Consistency in the Distribution of Bethesda System for Reporting Thyroid Cytology Categories Over 9 Years: A Single Institute, Retrospective Study

BACKGROUND

The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) has evolved since it was first introduced in 2009 to become a worldwide accepted cytologic analysis reference, due to its simplicity and reproducibility. To date, the consistency of BSRTC throughout time has yet to be investigated.

METHODS

Retrospective single institution case series with chart review of all patients who underwent fine-needle aspirations for a thyroid nodule in our institution between the years 2010 and 2018 with a documented BSRTC classification. Data collection included demographics, risk factors, sonographic evaluation, nodule size, and final pathology when feasible. The main outcome is the difference in the rates of BSRTC categories benign, atypia of undetermined significance (AUS), follicular neoplasm, suspicious for malignancy, and malignant (BSRTC II-VI, respectively) between the study years.

RESULTS

A total of 2830 thyroid nodules were included. BSRTC II-VI distribution was 83.9% (2373), 8.2%, (232), 2.7% (75), 3.3% (93), and 2.0% (57), respectively. There was no significant change in the overall trend of each BSRTC category distribution throughout the study. There was a significant increase in the benign cytology rate (BSRTC II) in 2011 compared to 2015 and 2018 (76.4% compared to 88.7% and 87.6%, respectively. P < .005) alongside a significant decline in the AUS category rate (BSRTC III) between the same years (13.0% compared to 4.8% and 5.5%, respectively. P < .005).

CONCLUSION

BSRTC showed consistency throughout the study across all observed categories. An overlap between AUS and benign may exist, possibly due to the heterogenic definition of AUS as reflected in the 2023 BSRTC subclassification for AUS.

Outcomes of abscess tonsillectomy in patients awaiting tonsillectomy: A comparison with interval tonsillectomy

PURPOSE

Peritonsillar abscesses (PTA) occasionally occur in patients who have a concurrent history of recurrent tonsillitis or prior PTA episodes. These patients sometimes meet the indications for elective tonsillectomy even prior to the current PTA event. Abscess ("Quinsy") tonsillectomy (QT) could serve as definitive treatment in this specific subgroup, though it is not performed often. The purpose of this study was to compare the perioperative outcomes between immediate QT and tonsillectomy performed several days (delayed QT) or weeks (Interval tonsillectomy, IT) after incision and drainage (I&D) of the PTA in this specific subgroup.

MATERIALS AND METHODS

A retrospective perioperative outcomes analysis of patients undergoing tonsillectomy (2002-2022) compared QT to delayed QT and IT in patients with PTA meeting AAO-HNS elective tonsillectomy criteria.

RESULTS

110 patients were included: 55 underwent IT, 36 underwent delayed QT, and 19 underwent immediate QT. Postoperative hemorrhage rates were 14.5 %, 11.1 %, and 5.3 % for IT, delayed QT, and immediate QT, respectively (P = 0.08). Mean hospitalization durations were 7.98, 6.92, and 5.37 days for IT, delayed QT, and immediate QT, respectively (P < 0.01). IT had a higher readmission rate due to pain compared to QT (14.5 % vs. 1.9 %, p = 0.032).

CONCLUSION

Immediate QT in PTA patients eligible for elective tonsillectomy is associated with lower postoperative hemorrhage, shorter admission time, and potentially reduced postoperative pain compared to I&D and delayed or interval tonsillectomy. These findings suggest that immediate QT should be considered as a primary treatment in this subgroup of eligible patients.

Evaluation of the Whiteout During Fiberoptic Endoscopic Evaluation of Swallowing and Examination of Its Correlation with Pharyngeal Residue and Aspiration

To evaluate the whiteout duration (WOd) and intensity (WOi) during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and examine their correlation with each other and age, gender, bolus consistencies, residue, and aspiration. Retrospective review of 75 videorecorded FEES. The first swallow of each of the following were scored: "Empty" swallow, semisolids, solids, and liquids (International dysphagia diet standardization initiative (IDDSI) 4, 7, 0, respectively). Data scored for each swallow included WOd, WOi, Penetration and aspiration scale (PAS), Pharyngeal residue (Yale Pharyngeal Residue Severity Rating Scale, YPR-SRS), and saliva pooling (Murray Secretion scale, MSS). The highest PAS and YPR-SRS for each consistency during the entire examination were also collected. WOd was significantly longer for stronger WOi in IDDSI4 swallows (p = 0.019). WOi was weaker for IDDSI0 swallows compared to IDDSI7, IDDSI4, and empty swallows (p < 0.05). Patients with saliva pooling had significantly shorter WOd (0.81 ± 0.3 s for MSS = 0 vs. 0.62 ± 0.24 for MSS = 3, p = 0.04). Lower WOi was associated with higher mean age for IDDSI0 (mean ages of 73 ± 12, 64 ± 14, 73 ± 7, 59 ± 16 years for intensity levels 1-4 respectively, p = 0.019). Swallows with weaker WOi and longer WOd had significantly more aspirations in IDDSI7 (28.8% of PAS ≥ 6 for intensity 2 vs 0% for intensity 4, p = 0.003 and 0.77 ± 0.4 s for PAS 1-2 vs. 1.02 ± 0.08 for PAS 6-8, p = 0.049). WOi and WOd are significantly associated with each other. WOi may vary for different bolus consistencies and decreases with age. Longer WOd and weaker WOi are associated with penetration-aspiration. Shorter WOd is associated with saliva pooling.

