Objective To compare the effectiveness, safety and acceptability of medical abortion before and after the introduction of no-test telemedicine Design Cohort study Setting The three main abortion providers in England Population All patients having an early medical abortion (comprising 85% of all medical abortions performed nationally) Methods Comparison of no-test telemedicine hybrid model vs. traditional model (blanket in-person provision including ultrasound), adjusted for baseline differences Main outcome measures Access: waiting time, gestation Effectiveness: successful medical abortion Safety: significant adverse events; ectopic pregnancy and late gestation Acceptability: Patient-reported outcomes Results 52,142 medical abortions were conducted, 29,984 in the telemedicine-hybrid cohort and 22,158 in the traditional cohort. Mean waiting times were 4.2 days shorter in the telemedicine-hybrid cohort and 40% were ≤6 weeks’ gestation vs. 25% in the traditional cohort (p<0.001). There was no difference in success rates (98.8% vs. 98.2%, p=1.0), nor in prevalence of serious adverse events (0.02% vs. 0.04%, p=0.557). Incidence of ectopic pregnancy was equivalent in both cohorts (0.2%, p=0.796); 0.04% of abortions appeared to have been provided after 10 weeks’ gestation with all completed safely at home. In the telemedicine-hybrid cohort, effectiveness was higher in the telemedicine group vs. the in-person group (99.2% vs. 98.1%, p<0.001). Acceptability was high (96% satisfied), 80% reported a future preference for telemedicine, and none reported that they were unable to consult in private using teleconsultation. Conclusions Medical abortion provided through a hybrid model that includes no-test telemedicine without ultrasound is effective, safe, acceptable, and improves access to care. Funding None

A document by Natalija Novak. Click on the document to view its contents.

Level and duration of protective immunity against SARS-CoV-2 after primary infection is of crucial importance for preventive approaches. In order to provide evidence for the longevity of specific antibodies, we investigated the generation and maintenance of neutralizing antibodies of convalescent SARS-CoV-2-afflicted patients over a five month period post primary infection using an immunofluorescence assay, a commercial chemiluminescent immunoassay and an in-house enzyme-linked plaque-reduction neutralization assay. We present the successful application of an improved version of the plaque-reduction neutralization assay, which can be analyzed optometrically, significantly simplifying the interpretation of the results. Based on the results of the plaque-reduction neutralization assay, neutralizing antibodies were maintained in 85.3% of convalescent individuals without significant decay over five months. Furthermore, a positive correlation between severity of infection and neutralizing titer was shown. In conclusion, SARS-CoV-2-afflicted individuals have been proven to be able to establish and maintain neutralizing antibodies over a five months’ period after primary infection which allows to hope for long-lasting presumably protective humoral immunity after wild-type infection or even after vaccination.

Kauri dieback, caused by Phytophthora agathidicida, is an ecosystem disturbance that poses a recent threat to the survival of kauri (Agathis australis) forests in New Zealand. Throughfall and stemflow play an important role in meeting the nutrient requirements of kauri forests. However, the effects of kauri dieback on canopy nutrient deposition remain unknown. Here we measured throughfall, stemflow and forest floor water yield and nutrient concentrations and fluxes (potassium, calcium, magnesium, manganese, silicon, sulphur, sodium, iron) of ten kauri trees differing in soil P. agathidicida DNA concentration and health status. We did not observe an effect of soil P. agathidicida DNA concentration on throughfall and stemflow water yield. Throughfall and forest floor nutrient concentrations and fluxes tended to decrease (up to 50%) with increasing soil P. agathidicida DNA concentration. Significant effects were found for potassium and manganese fluxes in throughfall, and calcium and silicon fluxes in forest floor leachate. The decline in nutrient input will have implications on plant nutrition, tree health and susceptibility to future pathogen infection in these ecologically unique kauri forests. Given our findings and the increasing spread of Phytophthora species worldwide, research on the underlying physiological mechanisms linking dieback and plant-soil nutrient fluxes is critical.

