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e stopwatch measurement is the limitation of the study. CONCLUSION Stopwatch measured average TitOr in the sample of women in our study, who were in a monogamous stable heterosexual relationship, is 13.41 minutes (95% confidence interval 12.76 minutes-14.06 minutes) and certain maneuvers as well as positions during penovaginal intercourse help achieving orgasm, more often than not. Bhat GS, Shastry A. Time to Orgasm in Women in a Monogamous Stable Heterosexual Relationship. J Sex Med 2020;XXXXX-XXX. INTRODUCTION Nutcracker syndrome (NS) defines an entity generated by the compression of the left renal vein resulting in venous hypertension, which transmitted in a retrograde direction may cause hematuria, proteinuria, and varicocele. The literature concerning exclusively pediatric patients is very rare. OBJECTIVE To report the authors' experience with pediatric NS in the last 18 years. STUDY DESIGN This is a retrospective review of the patients followed up in the authors' center with diagnosis of NS based on clinical and imaging tests (ultrasound, computed tomography/magnetic resonance imaging, and phlebography). The primary outcome was the success of the conservative approach in the study patients. RESULTS AND DISCUSSION A total of 21 patients were diagnosed with NS and followed up for a mean period of 52.3 months (37.1-67.5). The mean age at diagnosis was 11.7 years (9.9-13.4). The most frequent symptom of presentation was hematuria in 16 patients (76.2%), being macroscopic in 75% patients and related to based on non-invasive tests; phlebography should be reserved for severe cases that require an interventionist attitude. A long period of conservative treatment is the first approach for pediatric patients with NS. BACKGROUND Although bisoprolol has been established to prevent heart failure (HF), finding the optimal dose remains a challenge. It is crucial to understand the distribution of bisoprolol plasma concentration (Bis-PC) and association with outcomes. METHODS This was a single-center observational study in 114 HF patients under once-daily bisoprolol. After obtaining trough Bis-PC, patients were followed-up for 1 year. The primary endpoint was worsening of HF. Patients were divided according to the tertiles of Bis-PC. see more RESULTS In multivariate logistic regression analysis, independent predictors of high Bis-PC (1st tertile ≥ 5.38 ng/mL) were age, eGFR, and bisoprolol dose. The cumulative incidence rates of the primary endpoint were 10.5%/13.2%/26.3% in low/middle/high Bis-PC categories, respectively (log rank test, p = 0.087). Bis-PC was independently associated with the primary endpoint (hazard ratio [HR], 1.19 [per ng/mL], 95% CI 1.03-1.36). In subgroups, high Bis-PC was independently associated with the primary endpoint in elderly (HR 6.32, 95% CI 1.34-29.83) and HF with preserved ejection fraction (HFpEF) (HR 3.52, 95% CI 1.06-11.70). CONCLUSIONS Bis-PC was increased by age and renal dysfunction, and high Bis-PC was associated with worsening of HF in elderly and HFpEF patients. Care should be taken to avoid overdose. BACKGROUND The natural course of and risk factors for tear progression in full-thickness rotator cuff tears (FTRCTs) have not been clarified yet. The study's purpose was to retrospectively evaluate tear progression in FTRCTs by using magnetic resonance imaging (MRI) and to identify risk factors that are relevant to such tear progression. METHODS Between June 2010 and September 2019, a total of 345 patients with FTRCTs who had been diagnosed via MRI were treated conservatively. Of these, 48 patients who underwent post-treatment follow-up MRI were retrospectively enrolled. Tear progression was defined as significant when the tear size increased by >5 mm. RESULTS The mean MRI follow-up duration was 22 ± 14 months (range, 12-65 months). Among the 48 patients (mean age, 69 years; range, 53-81), 26 (54%) and 20 (41%) showed medial-lateral (M-L) and anterior-posterior (A-P) tear progression on MRI follow-up. Multivariate analysis revealed that MRI follow-up duration (P = .011), diabetes mellitus (P = .017), and infraspinatus muscle atrophy (P = .011) were independent risk factors for tear progression in the A-P plane. A high critical shoulder angle (P = .011) and supraspinatus (P = .024) and infraspinatus (P = .020) muscle atrophy were risk factors associated with M-L tear progression. CONCLUSION Among the assessed patients, a considerable number of FTRCTs increased in size during the follow-up period. Severe infraspinatus muscle atrophy was the independent risk factor for exacerbation of A-P and M-L tear progression. BACKGROUND Improved short-term outcomes have been demonstrated with higher surgical volume in shoulder arthroplasty. There is however, little data regarding long-term outcomes. METHOD Revision data from the Australian Orthopaedic Association National Joint Replacement Registry from 2004-2017 was analyzed according to 3 selected surgeon volume thresholds 20/yr group throughout the follow-up period (HR 1.66, 95% CI 1.21-2.28, P = .001). There was no significant difference for the primary diagnosis of fracture. CONCLUSION Lower surgical volume was associated with higher all-cause revision rates in the early postoperative period in TSA and rTSA for OA and throughout the follow-up period in rTSA for cuff arthropathy. Despite increases in the volume of shoulder arthroplasties performed in recent years, more than 78% of surgeons undertake fewer than 10 procedures per year. BACKGROUND Indications for reverse total shoulder arthroplasty (RTSA) are expanding, and more young patients are undergoing RTSA. Younger patients are expected to place increased functional demands on their shoulder, which may affect implant performance and longevity. Reports on longer-term outcomes in young patients remain limited. This study evaluates the minimum 5-year functional outcomes of RTSA in patients younger than 65 years. METHODS A retrospective review was performed using a multinational prospective shoulder