A Novel Trans-Tracheostomal Retrograde Inhalation Technique Increases Subglottic Drug Deposition Compared to Traditional Trans-Oral Inhalation

Subglottic stenosis represents a challenging clinical condition in otolaryngology. Although patients often experience improvement following endoscopic surgery, recurrence rates remain high. Pursuing measures to maintain surgical results and prevent recurrence is thus necessary. Steroids therapy is considered effective in preventing restenosis. Currently, however, the ability of trans-oral steroid inhalation to reach and affect the stenotic subglottic area in a tracheotomized patient is largely negligible. In the present study, we describe a novel trans-tracheostomal retrograde inhalation technique to increase corticosteroid deposition in the subglottic area. We detail our preliminary clinical outcomes in four patients treated with trans-tracheostomal corticosteroid inhalation via a metered dose inhaler (MDI) following surgery. Concurrently, we leverage computational fluid-particle dynamics (CFPD) simulations in an extra-thoracic 3D airway model to gain insight on possible advantages of such a technique over traditional trans-oral inhalation in augmenting aerosol deposition in the stenotic subglottic region. Our numerical simulations show that for an arbitrary inhaled dose (aerosols spanning 1–12 µm), the deposition (mass) fraction in the subglottis is over 30 times higher in the retrograde trans-tracheostomal technique compared to the trans-oral inhalation technique (3.63% vs. 0.11%). Importantly, while a major portion of inhaled aerosols (66.43%) in the trans-oral inhalation maneuver are transported distally past the trachea, the vast majority of aerosols (85.10%) exit through the mouth during trans-tracheostomal inhalation, thereby avoiding undesired deposition in the broader lungs. Overall, the proposed trans-tracheostomal retrograde inhalation technique increases aerosol deposition rates in the subglottis with minor lower-airway deposition compared to the trans-oral inhalation technique. This novel technique could play an important role in preventing restenosis of the subglottis.

The impact of birth weight and gestational age on acute mastoiditis in children

OBJECTIVE

Previous data correlate preterm and low birth weight (LBW) with acute otitis media, but there is a gap concerning the relations with acute mastoiditis (AM). This study investigates the effect of LBW and preterm birth on AM disease severity, neuro-otological complications, and recurrence.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary medical center.

METHODS

The cohort is retrospective in nature consisting of 294 children with AM admitted between 1999 and 2020. Data collection included: patient gestational age and birth weight, signs and symptoms, physical examination, laboratory tests, imaging findings, and long-term outcomes.

RESULTS

294 cases of AM were included, 41/281 (15%) had LBW (< 2500 g), and 46/294 (15.7%) were preterm (gestational age < 37 weeks). We found no significant differences in laboratory tests, imaging studies (CT), rate of mastoidectomy performed, or late complications between LBW and normal birth weight (NBW) and between preterm and normal gestational age children. LBW children tended to develop AM at an older age compared with NBW children, 2.28 + 1.64 Vs. 1.84 + 1.4 years, respectively (p-value = 0.016). Additionally, preterm children were more prone to develop a second event of AM, with a shorter interval between these episodes.

CONCLUSIONS

LBW and preterm birth are not independent risk factors for disease severity, need for intervention, or future complications in AM. Yet, LBW children present with AM at an older age, and preterm children are more prone for recurrent episodes of AM with a shorter interval between episodes suggesting a distinct disease course in these populations.

Post-hemithyroidectomy Pregnancy Thyroid Function Surveillance - Frequency, Adherence and Guideline Impact

OBJECTIVE

Post-hemithyroidectomy women are at increased risk for gestational subclinical hypothyroidism. Therefore, the American Thyroid Association (ATA) recommends increased thyroid function surveillance for this subgroup of pregnant women. The Purpose of this study was to evaluate the frequency of thyroid function surveillance during pregnancy in post-hemithyroidectomy women, and to evaluate the adherence to the 2017 ATA guidelines and its possible impact since being published, on thyroid function surveillance rates.

METHODS

A retrospective study including all pregnancies conceived by post-hemithyroidectomy women operated at our institution between the years 1997-2020. The study cohort was subdivided by pregnancy date prior to 2018 and 2018 and onwards to evaluate the impact of the 2017 ATA guidelines. Adherence to the guidelines was defined as at least one TSH test in each trimester.

