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In the setting of acetabular dysplasia, the increased translational motion of the femur may damage the labrum and cartilage, as well as stretch the capsule. The purpose of the study was to investigate the relationship between the acetabular coverage and the capsular stiffness by assessing the distension of anterior and posterior joint recesses on the hip computed tomography arthrography.One hundred thirty-three patients (138 hips) with a median age of 36 years (range 18-50 years) who received the computed tomography arthrography for evaluation of nonarthritic hip pain in our institute between 2015 and 2017 were retrospectively reviewed. The maximal distance between the anterior/posterior capsule and the anterior femoral head-neck junction/posterior femoral head on the axial imaging of computed tomography arthrography was defined as the width of anterior/posterior joint recess. The width of anterior/posterior joint recess was adjusted with the diameter of the femoral head and was then compared between acetabular dysplasia (lateral center-edge angle 25°), normal acetabulum (lateral center-edge angle between 25 and 39°), and deep acetabulum (lateral center-edge angle 39°). In addition, the standard univariate linear regression analysis was used to investigate the relationship between the adjusted width of anterior/posterior joint recess and anterior/posterior coverage of the hip, determined by the anterior/posterior wall index.The adjusted width of posterior joint recess was significantly greater in the acetabular dysplasia group than the normal acetabulum and deep acetabulum groups (p 0.01 and p = 0.02, respectively). There was no significant difference of the adjusted width of anterior joint recess between the groups (n.s.). The adjusted width of posterior joint recess had a significant but weak negative correlation with the anterior wall index (r = - 0.25, p 0.001), and no correlation with the posterior wall index (r = - 0.0004, n.s.). There was no significant correlation between the adjusted width of anterior joint recess and the anterior/posterior wall index (r = 0.05, n.s./r = 0.07, n.s.).The distension of posterior capsule on the computed tomography arthrography was significantly greater in acetabular dysplasia. In addition, there was a significant but weak negative correlation between the distension of posterior capsule and the anterior coverage of the hip. It indicated a looser posterior capsule was observed in a dysplastic hip. The relevance of posterior capsular laxity to clinical outcomes warrants further investigation. Given the fact that the distension of anterior capsule was not significantly higher in acetabular dysplasia, the need of anterior capsular plication in a dysplastic hip should be carefully evaluated.Level III.

Background Theta burst stimulation (TBS), a patterned repetitive transcranial magnetic stimulation (rTMS) protocol with shorter simulation duration and lower stimulus intensity, could be a better protocol for individuals with autism spectrum disorder (ASD). Our study aimed to explore the impacts of intermittent TBS (iTBS) over the bilateral posterior superior temporal sulcus (pSTS) on intellectually able adults with ASD. Material and methods In this randomized, single-blinded, sham-controlled crossover trial, 13 adults with ASD completed iTBS for 5 consecutive days over the bilateral pSTS and inion (as a sham control) in a 16-weeks interval and in a randomly assigned order. The neuropsychological function was measured with the Wisconsin Card Sorting Test (WCST) for cognitive flexibility while the clinical outcomes were measured with both self-rate and parents-rate Autism Spectrum Quotient (AQ) before and after 5-day iTBS interventions. Results The results revealed significantly immediate effects of multi-session iTBS over the bilateral pSTS on parent-rate autistic symptoms in adults with ASD. The post-hoc analysis revealed the impacts of multi-session iTBS on cognitive flexibility were affected by baseline social-communicative impairment and baseline cognitive performance. Besides, the impacts of multi-session iTBS on clinical symptoms was affected by the concurrent psychotropic medication use and baseline autistic symptoms. Conclusions Given the caveat of the small sample size and discrepancy of multiple informants, this pilot study suggests the therapeutic potential of 5-day multi-session iTBS over the pSTS in adults with ASD. Individual factors modulating the response to rTMS should be explicitly considered in the future trial.