ABSTRACT Objective: We aimed to investigate the prognostic significance of intraductal carcinoma in radical prostatectomy (RP) specimens and predictive value of IDC-P for biochemical recurrence and adjuvant therapy decision. Method: Patients who underwent RP between 2000-2014 with final pathological stage pT3a and negative surgical margins (Group 1, n=35) and pT2 with positive surgical margins (Group 2, n=32) were included. RP specimens were re-evaluated for the presence of IDC-P component and other prognostic factors. In both groups, prognostic factors were compared according to the presence of IDC-P and biochemical recurrence status. Results: In group 1, IDC-P was detected in 5 cases and biochemical recurrence was detected in 3 cases. Patients with IDC-P showed significantly higher biochemical recurrence than those without IDC-P (p=0.002). In univariate analysis, IDC-P was found to be significantly associated with worse progression free survival (p<0.001). In group 2, IDC-P was detected in 4 cases and biochemical recurrence was detected in 10 cases. Also, tumor volume was significantly higher in patients with IDC-P than those without IDC-P (p=0.02). IDC-P was also significantly associated with worse progression free survival in group 2 (p=0.033). Conclusions: In both groups, IDC-P is a prognostic factor for progression free survival and / or biochemical recurrence. Especially in these patients, presence of IDC-P might be helpful for postoperative adjuvant therapy management decision. Keywords: radical prostatectomy, intraductal carcinoma of prostate (IDC-P), prostate cancer, biochemical recurrence, progression free survival.

PURPOSE: We aim to do an efficacy-safety analysis of Mirabegron-Tamsulosin combination therapy versus tamsulosin-placebo monotherapy in a select subset of medication virgin BPH patients with coexisting predominantly overactive bladder symptoms (OABS). METHODS: After prior written informed consent and institutional ethics clearance, 80 patients of uncomplicated BPH with coexisting OABS and IPSS of >7 were computer randomized and allocated to receive therapy with either [50mg Mirabegronplus Tamsulosin 0.4 mg (Intervention arm)]or [Tamsulosin 0.4 mg plus capsule lactobacillus (Comparator arm)] once daily for a period of 8 weeks. Efficacy was evaluated using the OABS Score (OABSS), mean change in the frequency of nocturnal voiding, post void residue (PVR) and international prostate symptom score (IPSS) while safety was assessed by recording treatment emergent adverse events (TEAE). The protocol was registered prospectively with the clinical trials registry of India (CTRI/2018/12/016541). RESULTS: Significant improvements were visualised in the primary endpoint total OABS subscore (OABSS-ss) at the end of 8 weeks in the combination group (mean difference -5.62 vs -2.22p< 0.001).Similar significant improvements were seen with most of the secondary parameters such as the mean change in voiding episode/night, IPSS, IPSS-ss,OABS-ss, voided volume/micturition, Qmax, and Quality of Life (QOL) indices (p<0.001). No significant increase in PVR was observed in the Mirabegron arm and no patient developed urinary retention. The TEAE were minor, self-limiting and were managed symptomatically without any treatment discontinuity. CONCLUSION: Mirabegron was significantly efficacious and safe in ameliorating OABS induced by BPH versus placebo. This efficacy can be safely enhanced by initiating Mirabegron-Tamsulosin combination therapy from the start in medication virgin patients as opposed to the usual add on therapy protocol. This combination appeared to be superior in terms of overall safety, minimal side effects, better compliance and tolerability versus Tamsulosin monotherapy particularly in the select subset of patients of with BPH coexisting/predominant OABS.

Aims:Erectile dysfunction (ED) is a common condition affected by many factors. We aimed to show the impact of the metabolic syndrome (MeTS) on male sexual function based on VAI and the impact of increased levels of the VAI was investigated in patients with ED among the patients with and without MeTS. Methods:Participants who met MeTS criteria (Group 1, n=96) and without MeTS (Group 2, n=189) were included in this cross-sectional study. The MeTS diagnosis was made in the presence of at least three of the following criteria: serum glucose level higher than 100 mg/dl, HDL cholesterol level below 40 mg/dl, triglyceride level greater than 150 mg/dl, waist circumference greater than 102 cm and blood pressure greater than 130/85 mmHg. Demographic data were recorded; biochemical and hormonal tests were measured. Erectile and other sexual function scores were recorded. The VAI was calculated using the [(WC/39.68)+(1.88xMI)]xTG/1.03x1.31/HDL formula. Results:Mean age, smoking volume, T and T/E2 ratios of the groups were similar (p>0.05). Mean VAI was two-fold higher in patients in Group 1 (p<0.001) and erectile function score was lower in Group 1 than Group 2 (p=0.001). Other sexual function scores were similar (p>0.05). The METS was associated with an increased risk of ED (p=0.001). Logistic regression analysis showed that each integer increase of the VAI was associated with a 1.4-fold increased risk of ED (p<0.001). Higher T values were associated with a better erectile function (p=0.03). For the VAI=4.33, receiver-operating characteristic analysis showed a sensitivity of 89.6 % and specificity of 57.7 %. Conclusion:Compared to non-MeTS, the presence of MeTS has emerged as a risk factor for patients with ED with high VAI levels while the other sexual functions are preserved. Management of ED patients with MeTS should cover a comprehensive metabolic and endocrinological evaluation in addition to andrological work up.