RESULTS

After exclusions, a total of 120 pregnancies conceived by 66 women who underwent hemithyroidectomy surgeries were included in this study. Overall, serum TSH examinations were performed during the first, second and third pregnancy trimesters in 86.6%, 40% and 16.6% of pregnancies (P<0.005), respectively. The examination rate since 2018 was 88%, 40% and 8% for first, second and third trimester, respectively (P<0.005).

CONCLUSION

Adherence to the latest ATA guidelines is low and its publication in 2017 did not increase the thyroid function surveillance rate in post-hemithyroidectomy women. Better patient education regarding the risks of gestational hypothyroidism following hemithyroidectomy and improved communications between treating surgeons, obstetricians, and endocrinologists may improve these rates.

Thickness measurements taken with the spectralis OCT increase with decreasing signal strength

BACKGROUND

Optical coherence tomography (OCT) is used worldwide by clinicians to evaluate macular and retinal nerve fiber layer (RNFL) characteristics. It is frequently utilized to assess disease severity, progression and efficacy of treatment, and therefore must be reliable and reproducible.

OBJECTIVE

To examine the influence of signal strength on macular thickness parameters, macular volume measurement and RNFL thickness measured by spectral-domain optical coherence tomography (SD-OCT).

METHODS

Macular thickness parameters, macular volume measurement and RNFL thickness were measured by the Spectralis® OCT (Heidelberg Engineering, Heidelberg, Germany). In each eye, the focusing knob was adjusted to obtain 4 images with different signal strengths - Low (below 15), Moderate (15-20), Good (20-25) and Excellent (above 25). The relationship between signal strength and measured data was assessed using the mixed model procedure.

RESULTS

A total of 71 eyes of 41 healthy subjects were included. Central macular thickness, macular volume and mean RNFL thickness increased with decreasing signal strength. Specifically, eyes with excellent signal strength showed significantly thinner central macular thickness (p = 0.023), macular volume (p = 0.047), and mean RNFL thickness (p = 0.0139).

CONCLUSIONS

Higher signal strength is associated with lower macular thickness, macular volume and RNFL thickness measurements. The mean differences between excellent and low-quality measurements were small implicating that SD-OCT is a reliable imaging tool even at low quality scans. It is imperative that the physician compares the signal strength of all scans, as minute differences may alter results.

Retinal Vascular Signs as Screening and Prognostic Factors for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Current Evidence

BACKGROUND

The substantial burden of kidney disease fosters interest in new ways of screening for early disease diagnosis, especially by non-invasive imaging. Increasing evidence for an association between retinal microvascular signs and kidney disease prompted us to investigate the relevant current literature on such an association systematically by performing a meta-analysis of our findings.

METHODS

We scrutinized the current literature by searching PubMed and Embase databases from for clinical studies of the association between retinal microvascular signs and prevalent or incident kidney disease. After excluding cases that did not meet our criteria, we extracted relevant data from 42 published studies (9 prospective, 32 cross-sectional, and 1 retrospective).

RESULTS

Our investigation yielded significant associations between retinal vascular changes (including retinopathy and retinal vascular diameter) and kidney dysfunction (including chronic kidney disease (CKD), end-stage renal disease (ESRD), albuminuria, and estimated glomerular filtration rate (eGFR) decline). According to our meta-analysis, retinopathy was associated with ESRD (hazard ratio (HR) 2.12 (95% confidence interval CI; 1.39-3.22)) and with CKD prevalence in the general population (odds ratio (OR) 1.31 (95% CI; 1.14-1.50)), and specifically in type 2 diabetic patients (OR 1.68 (95% CI; 1.68-2.16)). CRAE was associated with prevalent CKD (OR 1.41 (95% CI; 1.09-1.82)).

CONCLUSIONS

Our findings suggest that the retinal microvasculature can provide essential data about concurrent kidney disease status and predict future risk for kidney disease development and progression.

Previous Military Medical Exposure as a Motivator for a Medical Career

INTRODUCTION

A variety of factors influence the motivation to choose a medical career; however, the influence of premedical experiences on health professional trainees' choices is a neglected one. We hypothesize that medical exposure during service in the Israeli Air Force special operations forces (SOFs) has an impact on motivation for medical studies. The Israeli scenario, in which career choice is anteceded by substantial military experience, allows us to examine this hypothesis.

MATERIALS AND METHODS

We conducted a retrospective cohort study among physicians and medical students who served as operators in the Israeli Air Force SOF; Unit 669 (an airborne combat search and rescue unit), and Shaldag (an airborne SOF unit). All medical students and physicians enlisted between January 2001 and December 2010 were eligible for enrollment.

RESULTS

Of over 700 operators screened, 3.7% of Shaldag veterans and 11.1% of Unit 669 veterans had started or finished medical school (P-value < 0.001). Overall, 49 veterans answered the questionnaire and enrolled in the study, of whom 17 (34.7%) were Shaldag veterans and 32 (65.3%) were Unit 669 veterans. Subjective questions implied a significant effect of the service in Unit 669 on career choice. Paramedics had a relative risk of becoming physicians of 7.37 when compared to nonparamedic operators, irrespective of their original unit.