The precise creation and control of osteotomy and distraction have been a problem in opening wedge high tibial osteotomy (OWHTO). This study aimed to investigate the impact of the cutting edge of a personalized surgical instrument (PSI) to control the distraction angle, tibial slope, and tibial twist of the distracted tibiae. This study correlated the PSI design with the results of biomechanical tests on wedge inclination (WI), saw progression (SP), and distraction site (DS) of the proximal tibiae, which were systematically varied and three-dimensionally (3D) printed as the specimens. The lateral hinge 3D orientation was determined by the WI and SP. Different DSs deviate from the hinged motion of the distracted tibiae to some extent. The coronal angle, which is the major OWHTO target, is more sensitive to the SP and DS. However, the concurrence of the sagittal and horizontal angles induces undesirable effects on knee biomechanics and potentially risks the lateral hinge. The cutting edge is a key design that serves as the cutting and sawing guide to control the initial cut on the medial tibia (i.e., WI) and the sawing path near the lateral cortex (i.e., SP). Intraoperative planning of manipulating the SP is the most effective method for adjusting the sagittal rotation. A higher WI angle is a determinant factor of the horizontal rotation that must be cautiously mitigated to reduce the risk of lateral hinge cracking and to adjust the patellofemoral contact.

Background To compare the outcomes of blunt splenic injuries (BSI) managed with proximal (P) versus distal (D) versus combined (C) splenic artery embolization (SAE). Methods This retrospective study included patients with BSI who demonstrated vascular injuries on angiograms and were managed with SAE between 2001 and 2015. The success rate and major complications (Clavien–Dindo classification ≥ III) were compared between the P, D, and C embolizations. Results In total, 202 patients were enrolled (P, n = 64, 31.7%; D, n = 84, 41.6%; C, n = 54, 26.7%). The median injury severity score was 25. The median times from injury to SAE were 8.3, 7.0, and 6.6 h for the P, D, and C embolization, respectively. The overall haemostasis success rates were 92.6%, 93.8%, 88.1%, and 98.1% in the P, D, and C embolizations, respectively, with no significant difference (p = 0.079). Additionally, the outcomes were not significantly different between the different types of vascular injuries on angiograms or the materials used in the location of embolization. Splenic abscess occurred in six patients (P, n = 0; D, n = 5; C, n = 1), although it occurred more commonly in those who underwent D embolization with no significant difference (p = 0.092). Conclusions The success rate and major complications of SAE were not significantly different regardless of the location of embolization. The different types of vascular injuries on angiograms and agents used in different embolization locations also did not affect the outcomes. Graphical abstract

Background Open-wedge high tibial osteotomy (OWHTO) has extensively been used for the correction of medial knee osteoarthritis. The proximal tibia is osteotomized and distracted to enable the rotation of tibial fragments around the lateral hinge. Both, wedge inclination on the medial side and saw progression near the lateral cortex determine the hinge orientation. This study focused on the interaction between hinge orientation and distraction sites on the coronal, sagittal, and horizontal planes of the distracted plateau. Methods Three parameters of wedge inclination, saw progression, and distraction site (i.e., posterior, middle, and anterior) were systematically varied. Using a three-dimensional (3D)-printing technique, the osteotomized tibiae were manufactured as the specimens for the in vitro experiments. In total, 27 variations (3 × 3 × 3) were tested. After distraction, the specimens were scanned by computed tomography and spatially registered with the original tibia to compare the 3D angles of the distracted plateaus. Results Coronal rotation is the main purpose of OWHTO; therefore, all the values of the coronal angles were positive and significantly higher than the other two. The sagittal and horizontal angles had relatively similar values. Distraction in the middle site seems to have the least impact on sagittal rotation. Large angles of hinge orientation show the superior ability in adjusting the sagittal rotation than small angles. However, the larger the horizontal angles the greater the wedge inclination. Conclusions The wedge inclination, saw progression, and distraction site constitute a complex mechanism that affects 3D rotations of the distracted plateau. The coronal angles are sensitive to hinge orientation and distraction site. The intraoperative planning of manipulating hinge orientation is an effective method to adjust sagittal rotation. A large angle of wedge inclination is an indicator of horizontal rotation, and it should be carefully mitigated to reduce the risk of cracking in the lateral hinge.

