novel words rather than replacing 1 of them. Together, these results show that known words in an otherwise meaningless stream serve as anchors for discovering new words. In interpreting the results, we contrast a mechanism where the lexical boost is merely the consequence of attending to the edges of known words, with a mechanism where known words enhance sensitivity to transitional probabilities more generally. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Statistical learning for speech segmentation: Age-related changes and underlying mechanisms.

Statistical learning (SL) is a powerful learning mechanism that supports word segmentation and language acquisition in infants and young adults. However, little is known about how this ability changes over the life span and interacts with age-related cognitive decline. The aims of this study were to: (a) examine the effect of aging on speech segmentation by SL, and (b) explore core mechanisms underlying SL. Across four testing sessions, young, middle-aged, and older adults were exposed to continuous speech streams at two different speech rates, both with and without cognitive load. Learning was assessed using a two-alterative forced-choice task in which words from the stream were pitted against either part-words, which occurred across word boundaries in the stream, or nonwords, which never appeared in the stream. Participants also completed a battery of cognitive tests assessing working memory and executive functions. The results showed that speech segmentation by SL was remarkably resilient to aging, although age effects were visible in the more challenging conditions, namely, when words had to be discriminated from part-words, which required the formation of detailed phonological representations, and when SL was performed under cognitive load. Moreover, an analysis of the cognitive test data indicated that performance against part-words was predicted mostly by memory updating, whereas performance against nonwords was predicted mostly by working memory storage capacity. Taken together, the data show that SL relies on a combination of implicit and explicit skills, and that age effects on SL are likely to be linked to an age-related selective decline in memory updating. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study).

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

Treatment of hypertrophic distal tibia nonunion and early malunion with callus distraction.

BACKGROUND: Hypertrophic nonunions and early malunions of pilon and distal tibia fractures result in complex, challenging to treat deformities. Callus distraction histiogenesis is an option for their management, allowing for the simultaneous correction of multiplanar deformity and limb length discrepancy. METHODS: A single-surgeon, retrospective case series was performed. Eight patients (6 males and 2 females) who were treated with callus distraction from 1991 to 2011 were reviewed. Six of 8 patients had varus deformities (range, 8-19 degrees) and 2 patients had valgus deformities (both 16 degrees) of the distal tibia metaphysis. Six of 8 had apex anterior deformities (range, 2-21 degrees) and 2 had apex posterior deformity (range, 9-20 degrees). An Ilizarov fixator or Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used to distract the nonunion or early malunion to correct alignment and shortening. Preoperative and postoperative radiographic outcomes, limb alignment, and ankle-hindfoot scores were reviewed. RESULTS: Union was achieved in all patients at a mean of 5.8 months (range, 4.1-7.6 months). The 3 patients treated with an Ilizarov-type fixator had deformity correction to within 5 degrees of neutral in 1 plane and to within 10 degrees in the other plane. All 5 patients treated with a Taylor Spatial Frame had correction to within 5 degrees of neutral alignment in both coronal and sagittal planes. There were 2 complications requiring reoperation and 1 persistent limb length discrepancy (2 cm) after treatment. Median AOFAS ankle-hindfoot score was 82.5 (range, 53-90) at an average follow-up of 30.4 months (range, 8-92). CONCLUSIONS: Callus distraction histiogenesis was a minimally invasive technique that can successfully treat patients with hypertrophic nonunion and early malunion of the distal tibia. We believe the application of a computer-assisted 6-axis frame to correct the deformity improved the correction of these multiplanar deformities. LEVEL OF EVIDENCE: Level IV, case series.

Semantic gradients in picture-word interference tasks: is the size of interference effects affected by the degree of semantic overlap?