Purpose: We designed a multicenter, retrospective study to investigate the current trends in initial management of reflux with respect to EAU guidelines in Urology clinics of our country. Materials and Methods: The study group consisted of 1988 renal units (RU) of 1345 patients treated surgically due to VUR between years 2003-2017 in 9 different institutions. Patients were divided into 2 groups according to time of initial treatment and also grouped according to risk factors by “EAU guidelines on VUR”. Results: 1426 RUs were treated initially conservatively and 562 RUs were initially treated with surgery. In initially surgically treated group, success rates of surgery decreased significantly in low and moderate risk groups after 2013 (p=0.046, p=0.0001, respectively), while success rates were not significantly different in high risk group (p=0.46). While 26.6% of patients in low risk group were initially surgically treated before 2013, this rate has increased to 34.6% after 2013, but the difference was not statistically significant (p=0.096). However, performing surgery as the initial treatment approach increased significantly in both moderate and high risk groups (p=0.000 and p=0.0001, respectively) after 2013. Overall success rates of endoscopic and UNC operations were 65% and 92.9% before 2013, 60% and 78.5% after 2013, respectively. Thus the overall success rate for surgery was 72.6%. There was significant difference between success rates of UNC operations before and after 2013(p=0.000), while the difference was not significant in the STING group (p=0.076). Conclusion: Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups.

Na+,K+ATPase (NKA), a transmembrane protein essential for maintaining the electrochemical gradient across the plasma membrane, acts as a receptor for cardiotonic steroids (CTS) such as ouabain. CTS binding to NKA, triggers signalling pathways or inhibits NKA activity in a concentration-dependent manner, resulting in a modulation of Ca2+ levels, which are essential for homeostasis in neurons. However, most of the pharmacological strategies for avoiding neuronal death do not target NKA activity, due to its complexity and poor comprehension of the mechanisms involved in NKA modulation. The present review aims to discuss two points regarding the interplay between NKA and Ca2+ signalling in the brain: NKA impairment causing illness as well as neuronal death due to Ca2+ signalling and benefits to the brain by modulating NKA activity. These interactions play an essential role in neuronal cell fate determination and are relevant to finding new targets for the treatment of neurodegenerative diseases.

Understanding what variables affect ungulate neonate survival is imperative to successful conservation and management of the species. Predation is commonly cited as a cause-specific source of mortality and ecological covariates often influence neonate survival. However, variation in survival estimates related to capture methodology has been documented with opportunistically captured neonates generally displaying greater survival than those captured via aid of vaginal implant transmitters (VITs), likely because of increased left truncation observed in the opportunistically captured datasets. Our goal was to assess if 3- and 6-month survival estimates varied by capture method while simultaneously assessing if capture method affected model selection and interpretation of ecological covariates for white-tailed deer neonates captured from three study sites in North Dakota and South Dakota, USA. We found survival varied by capture method for 3-month neonate survival with opportunistically captured neonates displaying up to 26% greater survival than their counterparts captured via VITs; however, this relationship was not present for 6-month survival. We also found model selection and subsequent interpretation of ecological covariates varied when analyzing datasets comprised of neonates captured via VITs, neonates captured opportunistically, and all neonates combined regardless of capture method. When interpreting results from our VIT only analysis for 3-month survival, we found survival varied by three time intervals and was lowest in the first two weeks of life. Capture method did not affect 6-month survival which was most influenced by total precipitation occurring during 3 – 8 weeks of a neonate’s life and percent canopy cover found at a neonate’s capture site. Our results support previous research that capture method must be accounted for when deriving survival estimates for ungulate neonates as it can impact derived estimates and subsequent interpretation of results.