arthroplasty database of a single implant system, Exactech Equinoxe (Gainesville, FL, USA). All RTSAs performed between 2007 and 2014 in patients younger than 65 years with minimum 5-year follow-up were included. Shoulder function was assessed preoperatively and at last follow-up via range-of-motion measurements and multiple patient-reported outcome measures. RESULTS Fifty-two shoulders were evaluated at an average follow-up of 6.3 years. Abduction, forward flexion, internal rotation, and Simple Shoulder Test, Constant, American Shoulder and Elbow Surgeons, University of California-Los Angeles, Shoulder Pain and Disability Index, and visual analog scale scores all showed statistically significant improvements greater than the minimum clinically important difference at the time of last follow-up. Three patients (5.8%) required revision surgery after a mean of 7.5 years and 1 more suffered an acromial stress fracture, bringing the total complication rate to 7.7%. Five patients (9.6%) demonstrated scapular notching, one of whom required revision arthroplasty. CONCLUSION RTSA provides clinically significant improvement in nearly all functional measures at a mean follow-up of 6.3 years in patients younger than 65 years. The implants appear to have good midterm survivorship; only 5.8% of patients required revision. BACKGROUND Radial head instability continues to be a challenge in the management of anterior Monteggia injuries; however, there is a paucity of literature on the factors that contribute to this instability. The aim of this biomechanical investigation was to examine the effects of ulnar angulation and soft tissue insufficiency on radial head stability in anterior Monteggia injuries. METHODS Six cadaveric arms were mounted in an elbow motion simulator. Radial head translation was measured during simulated active elbow flexion with the forearm supinated. After testing the elbows in the intact state, the ulna was osteotomized and tested at 0°, 10°, 20°, and 30° of extension angulation. To examine the effect of soft tissue insufficiency, the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane (IOM) were sequentially sectioned. RESULTS There was a significant increase in anterior radial head translation with greater ulnar extension angulation. Sequential soft tissue sectioning also significantly increased anterior radial head translation. There was no increase in radial head translation with isolated sectioning of the anterior radiocapitellar joint capsule. Additional sectioning of the annular ligament and quadrate ligament slightly increased anterior radial head translation but did not reach statistical significance. Subsequent sectioning of the proximal and middle IOM resulted in significant increases in anterior radial head translation. CONCLUSION Our study demonstrates that progressive ulnar extension angulation results in an incremental increase in anterior radial head translation in anterior Monteggia injuries. Moreover, increasing magnitudes of soft tissue disruption result in greater anterior radial head instability. BACKGROUND The purpose of this study was to compare long-term outcomes, complications, and reoperation rates of primary reverse total shoulder arthroplasty (RTSA) performed at a single institution using 2 implant designs a Grammont medialized prosthesis (medialized [M] group) and a Frankle glenoid-based lateralized prosthesis (glenoid-lateralized [GL] group). METHODS Between 2004 and 2008, 100 consecutive single-institution primary RTSAs were performed by reconstructive shoulder surgeons who were not design consultants, with the aim of obtaining 10-year follow-up 56 in the M group and 44 in the GL group. Patients were followed up until death, until revision surgery, or for a minimum of 10 years. RESULTS Of 100 patients, 87 had more than 2 years' follow-up (mean, 77 months). A subset analysis of 41 patients with an average of 10.2 years' follow-up showed sustained long-term outcomes. RTSA provided clinical improvements without significant differences between the M and GL groups, except for improved active forward elevation in the M group (144° in M group vs. 115° in GL group, P = .002). Reoperation was required in 6 shoulders (10-year cumulative incidence of 3 [5%] in M group vs. 3 [8%] in GL group) for a total of 16 complications (10-year cumulative incidence of 8 [14%] in M group vs. 8 [20%] in GL group). Notching rates were significantly higher in the M group (77% in M group vs. 47% in GL group, P = .013); differences in severe notching (grade 3 or 4) were clinically relevant but did not reach statistical significance (23% in M group vs. 9% in GL group, P = .22). CONCLUSION Primary RTSA using these first 2 prosthesis designs was associated with good outcomes and low reoperation (5%-8%) and complication (14%-20%) rates at 10 years. The M group had higher rates of notching. These results may provide a benchmark for comparison with newer implants, especially considering that these results include the early RTSA implantation learning curve. Established rheumatoid arthritis (RA) is a term used to distinguish patients with longer disease duration versus early RA or undifferentiated arthritis that may progress to RA. Although, there is no uniform definition for early disease, a cut-off of 2 years is used in most clinical trials and observational studies. In the evaluation of established RA, clinicians should incorporate a comprehensive set of measures addressing (1) disease activity, especially inflammation that may benefit of intensification of therapy, (2) health status, (3) comorbidities, and (4) damage. Ideally, measures should include the patient and physician perspectives and be feasible, reliable, valid and sensitive to change. Traditionally, measures have been incorporated in clinical research, but it would be worthwhile to integrate them into routine care. Data collection systems adapted to rheumatologists needs, could advance care for individual patients and facilitate large observational studies to evaluate interventions for the whole spectrum of RA.