We report two experiments attempting to identify the role of semantic relatedness in picture-word interference studies. Previously published data sets have rendered results which directly contradict each other, with one study suggesting that the stronger the relation between picture and distractor, the more semantic interference is obtained, and another study suggesting the opposite pattern. We replicated the two key experiments with only minor procedural modifications, and found semantic interference effects in both. Critically, these were largely independent of the strength of semantic overlap. Additionally, we attempted to predict individual interference effects per target picture, via various measures of semantic overlap, which also failed to account for the effects. From our results it appears that semantic interference effects in picture-word tasks are similarly present for weakly and strongly overlapping combinations. Implications are discussed in the light of the recent debate on the role of competition in lexical selection.

Lengthening of the femur over an existing intramedullary nail.

Leg length discrepancies can occur despite successful union of femur fractures after intramedullary nailing (IMN). Often, the leg length discrepancy can result in significant disability to the patient, altered gait biomechanics, pelvic obliquity, and pain. Therefore, a successful clinical result for such deformities after IMN involves addressing the leg length inequality. Femoral reconstruction with an osteotomy around an existing intramedullary nail was introduced to address axial deformity correction and limb lengthening without changing or removing a previously inserted IMN. This technique uses the principles of lengthening over an IMN. The presence of the nail has minimized the time needed for the external fixator because the nail supports the regenerate bone or osteotomy during the consolidation phase. With this technique, surgery is minimized by avoiding the need for exchange nailing.

The treatment of gustilo grade IIIB tibia fractures with application of antibiotic spacer, flap, and sequential distraction osteogenesis.

Gustilo grade III (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues. At the severe end of the spectrum are GIII B tibia fractures that combine segmental bone loss with soft tissue injuries which require flap reconstruction. These complex injuries can be treated combining circular tensioned wire fixation and distraction histiogenesis with flap reconstruction. GIII B tibia shaft fractures were retrospectively reviewed at an urban Level One Trauma Center from 1992 to 2008 which were treated with the Ilizarov method. Seventy-six patients with 78 fractures were treated. Thirty-eight fractures were treated with flaps. Out of this cohort, a subset of 19 fractures were treated using the protocol of initial multiple debridements, half pin resuscitation external fixation, soft tissue reconstruction over antibiotic spacers and delayed Ilizarov reconstruction after stabilization of the soft tissue envelope. The fractures had multiple aggressive debridements removing nonviable bone. Thirteen free flaps and 6 rotation flaps were applied. Flaps were applied a mean time of 34 days (12-77) after initial injury. Two free flaps failed and had a second successful application. Flap survival was 17 of 19 (89%). There was one partial necrosis and one flap hematoma. There was no flap complication from delayed elevation and spacer removal. Mean tibial bone defect was 9.4 cm (5-17). Reconstruction time was 26.5 months (12-73). Eighteen of 19 fractures were reconstructed with union and no deep infection or osteomyelitis. One fracture had a hypertrophic nonunion in a noncompliant patient. The use of antibiotic spacers and flaps to construct a soft tissue tunnel combined with distraction histiogenesis is an effective technique to salvage complex GIII B tibia fractures with segmental bone loss.

Involvement of the thromboxane A2 receptor in the regulation of steroidogenic acute regulatory gene expression in murine Leydig cells.

Recent studies suggested an involvement of thromboxane A2 in cyclooxygenase-2-dependent inhibition of steroidogenic acute regulatory (StAR) gene expression. The present study further investigated the role of thromboxane A2 receptor in StAR gene expression and steroidogenesis in testicular Leydig cells. The thromboxane A2 receptor was detected in several Leydig cell lines. Blocking thromboxane A2 binding to the receptor using specific antagonist SQ29548 or BM567 resulted in dose-dependent increases in StAR protein and steroid production in MA-10 mouse Leydig cells. The results were confirmed with Leydig cells isolated from rats. StAR promoter activity and StAR mRNA level in the cells were also increased after the treatments, suggesting an involvement of the thromboxane A2 receptor in StAR gene transcription. Furthermore study indicated that blocking the thromboxane A2 receptor reduced dosage sensitive sex reversal-adrenal hypoplasia congenita critical region on the X chromosome, gene 1 protein, a transcriptional repressor of StAR gene expression. Specific binding of the antagonists to the receptors on cellular membrane was demonstrated by binding assays using (3)H-SQ29548 and binding competition between (3)H-SQ29548 and BM567. Whereas SQ29548 enhanced cAMP-induced StAR gene expression, in the absence of cAMP, it was unable to increase StAR protein and steroidogenesis. However, when the receptor was blocked by the antagonist, subthreshold levels of cAMP were able to induce maximal levels of StAR protein expression, suggesting that blocking the thromboxane A2 receptor increase sensitivity of MA-10 cells to cAMP stimulation. Taken together, the results from the present and previous studies suggest an autocrine loop, involving cyclooxygenase-2, thromboxane A synthase, and thromboxane A2 and its receptor, in cyclooxygenase-2-dependent inhibition of StAR gene expression.