CONCLUSIONS

Medical exposure of Unit 669 operators during military service significantly contributed to their motivation for becoming physicians. Thus, military service in this setting acts de facto as an effective medical immersion program. This adds another factor to the myriad of factors that motivate young adults in their choice of a medical career.

Radial head excision and Achilles allograft interposition arthroplasty for the treatment of chronic pediatric radiocapitellar pathologies: A report of four cases

BACKGROUND

Severe radiocapitellar pathologies represent a unique problem in the pediatric population, as radial head excision can lead to substantial long-term complications. We present a case series of four pediatric patients treated by a novel technique-radial head excision followed by Achilles allograft interposition arthroplasty.

METHODS

Four children (ages 12-15 years) are described. Their clinical and radiographic outcomes were assessed by a visual analog scale, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder and Hand questionnaire, grip strength, and range of motion.

RESULTS

At a mean follow-up of two years, the average flexion-extension arc of motion improved from 107° to 131°, and the rotation arc improved from 100° to 154°. The average visual analog scale, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand scores were 2, 92.5, and 11.5, respectively. Two patients required subsequent additional procedures-manipulation under anesthesia and ulnar shortening osteotomy. Proximal migration of the radius was observed in three out of the four patients.

DISCUSSION

Combined radial head excision and Achilles allograft interposition arthroplasty represents a viable option for the treatment of chronic pediatric radiocapitellar pathologies, with good results in terms of clinical and functional outcomes as well as patient satisfaction in the short-medium term.

Retinal Microvascular Signs as Screening and Prognostic Factors for Cardiac Disease: A Systematic Review of Current Evidence

The substantial burden of heart disease promotes an interest in new ways of screening for early disease diagnosis, especially by means of noninvasive imaging. Increasing evidence for association between retinal microvascular signs and heart disease prompted us to systematically investigate the relevant current literature on the subject. We scrutinized the current literature by searching PubMed and Embase databases from 2000 to 2020 for clinical studies of the association between retinal microvascular signs and prevalent or incident heart disease in humans. Following exclusions, we extracted the relevant data from 42 publications (comprising 14 prospective, 26 cross-sectional, and 2 retrospective studies). Our search yielded significant associations between retinal vascular changes, including diameter, tortuosity, and branching, and various cardiac diseases, including acute coronary syndrome, coronary artery disease, heart failure, and conduction abnormalities. The findings of our research suggest that the retinal microvasculature can provide essential data about concurrent cardiac disease status and predict future risk of cardiac-related events.

Combined trans-stomal endotracheal approach to peri-stomal tracheal pathologies in children

IMPORTANCE

Peristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved.

OBJECTIVE

We evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies.

METHODS

The medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed.

RESULTS

In total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure.

CONCLUSION

Combined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies.

Long-term Outcomes for Revision Endoscopic Dacryocystorhinostomy-The Effect of the Primary Approach

OBJECTIVES/HYPOTHESIS

Revision endoscopic dacryocystorhinostomy (END-DCR) is the preferred approach for failed primary surgeries, yet quality data on long-term outcomes are lacking. This study aimed to evaluate three aspects of revision END-DCR: 5-year success rates, patient satisfaction, and the primary surgical approach's possible impact on revision.

METHODS

This retrospective study included all revision END-DCRs conducted at Kaplan Medical Center between the years 2002 and 2015. For long-term follow-up analysis, two subgroups of first and second revision END-DCRs with a minimum of documented 5-year follow-up after surgery were defined. Data were analyzed according to the primary surgical approach. Surgical success was defined by either anatomical (observed patent lacrimal flow) or functional (symptoms cessation) success. Patient satisfaction was measured by a questionnaire.

RESULTS

After exclusions, a total of 45 eyes from 38 patients who underwent revision END-DCR surgeries were included in the study. The yearly success rates from immediate to 5 years following the first revision were 93.3%, 75.5%, 71.1%, 68.9%, 68.9%, and 68.9% for the entire cohort, respectively. Immediate and 5-year success rates following the second revision were 88.8% and 77.8%, respectively. Primary END-DCR showed favorable 5-year success rates and patient satisfaction over primary external dacryocystorhinostomy (EXT-DCR) in both first and second revisions, but this did not reach significance.

CONCLUSIONS

Revision END-DCR carries an excellent short-term success rate, which decreases mainly throughout the first 2 years following surgery. Postoperative follow-up should be maintained within this timeframe. Revision END-DCR following either primary endoscopic or EXT-DCR produces comparable surgical outcomes and patient-reported satisfaction.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:E682-E688, 2021.