Excessive version and inclination of the glenoid component during total shoulder arthroplasty can lead to glenohumeral instability, early loosening, and even failure. The orientation and position of the central pin determine the version and inclination of the glenoid component. The purpose of this study was to compare the differences in centerline position and orientation obtained using "3D preoperative planning based on the best-fit method for glenoid elements" and the surgeon's manipulation.Twenty-nine CT images of glenohumeral osteoarthritis of the shoulder were reconstructed into a 3D model, and a 3D printer was used to create an in vitro model for the surgeon to drill the center pin. The 3D shoulder model was also used for 3D preoperative planning (3DPP) using the best-fit method for glenoid elements. The in vitro model was scanned and the version, inclination and center position were measured to compare with the 3DPP results.The respective mean inclinations (versions) of the surgeon and 3DPP were -2.63° ± 6.60 (2.87° ± 5.97) and -1.96° ± 4.24 (-3.21° ± 4.00), respectively. There was no significant difference in the inclination and version of the surgeon and 3DPP. For surgeons, the probability of the inclination and version being greater than 10° was 13.8% (4/29) and 10.3% (3/29), respectively. Compared to the 3DPP results, the surgeon's center position was shifted down an average of 1.63 mm. There was a significant difference in the center position of the surgeon and 3DPP (p 0.05).The central pin drilled by surgeons using general instruments was significantly lower than those defined using 3D preoperative planning and standard central definitions. 3D preoperative planning prevents the version and inclination of the centerline from exceeding safe values (± 10°).

Background/Purpose Splenic abscess is a life-threatening surgical emergency which requires early diagnosis and intervention to maximize patient outcomes. This can be achieved through accurate risk stratification in the emergency department (ED). Sarcopenia refers to an age-related loss of skeletal muscle mass and strength that is accompanied by major physiologic and clinical ramifications, and often signifies decreased physiologic reserves. It is associated with poor clinical outcomes in sepsis, acute respiratory failure, oncological surgery, and liver transplantation. This study evaluates the utility of sarcopenia as a radiological stratification tool to predict in-hospital mortality of splenic abscess patients in the ED. This will assist emergency physicians, internists and surgeons in rapid risk stratification, assessing treatment options, and communicating with family members. Methods 99 adult patients at four training and research hospitals who had undergone an abdominal contrast computed tomography scan in the ED with the final diagnosis of splenic abscess from January 2004 to November 2017 were recruited. Evaluation for sarcopenia was performed via calculating the psoas cross-sectional area at the level of the third lumbar vertebra and normalising for height, before checking it against pre-defined values. Univariate analyses were used to evaluate the differences between survivors and non-survivors. Sensitivity, specificity, and predictive values of the presence of sarcopenia in predicting in-hospital mortality were calculated. Kaplan–Meier methods, log-rank test, and Cox proportional hazards model were also performed to examine survival between groups with sarcopenia versus non-sarcopenia. Results Splenic abscess patients with sarcopenia were 7.56 times more at risk of in-hospital mortality than those without sarcopenia (multivariate-adjusted HR: 7.56; 95% CI: 1.55–36.93). Presence of sarcopenia was found to have 84.62% sensitivity and 96.49% negative predictive value in predicting mortality. Conclusion Sarcopenia is associated with poor prognoses of in-hospital mortality in patients with splenic abscess presenting to the ED. We recommend its use in the ED to rapidly risk stratify and predict outcome to guide treatment strategies.

Background Sonoelastography (SEL) is widely used for assessing tissue stiffness and pathophysiology. It has also been used to diagnose carpal tunnel syndrome (CTS). However, the current criteria to diagnose CTS in SEL are diverse. The aim of this study was to systematically review the literature and assess the diagnostic value of SEL for CTS. Methods A literature review was performed using MEDLINE (PubMed), EMBASE, and the Cochrane Collaboration Library for primary research articles using the keywords sonoelastography and carpal tunnel syndrome. Data related to diagnostic and cutoff value were extracted. Bias assessment was performed. Results A total of 121 publications were reviewed. Nineteen primary case series met the inclusion criteria and were selected for full analysis. Different diagnostic approaches were identified, with units/expressions including kilopascals, conduct velocity, and strain ratio. The kilopascals and conduct velocity were measured using shear wave elastography, whereas strain ratio was calculated by relative compression quantification. A mean shear modulus cutoff value from 38.25 to 86 kPa and an acoustic radiation force impulse cutoff value of 3.0 to 3.23 m/s were used to diagnose CTS. Eight articles reported strain ratio between the median nerve and nearby tissues with diverse results due to different reference points. The other 3 additional diagnostic values were reported. Conclusions Sonoelastography is a useful noninvasive and promising modality to diagnose CTS. It may reflect both the condition of soft tissue scarring and quantitative values for CTS and median nerve stiffness. A diversity of examination values was found in different modalities. A high level of evidence was absent.