Introduction: Advanced intraocular retinoblastoma can be cured by enucleation, but spread of retinoblastoma cells beyond natural limits of the eye may lead to metastatic disease which is related to a high mortality. Adjuvant therapy after enucleation has been shown to prevent metastasis in children with risk factors for extraocular retinoblastoma. However, histological criteria and adjuvant treatment regimens vary and there is no unifying consensus on the optimal choice of treatment. Method: Data on guidelines for adjuvant treatment in European retinoblastoma referral centres were collected in an online survey among all members of the European Retinoblastoma group (EURbG) network. Extended information were gathered via personal Email communication. Results: Data were collected from 26 centres in 17 countries. Guidelines for adjuvant treatment were in place at 92.3% of retinoblastoma centres. There was a consensus on indication for and intensity of adjuvant treatment among more than 80% of all centres. The majority of centres use no adjuvant treatment for isolated focal choroidal invasion or prelaminar optic nerve invasion. Patients with massive choroidal invasion or postlaminar optic nerve invasion receive adjuvant chemotherapy, while microscopic invasion of the resection margin of the optic nerve or extension through the sclera are treated with combined chemo- and radiotherapy. Conclusion: Indications and adjuvant treatment regimens in European retinoblastoma referral centres are similar but not uniform. Further biomarkers in addition to histopathological risk factors could improve treatment stratification. The high consensus in European centres is an excellent foundation for a common European study with prospective validation of new biomarkers.

Background: Mutations in the filaggrin gene (FLG) affect epidermal barrier function and increase the risk of atopic dermatitis (AD). We hypothesized that FLG mutations affect immune cell composition in a general pediatric population. Therefore, we investigated if school-aged children with and without FLG mutations have differences in immune cell numbers. Methods: This study was embedded in a population-based prospective cohort study, the Generation R Study, and included 523 children of European genetic ancestry aged 10 years. The most common FLG mutations in the European population (R501X, S1085CfsX36, R2447X and S3247X) were genotyped. Additionally, 11-color flow cytometry was performed on peripheral blood samples to determine helper T (Th), regulatory T (Treg) and CD27+ and CD27- memory B cells. Sensitivity analysis was performed in 102 AD cases, assessed by parental questionnaires. Results: FLG mutations were observed in 8.4% of the total population and in 15.7% of the AD cases. Children with any FLG mutation had higher Th22 cell numbers compared to FLG wild-type children. Children with and without FLG mutations had no difference in Th1, Th2, Th17, Treg or memory B cell numbers. Furthermore, in children with AD, FLG mutation carriership was not associated with differences in T- and B-cells or their subsets. Conclusions: School-aged children with FLG mutations have higher Th22 cell, which might suggest an immunological defense mechanism to an altered skin barrier function. No associations between Th or Treg cells and FLG mutations suggests that FLG mutations do not otherwise affect immune composition in a general pediatric population.

Introduction The mechanisms that drives SLE remission.The aim of the present study was to measure CD4+ and CD8+ T cell exhaustion in SLE patients in prolonged remission (PR-SLE) and compared them with patients with active SLE (Act-SLE) and healthy subjects Methods We included 15 PR-SLE patients, 15 Act-SLE and 29 healthy subjects. T-cell exhaustion was determined by flow cytometry according to the expression of PD-1, Tim-3, 2B4, EOMES and T-bet in CD4+ and CD8+ T cells. Dimensionality reduction using the t-Distributed Stochastic Neighbor Embedding algorithm and Clustering Analysis was used for the identification of relevant populations. Results Percentages of CD3+, CD4+ and CD8+ T cells were similar among groups. We identified five subpopulations of CD8+ and seven of CD4+ cells. The CD4+Tbet+CD45RO+ cells identified in the unsupervised analysis were significantly increased in PR-SLE vs Act-SLE (median: 10.20, IQR: 1.74-30.50 vs. 1.68, IQR: 0.4-2.83; p<0.01). CD4+EOMES+ cells were also increased in PR-SLE vs Act-SLE (5.24, IQR: 3.38-14.70 vs. 1.39, IQR: 0.48-2.87; p<0.001). CD8+ EOMES+ cells were increased in PR-SLE vs Act-SLE (37.6, IQR: 24.9-53.2 vs 8.13, IQR: 2.33-20.5; p<0.001). Exhausted and activated T cells presented an increased frequency of PD-1, CD57 and EOMES in SLE patients vs healthy subjects. Conclusions Some subpopulations of T cells expressing markers associated with exhaustion are increased in patients in remission, supporting T-cell exhaustion as a tolerance mechanism in SLE. Exhaustion of specific populations of T cells might represent a potential therapeutic tool that will contribute to the goal of achieving sustained remission in these patients.