Assessment of the Frequency of Online Searches for Symptoms Before Diagnosis: Analysis of Archival Data

Background

Surveys suggest that a large proportion of people use the internet to search for information on medical symptoms they experience and that around one-third of the people in the United States self-diagnose using online information. However, surveys are known to be biased, and the true rates at which people search for information on their medical symptoms before receiving a formal medical diagnosis are unknown.

Objective

This study aimed to estimate the rate at which people search for information on their medical symptoms before receiving a formal medical diagnosis by a health professional.

Methods

We collected queries made on a general-purpose internet search engine by people in the United States who self-identified their diagnosis from 1 of 20 medical conditions. We focused on conditions that have evident symptoms and are neither screened systematically nor a part of usual medical care. Thus, they are generally diagnosed after the investigation of specific symptoms. We evaluated how many of these people queried for symptoms associated with their medical condition before their formal diagnosis. In addition, we used a survey questionnaire to assess the familiarity of laypeople with the symptoms associated with these conditions.

Results

On average, 15.49% (1792/12,367, SD 8.4%) of people queried about symptoms associated with their medical condition before receiving a medical diagnosis. A longer duration between the first query for a symptom and the corresponding diagnosis was correlated with an increased likelihood of people querying about those symptoms (rho=0.6; P=.005); similarly, unfamiliarity with the association between a condition and its symptom was correlated with an increased likelihood of people querying about those symptoms (rho=−0.47; P=.08). In addition, worrying symptoms were 14% more likely to be queried about.

Conclusions

Our results indicate that there is large variability in the percentage of people who query the internet for their symptoms before a formal medical diagnosis is made. This finding has important implications for systems that attempt to screen for medical conditions.

Association between Functional Outcomes and Radiographic Reduction Following Surgery for Distal Radius Fractures

Background: Quality of reduction in distal radius fractures (DRF) is assessed using radiographic parameters, however few studies examine the association between radiographic measurements and functional outcomes. Our purpose was to evaluate the relationship between radiographic measurements and clinical outcome measures following surgery for DRF using detailed testing to demonstrate further associations between post-surgical radiographic measurements and function.

Methods: Measurements were performed on postoperative radiographs of 38 patients following ORIF of DRF. Measurements included: radial inclination, radial height, ulnar variance, volar tilt, radiocarpal interval (d2/w2), and the intra-articular step-off. Clinical outcome measures included motion, grip strength, functional dexterity testing, Moberg pick-up test, specific activities of daily living, DASH score, pain scale, manual-assessment questionnaire.

Results: Different radiographic parameters correlated with different specific tasks. The parameter correlated with most functional tasks was ulnar-variance. Radial inclination, radial-styloid scaphoid distance, and fracture classification correlated with some functions. Intraarticular step-off, and radial height were not associated with functional testing.

Conclusions: Surgical radiographic results may affect post-operative function. Detailed task specific testing may enable a better evaluation of surgical outcomes. Further study and refinement of functional assessment may change our surgical goals in DRF.

Postoperative Treatment of Distal Radius Fractures Using Sensorimotor Rehabilitation

Background  Sensorimotor and specifically proprioception sense has been used in rehabilitation to treat neurological and joint injuries. These feedback loops are not well understood or implemented in wrist treatment. We observed a temporary sensorimotor loss, following distal radius fractures (DRF) that should be addressed postsurgery. Purpose  The purpose of this prospective therapeutic study was to compare the outcomes of patients following surgery for DRF treated using a sensorimotor treatment protocol with those patients treated according to the postoperative standard of care. Patients and Methods  Patients following surgery for DRF sent for hand therapy were eligible for the study. Both the evaluation and treatment protocols included a comprehensive sensorimotor panel. Patients were randomized into standard and standard plus sensorimotor postoperative therapy and were evaluated a few days following surgery, at 6 weeks, and 3 months postsurgery. Results  Sixty patients following surgery were randomized into the two treatment regimens. The initial evaluation was similar for both groups and both demonstrated significant sensorimotor deficits, following surgery for DRF. There was documented sensorimotor and functional improvement in both groups with treatment. The clinical results were better in the group treated with the sensorimotor-proprioception protocol mostly in the wrist; however, not all of the differences were significant. Conclusion  Patients after surgery for DRF demonstrate significant sensorimotor deficits which may improve faster when utilizing a comprehensive sensorimotor treatment protocol. However, we did not demonstrate efficacy of the protocol in treating proprioceptive deficits. Further study should include refinement of functional outcome evaluation, studying of the treatment protocol, and establishment of sensorimotor therapeutic guidelines for other conditions. Level of Evidence This is a level II, therapeutic study.

A Comparison of Locking Plates and Intramedullary Pinning for Fixation of Metacarpal Shaft Fractures

BACKGROUND

Metacarpal shaft fractures that necessitate surgery are frequently fixated with either intramedullary pins or plates and screws. This study compared outcome measurements of these two techniques.