Background This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE). Methods We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE. Results In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p Conclusions Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI. Graphical abstract

This study aimed to compare the differences in gray matter volumes (GMVs) of subcortical nuclei between major depressive disorder (MDD) patients with and without persistent depressive disorder (PDD) at long-term follow-up.114 and 94 subjects with MDD, including 48 and 41 with comorbid PDD, were enrolled to undergo high-resolution T1-weighted imaging at first (FIP) and second (three years later, SIP) investigation points, respectively. FreeSurfer was used to extract the GMVs of seven subcortical nuclei, and Generalized Estimating Equation models were employed to estimate the differences in GMVs of subcortical nuclei between the two subgroups.The PDD subgroup had a significantly greater depressive severity and a higher percentage of patients undergoing pharmacotherapy at the FIP as compared with the non-PDD subgroup. These differences became insignificant at the SIP. The PDD subgroup had a significantly (p 0.003) smaller GMV in the right putamen at the SIP and in the right nucleus accumbens (NAc) at the FIP and SIP as compared with the non-PDD subgroup. After controlling for clinical variables, PDD was independently associated with smaller GMVs in the right putamen and NAc.Imaging was not performed at baseline and pharmacotherapy was not controlled at the FIP and SIP.MDD with PDD was associated with smaller GMVs in the right putamen and NAc as compared with MDD without PDD. Whether the two regions are biomarkers related to a poor prognosis and the chronicity of depression requires further study.

Intra-articular corrective osteotomy can be used to restore the anatomic position of knee surfaces for tibial plateau malunion (TPM) but precise restoration is not easy. The personalized surgical guide (PSG) might improve the TMP outcomes. This study developed a two-staged PSG method to provide registration and drill the bone for subsequent osteotomy. The tests were performed to compare the accuracy the proposed PSG and the conventional guide (Anterior cruciate ligament guide, ACLG). The results showed that the PSG provides better accuracy (0.50 ± 0.19 mm) than the ACLG (1.58 ± 0.67 mm). The results show the PSG method is a feasible alternative to the conventional ACLG procedure.

Background:There is limited research investigating the diagnostic strength of 3-dimensional computed tomography (3D-CT) and multidirectional CT arthrography (CTA) for femoroacetabular impingement (FAI) and related hip lesions.Purpose:To evaluate the diagnostic strength of combined 3D-CT and CTA in patients with FAI and related hip lesions by comparing it with hip arthroscopic surgery findings.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:This study included patients who were suspected of having FAI and related hip lesions and who underwent a combination of 3D-CT and CTA and subsequent hip arthroscopic surgery between December 2013 and December 2017. The CT and intraoperative arthroscopic findings were recorded and compared. The sensitivity, specificity, and accuracy of 3D-CT for FAI and those of CTA for related hip lesions were calculated.Results:A total of 114 patients with 114 hips were included in our study. There were 101 patients with positive findings and 13 patients with negative findings for FAI (including cam, pincer, and combined morphology) according to 3D-CT. The sensitivity, specificity, and accuracy of 3D-CT for FAI were 91.58%, 57.14%, and 89.47%, respectively. The sensitivity, specificity, and accuracy of CTA for labral tears were 94.64%, 100.00%, and 94.73%, respectively. For acetabular cartilage defects, the sensitivity, specificity, and accuracy of CTA were 60.71%, 91.37%, and 76.31%, respectively. For femoral cartilage defects, the sensitivity, specificity, and accuracy of CTA were 82.22%, 76.81%, and 78.94%, respectively.Conclusion:The study results indicated that 3D-CT was able to provide excellent accuracy for FAI compared with hip arthroscopic surgery findings. In addition, multidirectional CTA demonstrated promising diagnostic strength for hip lesions such as labral tears and chondral defects.