Tibiocalcaneal arthrodesis using the Ilizarov technique in the presence of bone loss and infection of the talus.

BACKGROUND: Infected nonunions and extrusions of the talus can often lead to below-knee amputation. Limb-salvage procedures have goals of eradicating infection and creating a painless, stable limb. Often, a tibiocalcaneal fusion is the best option; however, in the presence of infection and bone loss, it can be difficult to achieve a successful outcome using internal fixation. We review the results of circular ring external fixation to obtain a tibiocalcaneal arthrodesis despite these obstacles. METHODS: A retrospective review of 11 patients who underwent tibiocalcaneal arthrodesis using an Ilizarov external fixator for infected talar nonunions or extrusions was performed. Each patient had a debridement of all nonviable talus. The bony surfaces were prepared for the fusion followed by application of a circular ring fixator. Clinical outcomes were measured using the AOFAS ankle-hindfoot scale. There was a mean followup of 35 months. RESULTS: Nine of the 11 patients had successful fusions. One fused successfully after a revision and the other developed a stable pseudoarthrosis. Eight patients underwent concomitant lengthening with the Ilizarov fixator. Mean AOFAS score at final followup was 65. This was out of a maximum of 86 since the tibiotalar and subtalar joint motion were removed. There were no recurrent deep infections or amputations. CONCLUSIONS: Tibiocalcaneal arthrodesis using the Ilizarov technique is a viable alternative to amputation in patients with infected nonunions or large bone loss of the talus.

Salvage of pilon fracture nonunion and infection with circular tensioned wire fixation.

Nonunion, malunion, and infection are complications encountered when treating fractures of the distal tibia extending into the joint surface. There is rank order of severity of those complications extending from a varus collapse of the medial column of the distal tibia with a reduced joint surface to an infected nonunion with destruction of the joint surface, segmental bone loss, and damaged soft tissue envelope. Malunion and malposition of nonunion of the distal tibia have a combination of angular deformity, translation, rotational malalignment, and shortening. These deformities require correction in the reconstruction and there are multiple technique pathways to achieving a successful reconstruction.

Expression of morphogenic genes in mature ovarian and testicular tissues: potential stem-cell niche markers and patterning factors.

Morphogens are developmental regulators that modulate different tissue patterning, proliferation, differentiation, or remodeling processes in embryonic and adult tissues. Morphogens may also evoke specific regulatory programs in stem cells. Some of the morphogens involved in these processes have been characterized, while others remain unidentified. A microarray containing 3,557 salmonid cDNAs was used to compare the transcriptomes of rainbow trout precocious ovary at three different stages during second year (June, August, and October) with a reference (June normal ovary) transcriptome. During this study, we detected morphogen transcript hybridizations to salmonid elements and the study was enlarged to investigate these activities in various developmental stages of both ovary and testis. Genes from diverse development regulator families such as Anterior gradient-2, BMP, Epimorphin, Flightless, Frizzled, Notch, Tiarin, Twisted gastrulation, and Wnt were demonstrated to be expressed in the adult trout gonads. In mice or rats, expression of mammalian bmp-4, epimorphin, flightless, twisted gastrulation, and GW112 transcripts were localized to cell types isolated from the developed ovary and testis. Comparisons of salmonid and mammalian morphogens at the amino acid residue level show high similarities, suggesting functional conservation. This report provides evidence for local regulation by various morphogens and their potential to control distinct programs of gene expression in the gametes and their accessory cells during gametogenesis.