METHODS

Patients operated on for closed shaft fractures of metacarpals 2-5 were examined at least 1 year after injury. All fractures were fixated by pinning between years 2013 and 2015 and by locking plates and screws between 2016 and 2017. Evaluation included range of motion measurements for all fingers compared with the contralateral hand; comparison of grip strength; finger alignment and rotation; Disabilities of the Arm, Shoulder and Hand (DASH) score; and radiographic measurements of fracture reduction and healing.

RESULTS

Thirty patients with 39 fractured metacarpals treated by pinning were compared with 29 patients with 35 fractured metacarpals treated by locking plate and screws. Both groups had similar characteristics and preoperative fracture patterns on radiograph. Patients in the plate group were found to have significantly improved outcomes in total range of motion of the operated digits (loss of 4° extension, 10° flexion, and 14° total vs 10° extension, 19° flexion, and 29° total), grip strength (93% vs 83% of contralateral hand), rotational deformity (5 digits, 1° vs 15 digits, 6°), and DASH score (10.5 vs 15.6). Radiographic bone healing time (59 vs 50 days) and operative time (58 vs 41 minutes) were both significantly longer in fractures fixated by plates.

CONCLUSIONS

Fixation with locking plates allows earlier mobilization without need for splinting. Our study supports the use of this method over intramedullary pinning for metacarpal shaft fractures.

How to Best Predict Fragility Fractures: An Update and Systematic Review

Because fragility fractures have an enormous impact on the practice of medicine and global health systems, effective screening is imperative. Currently, dual-energy X-ray absorptiometry (DXA), which has limited ability to predict fractures, is being used. We evaluated the current literature for a method that may constitute a better screening method to predict fragility fractures. A systematic review of the literature was conducted on computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound to evaluate screening methods to predict fragility fractures. We found that ultrasound had sufficient data on fracture prediction to perform meta-analysis; therefore, we analyzed prospective ultrasound cohort studies. Six study populations, consisting of 29,299 individuals (87,296 person-years of observation) and including 992 fractures, were analyzed. MRI was found to be sensitive and specific for osteoporosis, but its use for screening has not been sufficiently evaluated and more research is needed on cost, accessibility, technical challenges, and sensitivity and specificity. CT could predict fracture occurrence; however, it may be problematic for screening due to cost, exposure to radiation, and availability. Ultrasound was found to predict fracture occurrence with an increased risk of 1.45 (95% confidence interval 1.21-1.73) to fracture. Ultrasound has not replaced DXA as a screening tool for osteoporosis, perhaps due to operator-dependency and difficulty in standardization of testing.

Distinct Wrist Patterns Founded on Measurements in Plain Radiographs

Background  In joints, structure dictates function and consequently pathology. Interpreting wrist structure is complicated by the existence of multiple joints and variability in bone shapes and anatomical patterns in the wrist. Previous studies evaluated lunate and capitate shape in the midcarpal joint, and two distinct patterns have been identified. Purpose  Our purpose was to further characterize the two wrist patterns in normal wrist radiographs using measurements of joint contact and position. Our hypothesis was that we will find significant differences between the two distinct anatomical patterns. Patients and Methods  A database of 172 normal adult wrist posteroanterior (PA) radiographs was evaluated for radial inclination, height, length, ulnar variance, volar tilt, radial-styloid-scaphoid distance, and lunate and capitate types. We measured and calculated percent of capitate facet that articulates with the lunate, scapholunate ligament, scaphoid, and trapezoid. These values were compared between the wrist types and whole population. Results  Type-1 wrists (lunate type-1 and spherical proximal capitate) were positively associated with a longer facet between capitate and distal lunate ( p  = 0.01), capitate and base of middle metacarpal ( p  = 0.004), and shorter facet between the capitate and hamate ( p  = 0.004). The odds ratio of having a type-1 wrist when the interface between the capitate and lunate measures >8.5 mm is 2.71 (confidence interval [CI] 1.07, 6.87) and when the line between the capitate and the base of middle metacarpal >9.5 mm is 3.5 (CI 1.38, 9.03). Conclusion  We characterized the two-wrist patterns using intracarpal measurements. Translating these differences into three-dimensional contact areas may help in the understanding of biomechanical transfer of forces through the wrist. Level of Evidence  This is a Level II, diagnostic study.

Rosmarinic Acid Restores Complete Transparency of Sonicated Human Cataract Ex Vivo and Delays Cataract Formation In Vivo

Cataract, the leading cause of vision impairment worldwide, arises from abnormal aggregation of crystallin lens proteins. Presently, surgical removal is the only therapeutic approach. Recent findings have triggered renewed interest in development of non-surgical treatment alternatives. However, emerging treatments are yet to achieve full and consistent lens clearance. Here, the first ex vivo assay to screen for drug candidates that reduce human lenticular protein aggregation was developed. This assay allowed the identification of two leading compounds as facilitating the restoration of nearly-complete transparency of phacoemulsified cataractous preparation ex vivo. Mechanistic studies demonstrated that both compounds reduce cataract microparticle size and modify their amyloid-like features. In vivo studies confirmed that the lead compound, rosmarinic acid, delays cataract formation and reduces the severity of lens opacification in model rats. Thus, the ex vivo assay may provide an initial platform for broad screening of potential novel therapeutic agents towards pharmacological treatment of cataract.