Objective To evaluate the safety and efficacy of intra-articular (IA) injection of allogeneic adipose-derived stem cells (ADSCs) ELIXCYTE® for knee osteoarthritis. Methods This was a patient-blind, randomized, active-control trial consisted of 4 arms including hyaluronic acid (HA) control and 3 ELIXCYTE® doses. A total of 64 subjects were screened, and 57 subjects were randomized. The primary endpoints included the changes from baseline to post-treatment visit of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at Week 24 and the incidence of adverse events (AEs) and serious adverse events (SAEs). Results No ELIXCYTE®-related serious adverse events were reported during 96 weeks of follow-up and no suspected unexpected serious adverse reaction (SUSAR) or death was reported. The changes of the primary endpoint, WOMAC pain score at Week 24, showed significant differences in all ELIXCYTE® groups, as well as in HA groups between post-treatment visit and baseline. The ELIXCYTE® groups revealed significant decreases at Week 4 compared to HA group in WOMAC total scores, stiffness scores, functional limitation scores suggested the potential of ELIXCYTE® in earlier onset compared to those from HA. The significant differences of visual analog scale (VAS) pain score and Knee Society Clinical Rating System (KSCRS) functional activities score at Week 48 after ELIXCYTE® administration suggested the potential of ELIXCYTE® in the longer duration of the effectiveness compared to HA group. Conclusions ELIXCYTE® for knee osteoarthritis treatment was effective, safe, and well-tolerated. The efficacy results were showed that ELIXCYTE® conferred the earlier onset of reductions in pain scores and improvements in functional scores than HA group. Trial registration: ClinicalTrials.gov Identifier: NCT02784964. Registered 16 May, 2016—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02784964

The objective of this study is to compare the clinical outcomes after arthroscopic hip labral repair in athletes and non-athletes. The design of this study is a retrospective comparative study. The setting of this study is an institutional study. One hundred and sixteen patients of hip labral tears who underwent arthroscopic labral repair were included. Eighty-five of these patients met the inclusion/exclusion criteria (25 athletes and 60 non-athletes). Hip labral tears underwent arthroscopic labral repair. The main outcome measures are as follows: visual analog scale (VAS) and modified Harris Hip Score (mHHS) 2 years postoperatively and the rate of return to sports at previous level. There was no significant difference in the gender, alpha angle, lateral center-edge angle between the two groups, except for the mean age (19.3 versus 42.2, P

Unicompartmental knee arthroplasty (UKA) can achieve better kinematics and faster recovery than total knee arthroplasty. The Phase III Oxford UKA system has five sizes of femoral components to approximate the normal knee geometry. However, these different sizes may also induce problems, such as the misselection of component size. Different criteria have been proposed to predict the ideal size preoperatively. However, no single method can be applied universally. Therefore, this study aimed to develop a preoperative measurement using knee magnetic resonance imaging (MRI) to predict femoral component size. A total of 68 patients who underwent UKA were investigated from June 2019 to April 2020. 16 knees using a different MRI protocol were excluded. We developed an MRI measurement method to determine femoral size instead of gender- and height-based methods. The accuracy of different methods was compared using postoperative true lateral view radiographs. Three different kinds of gender- and height-based criteria, preoperative templating and intraoperative spoon measurement were compared. The accuracy of MRI measurement was 90.3%. Therefore, a significant difference was found between MRI measurements and all other methods, such as templating or gender- and height-based methods. In conclusion, the MRI measurement method can be concluded to accurately predict femoral component size in UKA. This method could be used regardless of different ethnic groups, individual knee geometry, or soft tissue tension.