Frontal chromatography has seen increased interest for protein purification, in particular as a polishing step in downstream processes for therapeutic proteins production, as for example the purification of monoclonal antibodies (mAbs) from high molecular weight impurities, e.g., aggregates, using cation exchange resins. In this work we introduce a new two-column continuous process implementing frontal chromatography. The design procedure and its performance, compared to classical batch technology, are discussed. This represents an additional option in the realisation of optimised continuous downstream processing of therapeutic proteins.

Benzo[a]pyrene (B[a]P) as a representative polycyclic aromatic hydrocarbons is concerned by global scientists in various fields, but its biological and biochemical actions in soil-wheat systems are still rarely reported. The B[a]P as a ubiquitous soil pollutant possesses varied contents in real environment, and herein was studied in systems of soil and wheat to obtain relative results to reveal their variations in different systems. Its bioavailability (extractability and bioaccumulation) and basic biological toxicity were tested based on three typical soil types (red, black, and brown) in China and spiked amounts (0.1, 1, and 10 mg/kg) with several orders of magnitude. Results showed that B[a]P concentrations in soil-wheat systems extracted by HPCD were insignificantly (p > 0.05) higher than Tenax-TA, and varied with soil types and spiked concentrations. Besides, the root and shoot length were mostly inhibited, in a range of -21.85%-26.35% and -0.48%-54.85%, respectively, by B[a]P in different soil types and increased with its increasing concentration. Comparatively, higher bioconcentration factor and translocation factor values were observed under lower group in red soil-wheat systems, and higher spiked groups in black and brown soil-wheat systems. Moreover, inhibitive effects posed by B[a]P were mainly targeted at wheat shoots in these soils. The simultaneous studies provided a comparable knowledge of B[a]P in ecosystems of different soil types combined with different plant species due to lots of variations, further to serve for contaminated soil remediation and sustainable agricultural management.

In this paper, an identical approximate regularization method is extended to the Cauchy problem of two-dimensional heat conduction equation, this kind of problem is severely ill-posed. The convergence rates are obtained under a priori regularization parameter choice rule. Numerical results are presented for two examples with smooth and continuous but not smooth boundaries, and compared the identical approximate regularization solutions which are displayed in paper. The numerical results show that our method is effective, accurate and stable to solve the ill-posed Cauchy problems.