[CRITICAL EVALUATION OF THE ABILITY TO DIAGNOSE PERIPROSTHETIC INFECTION IN A MEDICAL SYSTEM IN ISRAEL]

INTRODUCTION

Prosthetic joint infection is a dangerous complication of joint replacement arthroplasty. Besides its catastrophic consequences, differentiating a deep infection from other complications is not always trivial due to lack of clinical signs of infection, inaccurate tests, lab-dependent analysis, variable normal values and ongoing dispute in the literature regarding the recommended diagnosis algorithm.

AIMS

The purpose of this study was to examine the diagnosis algorithm in our medical center.

METHODS

We reviewed all patients who underwent hip or knee replacement and developed prosthetic joint infection between January 2005 and December 2012. The data collected included the patient's demographics, lab and imaging results such as white blood cells (WBC) and C reactive protein (CRP) levels in serum, as well as leukocytes scan and microbiological culture results. In addition, our diagnosis algorithm was compared to those suggested in the literature.

RESULTS

Out of 1142 patients who underwent knee or hip replacement arthroplasty, we included 34 patients (2.97%) who were diagnosed with prosthetic joint infection, including 21 knee joints (61.8%) and 13 hip joints (38.2%). Twelve patients (35.3%) had a positive culture, six (50%) grew a gram-negative bacterium. In addition, a significant association was found between CRP levels in the serum at diagnosis, hospital release and at 1 month post hospitalization (p<0.0001).

DISCUSSION

The study raises questions in regards to the diagnostic technique used and suggests it may lead to under-diagnosis, maltreatment and inefficient use of resources. We suggest evaluating these algorithms in other departments.

Emergency Department waiting times in a tertiary children's hospital in Israel: a retrospective cohort study

Background

The purpose of this study was to assess ethnic differences in Emergency Department (ED) waiting times between Jewish and Arab children in a tertiary childrens’ hospital in Israel.

Methods

This was a retrospective cohort study of all children who were admitted to the pediatric ED of the largest hospital in northern Israel, between January 2011 and December 2015. Univariate and multivariate analyses were used to assess the strength of association between ethnicity category and waiting time. The following were tested as possible confounders: triage category, age, gender, time of arrival category. The effect of nurse-patient ethnic concordance was assessed.

Results

Full data were available in 82,883 patients, 55,497 (67.0%) Jews and 27,386 (33.0%) Arabs. Jews and Arabs had a similar median waiting time of 38 min (interquartile range [IQR] 22–63 and IQR 21–61, respectively). Ethnicity was not associated with a change in waiting time (p = 0.36). Factors that most influenced shorter waiting time were triage category 1 (change in waiting time: −25.5%; 95% confidence interval [CI]: −29.3 to −21.7), or triage category 2 (change in waiting-time: −21.8%; 95% CI: -23.7 to −20.05). Factors that most influenced longer waiting time were patient arrival during the morning shift period (change in waiting time: 5.45%; 95% CI: 4.59 to 6.31), or during the evening shift period (change in waiting time: 4.46%; 95% CI: 3.62 to 5.29). Ethnic discordance between triage nurses and patients did not yield longer waiting times.

Conclusion

In this large pediatric cohort, ethnic differences in ED waiting time were not found.

Anatomical Wrist Patterns on Plain Radiographs

BACKGROUND

Interpreting the structure in the wrist is complicated by the existence of multiple joints as well as variability in bone shapes and anatomical patterns. Previous studies have evaluated lunate and capitate shape in an attempt to understand functional anatomical patterns.

OBJECTIVE

The purpose of this study was to describe anatomical shapes and wrist patterns in normal wrist radiographs. We hypothesized that there is a significant relationship in the midcarpal joint with at least one consistent pattern of wrist anatomy.

METHODS

Seventy plain posteroanterior (PA) and lateral wrist radiographs were evaluated. These radiographs were part of a previously established normal database, had all been read by a radiologist as normal, and had undergone further examination by 2 hand surgeons for quality. Evaluation included: lunate and capitate shape (type 1 and 2 lunate shape according to the classification system by Viegas et al.), ulnar variance, radial inclination and height, and volar tilt.

RESULTS

A significant association was found between lunate and capitate shape using a dichotomal classification system for both lunate and capitate shapes (p=0.003). Type 1 wrists were defined as lunate type1and a spherical distal capitate. Type 2 wrists had a lunate type 2 and a flat distal capitate. No statistically significant associations were detected between these wrist types and measurements of the radiocarpal joint.