Background Concurrent chemoradiotherapy (CCRT) is an optimal recommended treatment for stage III non‐small cell lung cancer (NSCLC). Herein, we aimed to investigate the efficacy and safety of oral vinorelbine plus cisplatin with concomitant radiotherapy for stage III NSCLC. Methods This prospective, open‐label, single‐arm, observational cohort study was performed between January 2010 and September 2016. Patients were treated with two cycles of chemotherapy with 60 mg/m2 intravenous cisplatin on day 1 and 50 mg/m2 oral vinorelbine on days 1, 8, and 15; radiotherapy was administered concurrently from day 1 when chemotherapy was initiated. A total dose of 66–70 Gy radiotherapy was delivered in daily fractions of 2 Gy for 6.5–7 consecutive weeks. The tumor response was assessed after completing concomitant treatment. Results A total of 58 patients were enrolled and analyzed; 31 patients had stage IIIA NSCLC and 27 had stage IIIB NSCLC. After induction CCRT, 31 patients achieved an objective response (complete response in one and partial response in 30; the response rate was 53.4%). The median progression‐free survival was 6.73 months (95% confidence interval [CI], 5.42–7.91), duration of response was 12.30 months (95% CI, 5.59–19.01), and overall survival was 24.83 months (95% CI, 19.26–30.21). No treatment‐related mortality was observed, and neutropenia was the most common grade 3 and 4 treatment‐related toxicity (11 patients; 18.9%). Conclusions CCRT with the weekly regimen of oral vinorelbine plus triweekly cisplatin was effective and safe for stage III NSCLC.

Background Prosthetic joint infections may lead to failures of total joint arthroplasty. Radionuclide imaging can play a diagnostic role in identifying such infections, which require two-stage exchange arthroplasty (instead of simple revision surgery performed in non-infected cases). Although 18F-FDG PET/CT has emerged as a novel diagnostic tool in this setting, the clinical usefulness of 68Ga-citrate PET/CT has not been previously investigated. This single-center prospective study was designed to address this issue. Methods Between January 2016 and October 2017, we examined 34 patients with clinically proven or suspected prosthetic hip/knee joint infections scheduled to undergo surgery. All patients underwent 68Ga-citrate PET/CT scans and sequential 18F-FDG PET/CT imaging for comparative purposes. Intraoperative findings and the results of microbiological analyses of surgical specimens served as gold standard. The diagnostic results were examined according to (1) image interpretation based on radiotracer uptake patterns and (2) quantitative analysis using volumes of interest (VOIs) to calculate standard uptake values (SUVs) and metabolic volumes (MVs). Results A total of 26 (76%) patients were diagnosed as having infections. Based on radiotracer uptake pattern criteria, the sensitivity, specificity, and accuracy of 68Ga-citrate PET/CT and 18F-FDG PET/CT were 92%, 88%, and 91% and 100%, 38%, and 85%, respectively. MV was significantly higher in the infected group when 68Ga-citrate PET/CT was used (422.45 vs. 303.65 cm3, p = 0.027), whereas no significant differences were observed on 18F-FDG PET/CT. According to receiver operating characteristic (ROC) curve analysis, a cut-off value of 370.86 for MV resulted in a sensitivity of 61.5% and a specificity of 87.5% (area under curve: 0.75, 95% confidence interval: 0.57–0.88, p = 0.035). Conclusions Subject to future confirmation, our data provide preliminary evidence that 68Ga-citrate PET/CT may have a complimentary role to 18F-FDG PET/CT in detecting prosthetic joint infections, being characterized by a higher specificity and the possibility to discriminate between an infectious condition and sterile inflammation. Trial registration This prospective study was registered at clinicaltrials.gov (registration number: NCT02855190).