Physiologic interactions between macrophages and Leydig cells.

The purpose of this minireview is to present information concerning the morphologic and functional relationship between testicular macrophages and Leydig cells. Although data concerning the negative influence of macrophage-derived products on testicular Leydig cells exist, this review is focused on the stimulatory influences thought to be involved in the physiologic interactions between these two diverse cell types.

Cyclooxygenase-2 regulation of the age-related decline in testosterone biosynthesis.

The age-related decline in testosterone biosynthesis in testicular Leydig cells has been well documented, but the mechanisms involved in the decline are not clear. Recent studies have described a cyclooxygenase-2 (COX2)-dependent tonic inhibition of Leydig cell steroidogenesis and expression of the steroidogenic acute regulatory protein (StAR). The present study was conducted to determine whether COX2 protein increases with age in rat Leydig cells and whether COX2 plays a role in the age-related decline in testosterone biosynthesis. Our results indicate that from 3 months of age to 30 months, COX2 protein in aged rat Leydig cells increased by 346% over that of young Leydig cells, StAR protein decreased to 33%, and blood testosterone concentration and testosterone biosynthesis in Leydig cells decreased to 41 and 33%, respectively. Further experiments demonstrated that overexpressing COX2 in MA-10 mouse Leydig cells inhibited StAR gene expression and steroidogenesis and that the inhibitory effects of COX2 could be reversed by blocking COX2 activity. Notably, incubation of aged Leydig cells with the COX2 inhibitor NS398 enhanced their testosterone biosynthesis. Blood testosterone concentrations in aged rats fed the COX2 inhibitor DFU, at doses of 5, 10, 15, and 20 mg/kg body weight per day were increased by 15, 23, 56, and 120%, respectively, over the levels in the rats receiving no DFU. The present study suggests a novel mechanism in male aging involving COX2 and a potential application of the mechanism to delay the age-related decline in testosterone biosynthesis.

Paracrine modulation of androgen synthesis in rat leydig cells by nitric oxide.

The free radical nitric oxide (NO), generated through the oxidation of L-arginine to L-citrulline by NO synthases (NOSs), has been shown to inhibit steroidogenic pathways. NOS isoforms are known to be present in rat and human testes. Our study examined the sensitivity of Leydig cells to NO and determined whether NOS activity resides in Leydig cells or in another cell type such as the testicular macrophage. The results showed a low level of L-[14C]arginine conversion in purified rat Leydig cell homogenates. Administration of the NOS inhibitor L-N(G)-nitro-arginine methyl ester (L-NAME), or the calcium chelator ethylenebis (oxyethylenenitrilo)tetraacetic acid (EGTA), had no effect on L-[14C]citrulline accumulation. Increased intracellular Ca2+ concentrations that were induced by a calcium ionophore, or the addition of luteinizing hormone (LH), failed to affect NO formation in intact cells that were cultured in vitro. Introduction of a high concentration of the NO precursor L-arginine did not decrease testosterone (T) production, and NOS inhibitors did not increase T biosynthesis. However, exposing Leydig cells to low concentrations of the NO donor S-nitrosoglutathione (GSNO) induced a dramatic blockade of T production under basal and LH-stimulated conditions. DNA array assays showed a low level of expression of endothelial NOS (eNOS), while the neuronal and inducible isoforms of NOS (nNOS and iNOS) were below detection levels. Reverse transcriptase-polymerase chain reaction (RT-PCR) analyses confirmed these findings and demonstrated the presence of high iNOS messenger RNA (mRNA) levels in activated testicular macrophages that produced large amounts of NO. These data suggest that, while T production in rat Leydig cells is highly sensitive to NO and an endogenous NO-generating system is not present in these cells, NOS activity is more likely to reside in activated testicular macrophages.