Medical Marijuana in Pediatric Oncology: What Your Patients Are ThinkingDavid Brumbaugh, MD MSCS FAAPDepartment of Pediatrics, University of Colorado School of MedicineChildren’s Hospital Colorado13123 E. 16th Avenue, B290Aurora, CO [email protected] count: 837Short Running Title: Medical Marijuana in Pediatric OncologyKeywords: marijuana, cannabis, complementary, pediatricsAbbreviations:MM Medical MarijuanaAYA Adolescent/young adultTHC TetrahydrocannabinolUse of complementary therapies occurs by up to 40-80% of pediatric oncology patients.1,2 Although cannabis is hardly new to the scene as a complementary treatment, legalization of both medical and recreational marijuana in many states has made these products ubiquitous. Use of and interest in medical marijuana (MM) by hospitalized pediatric patients appears to be concentrated in oncology units for the purpose of relieving symptoms such as nausea, pain, and anorexia.3 Yet clinical practitioners are still limited by the absence of high-quality research in MM to guide them. FDA approval of Epidiolex™ for specific pediatric epilepsy syndromes was an important research milestone, but marijuana remains classified as a Drug Enforcement Administration Schedule I drug, imposing an enormous barrier for clinical researchers.So how should pediatric oncology programs approach the topic of MM? In this issue of Pediatric Blood and Cancer , Ananth and colleagues used a qualitative research design to characterize patient and family perception of MM from a single institution in a state with permissive rules towards both medical and recreational marijuana. The authors interviewed both parents of younger children as well as adolescent/young adult (AYA) patients. In this cohort of pediatric oncology patients/families, although the proportion of subjects using MM was only 27%, a higher proportion were interested in MM, though with concerns about safety and effectiveness.In the Ananth study, patients/families were primarily using or interested in MM for treatment of nausea, anorexia, and anxiety. A concerning number of families in this study expressed a hope that MM would be effective as anti-cancer therapy. With the absence of high-quality randomized controlled trials of MM for treatment of cancer or treatment-related symptoms in children to inform practitioners on safety, dosing, and toxicity, there is no evidence base for pediatric oncologists to base a recommendation of MM. But should we be dissuading interested families from using MM products because they are harmful?Regarding safety of MM use, most parents and nearly all AYA patients minimized risks. When expressed, safety concerns of MM were perceived as less than with alcohol, illicit drugs, or other prescribed medications. This is not surprising, as perceived risk of marijuana in AYA has been steadily failing over last five years in the National Survey on Drug Use and Health.4 Understandably, in this study safety concerns focused on the potential for addiction, which would be associated with MM products enriched in Tetrahydrocannabinol (THC), the principal psychoactive cannabinoid found in cannabis. However, cannabis is a complex plant with over 70 distinct cannabinoids, and the MM industry now contains a broad range of different types of products that have varying concentrations of THC and consequent psychoactive potential. Carver and colleagues noted in their study of 19 hospitalized patients actively using MM, the majority were using products enriched in Cannabidiol with low concentration of THC. One limitation of the study by Ananth, et al. is that there was no attempt to classify the type of MM either being actively used or of interest to patients and parents, so the appropriateness of the concern for addiction cannot be assessed. Absent in patients/families’ perception of risk was any potential for interaction with chemotherapeutics or other prescribed medications. Since both THC and Cannabidiol can impact drug bioactivation and metabolism through multiple pathways, this potential safety concern should be known to the patient and treatment team.Despite the high level of interest in MM in their study population, the minority of patients/families had discussed MM with their oncologist and in those cases, the patient/family initiated the conversation. Absent advice from their treatment team, there was reliance on friends, family, and the internet for more information. A majority of parents desired the involvement of their physician team in any consideration of MM, and previous research has shown a high level of willingness amongst pediatric oncology providers to consider MM use by their patients, particularly when patients are seriously ill, so what stands in the way of talking about it? Providers are concerned about the absence of good research and are less knowledgeable in the domain of rules/laws regulating access to MM, particularly at the state level where there has been so much change over the last decade.5 These gaps may explain why we don’t bring up the topic of MM with our patients and families as often as they would like.Institutions may consider designating a multidisciplinary team of providers to develop greater experience in the legal and pharmacologic aspects of MM use. This team can support providers in the shared decision-making process around MM. In some institutions, it may make sense to house this expertise within the pediatric palliative care program supporting oncology patients.In summary, MM presently is an important part of the complementary therapeutic options available to pediatric oncology patients and their families, who desire the involvement of their provider team in decision making around MM. Despite the lack of evidence supporting use of MM, many patients are using MM products or may in the future, so we should invite this discussion as this will strengthen our therapeutic partnership.1. Fernandez CV, Stutzer CA, MacWilliam L, Fryer C. Alternative and complementary therapy use in pediatric oncology patients in British Columbia: prevalence and reasons for use and nonuse. J Clin Oncol. 1998;16(4):1279-1286.2. Kelly KM, Jacobson JS, Kennedy DD, Braudt SM, Mallick M, Weiner MA. Use of unconventional therapies by children with cancer at an urban medical center. J Pediatr Hematol Oncol. 2000;22(5):412-416.3. Carver AE, Jorgensen J, Barberio MW, Lomuscio CE, Brumbaugh D. A Pediatric Hospital Policy for Medical Marijuana Use. Pediatrics.2020;146(2).4. Administration SAaMHS. 2019 NSDUH Detailed Tables. samhsa.gov/data/report/2019-nsduh-detailed-tables. Published 2019. Accessed.5. Ananth P, Ma C, Al-Sayegh H, et al. Provider Perspectives on Use of Medical Marijuana in Children With Cancer. Pediatrics.2018;141(1).

Deltoid tendon rupture is an infrequent injury. We report on a young active white male who sustained a humeral sided deltoid avulsion tendon rupture while attempting a 450-pound barbell shoulder shrug. Early surgical fixation and a progressive rehabilitation program provided successful short and long-term outcomes in our young active patient.