The posterior superior temporal sulcus is a potential therapeutic target of brain stimulation for autism spectrum disorder. We conducted a 4-week randomized, single-blind parallel sham-controlled trial, followed by additional 4-week open-label intervention to evaluate the feasibility and efficacy regarding intermittent theta burst stimulation over the bilateral posterior superior temporal sulcus in autism spectrum disorder. In total, 78 intellectually able children and adolescents were randomized to the active ( n = 40) and sham groups ( n = 38). During the first 4 weeks, the active group received two-session/week intermittent theta burst stimulation, whereas the sham group received the same number of sham stimulation. After unblinding, both groups received eight-session real stimulation over the additional 4 weeks. In total, 91% participants completed the protocol with mild and transitory side-effects. There was no significant group-by-time interaction for active versus sham group on clinical symptoms and social cognitive performances in the first 4 weeks. The within-group analysis revealed 8 weeks (including a 4-week blind trial and a 4-week open-label intervention) of intermittent theta burst stimulation achieved greater efficacy than 4-week interventions. Participants with higher intelligence, better social cognitive performances, alongside less attention-deficit hyperactivity disorder severity at baseline, were more likely to be responders. Our study demonstrated the feasibility of long-term intermittent theta burst stimulation over the posterior superior temporal sulcus in children and adolescents with autism spectrum disorder. However, the findings from the first 4-week blind trial do not support the therapeutic efficacy of intermittent theta burst stimulation over the posterior superior temporal sulcus on the clinical symptoms and cognitive performance of social impairment, given the current stimulation protocol. The exploratory analyses suggest that the therapeutic efficacy might be moderated by several individual characteristics and more intermittent theta burst stimulation sessions. Lay abstract Intermittent theta burst stimulation is a varied form of repetitive transcranial magnetic non-invasive brain stimulation technique used to treat several neurological and psychiatric disorders. Its feasibility and therapeutic effects on the bilateral posterior superior temporal sulcus in children with autism are unknown. We conducted a single-blind, sham-controlled parallel randomized clinical trial in a hitherto largest sample of intellectually able children with autism ( N = 78). Participants randomized to the active group received two-session/week intermittent theta burst stimulation for continuous 8 weeks. Those in the sham group received two-session/week sham stimulations in the first 4 weeks and then active intervention for the following 4 weeks after unblinding. First, we found that continuous 8-week intermittent theta burst stimulation on the bilateral posterior superior temporal sulcus in children with autism is safe and tolerable. Second, we found that 8-week intermittent theta burst stimulation produced greater therapeutic efficacy, although we did not find any significant effects of 4-week intermittent theta burst stimulation on core symptoms and social cognitive performances in autism. Further analysis revealed that participants with higher intelligence and better social cognitive performance, alongside less attention-deficit hyperactivity disorder severity at baseline, were more likely to be responders. This study identified that the factors contribute to responders and the results suggest that longer courses of non-invasive brain stimulation may be needed to produce therapeutic benefits in autism, with consideration of heterogeneous responses.

Supplemental material, sj-pdf-1-aut-10.1177_1362361321990534 for Intermittent theta burst stimulation over the posterior superior temporal sulcus for children with autism spectrum disorder: A 4-week randomized blinded controlled trial followed by another 4-week open-label intervention by Hsing-Chang Ni, Yi-Lung Chen, Yi-Ping Chao, Chen-Te Wu, Yu-Yu Wu, Sophie Hsin-Yi Liang, Wei-Chih Chin, Tai-Li Chou, Susan Shur-Fen Gau, Ying-Zu Huang and Hsiang-Yuan Lin in Autism

Quantum noise is a random process in X-ray-based imaging systems. We addressed and measured the uncertainty of radiomics features against this quantum noise in computed tomography (CT) images.A clinical multi-detector CT scanner, two homogeneous phantom sets, and four heterogeneous samples were used. A solid tumor tissue removed from a male BALB/c mouse was included. We the placed phantom sets on the CT scanning table and repeated 20 acquisitions with identical imaging settings. Regions of interest were delineated for feature extraction. Statistical quantities-average, standard deviation, and percentage uncertainty-were calculated from these 20 repeated scans. Percentage uncertainty was used to measure and quantify feature stability against quantum noise. Twelve radiomics features were measured. Random noise was added to study the robustness of machine learning classifiers against feature uncertainty.We found the ranges of percentage uncertainties from homogeneous soft tissue phantoms, homogeneous bone phantoms, and solid tumor tissue to be 0.01-2138%, 0.02-15%, and 0.18-16%, respectively. Overall, it was found that the CT features ShortRunHighGrayLevelEmpha (SRHGE) (0.01-0.18%), ShortRunLowGrayLevelEmpha (SRLGE) (0.01-0.41%), LowGrayLevelRunEmpha (LGRE) (0.01-0.39%), and LongRunLowGrayLevelEmpha (LRLGE) (0.02-0.66%) were the most stable features against the inherent quantum noise. The most unstable features were cluster shade (1-2138%) and max probability (1-16%). The impact of random noise to the prediction accuracy by different machine learning classifiers was found to be between 0 and 12%.Twelve features were used for uncertainty measurements. The upper and lower bounds of percentage uncertainties were determined. The quantum noise effect on machine learning classifiers is model dependent.• Quantum noise is a random process and is intrinsic to X-ray-based imaging systems. This inherent quantum noise creates unpredictable fluctuations in the gray-level intensities of image pixels. Extra cautions and further validations are strongly recommended when unstable radiomics features are selected by a predictive model for disease classification or treatment outcome prognosis. • We addressed and used the statistical quantity of percentage uncertainty to measure the uncertainty of radiomics features against the inherent quantum noise in computed tomography (CT) images. • A clinical multi-detector CT scanner, two homogeneous phantom sets, and four heterogeneous samples were used in the stability measurement. A solid tumor tissue removed from a male BALB/c mouse was included in the heterogeneous sample.