CONCLUSION

There was a significant relationship between the bone shapes within the midcarpal joint. These were not related to radiocarpal anatomical shape. Further study is necessary to better describe the two types of wrist patterns that were defined and to understand their influence on wrist biomechanics and pathology.

Intramedullary Screw and Kirschner Wire Fixation for Unstable Scaphoid Nonunion

Surgical treatment of scaphoid nonunion is not always successful, often requiring stabilization and bone grafting to achieve healing. Even after intramedullary screw fixation, residual instability may still hinder union. The purpose of this study was to describe the addition of Kirschner wires (KWs) through the capitate and the lunate to supplement an intramedullary screw for temporary enhanced stability, possibly improving healing of unstable fractures. A case-control study reviewing 25 cases with addition of KWs and 19 controls was performed. Demographic and fracture information, time to diagnosis, and healing time were documented. We found no differences in population characteristics, fracture characteristics, or outcome measures between patients treated with this method and those treated with a screw alone. We had no complications related to the addition of KWs. Preoperative lunate type and scapholunate gapping was suggestive but not significantly associated with KW insertion. Addition of KWs is safe and may be considered in scaphoid nonunion in the presence of intraoperative suboptimal stability. Intraoperative stability may possibly be inferred by reviewing preoperative radiographs for signs of instability.

Cloning and expression in Escherichia coli of an esterase-coding gene from the oil-degrading bacterium Acinetobacter calcoaceticus RAG-1

A putative esterase gene (est) from Acinetobacter calcoaceticus RAG-1 has been cloned into Escherichia coli. Esterase-positive clones exhibited high levels of esterase activity even in intact cells. In addition, expression of the est gene conferred on E. coli the ability to grow on simple triglycerides such as triacetin (TAC). The original esterase-positive plasmid pRA17 carried a 2.2-kb insert from a partial MboI digest of RAG-1 DNA, which gave a single band with RAG-1 DNA following Southern hybridization. By subcloning and sequencing the est gene was found to contain a sequence of 870 bp which could be translated to yield a protein of Mr 32,700. In support of the sequencing results was the finding that when pRA17 was expressed in minicells, a unique peptide of Mr 32,500 was identified. This peptide was not found in minicells transformed with esterase-negative plasmids, such as pRA176, which contained a Tn5 insertion in the est gene. The fact that the production of active esterase depended on the orientation of the est gene within the vector suggested that transcription proceeded from the tet promoter in pBR322.

EEG alpha reactivity and self-regulation correlates of smoking and smoking deprivation

Twelve nonsmokers, ten ex-smokers, ten deprived smokers (2-3 hours), and ten nondeprived smokers were exposed to a short-term (18-sec) vigilance task and underwent 6 min of biofeedback-assisted alpha amplitude enhancement and suppression training. Cigarette smoking was found to be associated with decreased alpha suppression to the vigilance task. However, no consistent role of cigarette smoking in alpha self-regulation emerged from the results.

Type A personality as psychopathology: personality correlates and an abbreviated scoring system

This study investigated the relationship between the Jenkins Activity Survey, a questionnaire developed to measure the Type A 'coronary-prone' personality described by Friedman and Rosenman, and other personality measures, comprising the Eysenck Personality Inventory, the Personal Deviance Scale, and a measure of Achievement Need. Significant correlations were obtained between Neuroticism and both the Type A scale, and the Speed and Impatience subscale of the J.A.S. The Type A scale was also found to correlate with Dominance and Extrapunitiveness, and the Speed and Impatience subscale correlated with Extrapunitiveness. No correlation was found between any J.A.S. scale and the measure of Achievement Need. When subjects were divided into Types A and B using the group mean as division point, significant differences in certain questionnaire variables, most noticeably in Neuroticism were apparent, with the Type A group being found significantly more Neurotic. Theoretical implications of this for susceptibility to stress-related disease were discussed. Additionally, the paper explored a briefer alternative to the complex, computerised scoring system for the J.A.S., and found this to correlate well with the weighted scoring system.

Conditional probabilities and the grid test for schizophrenic thought disorder

The grid test for schizophrenic thought disorder was administered to a sample of 149 psychiatric patients. This sample was drawn from a population with a known base rate of schizophrenia and an estimated base rate of thought disorder, thus allowing for the calculation of population specific cutting scores for the grid test. The grid test, using these data along with others from previous grid test studies, was then analysed for diagnostic efficiency using conditional probability formulae. The conclusion reached is that the grid test for schizophrenic thought disorder is unsatisfactory as a diagnostic instrument.

Intercorrelations of factor scores from the opinions about mental illness scale

The Opinions About Mental Illness Scale (OMI) was administered to 157 psychiatrists, residents, nurses, and aides from an urban, short-term psychiatric hospital. The 5 factor scores of the scale were intercorrelated; correlations were higher among factors and, in some cases, in different direction, than previous studies have reported. Differences among occupational groups were also found. Caution should be exercised in generalizing about relationships among OMI factors from one sample to another.