Background In cases of Oxford unicompartmental knee arthroplasty (UKA), an increase in anteroposterior and medial-lateral length is usually disproportional when comparing AA and A-sized tibial components. Asynchronous increments may cause tibial keel impingement leading to complications. Methods Radiographic measurements were performed in five patients with AA-sized tibial implants. The posterior cortex of proximal tibia had two angles recorded as ∠ M1 and ∠ M2. The minimum distance between the tibial component keel and outer margin of the posterior tibial cortex (mDKC) was measured, and the correlation between the preoperative posterior slope angle (PSA), ∠ M1, and mDKC was analyzed. Results All patients showed an acceptable component positioning. Only one patient had an mDKC of < 4 mm that fulfilled the criteria for the posterior tibial cortex at risk. The patient had an increased PSA and ∠ M1 compared to other patients. A negative correlation was found between preoperative PSA and mDKC (r = − 0.935, p = 0.0193); and ∠ M1 and mDKC (r = − 0.969, p = 0.0032). However, no stem tip pain, periprosthetic fracture, or component loosening were observed. Conclusions The distance between the tibial keel and posterior tibial cortex was reduced in AA-sized patients with a large PSA and ∠M1; therefore, the risk of the tibial cortex injury should be considered.

Rationale: Abdominal aortic aneurysm is an extremely rare cause of deep vein thrombosis. Here we report an elderly gentleman who presented with deep vein thrombosis and was found to have concomitant abdominal aortic aneurysm upon ultrasonographic screening. It illustrates the possibility of such an aetiology, and the importance of screening for such aneurysms in a select patient population before heparinization. Patient concerns: A 73-year-old Asian gentleman with underlying hypertension, hyperlipidaemia, chronic renal failure, and history of chronic smoking presented to the emergency department with acute left lower limb swelling of 1 day. On examination, the patient was tachycardic (110 beats/minute) and hypertensive (168/84 millimeters mercury (mmHg)). The entire left lower limb was swollen with notable pitting oedema, tenderness, and warmth; left calf swelling was measured to be 4 centimeters (cm). Diagnoses: The patient's Wells score of 4 placed him in the high-risk group for deep vein thrombosis. Serum D-dimer was subsequently found to be elevated at 926 nanograms/milliliter (ng/ml). Compression ultrasonography revealed a thrombus in the left deep femoral vein, confirming the diagnosis of deep vein thrombosis. The ultrasonographic evaluation was extended to the abdominal aorta due to the patient's high risk of abdominal aortic aneurysm, and a 7-cm aneurysm was indeed found. Further computed tomography and magnetic resonance imaging localized it to the infrarenal region, with left common iliac vein compression resulting in stagnant venous return. Interventions: Emergency endovascular repair was performed with insertion of an inferior vena cava filter. Outcomes: The patient was subsequently monitored in the intensive care unit and uneventfully discharged after 2 weeks. Lessons: Such clinical presentations of deep vein thrombosis are rare, but physicians are reminded to consider screening for abdominal aneurysms and other anatomical causes before heparinization in patients who seemingly do not have thromboembolic risk factors. This is especially so for the high risk group of male deep vein thrombosis patients aged 65–75 years with a history of smoking who have yet to be screened for abdominal aortic aneurysms, in line with United States Preventive Services Task Force recommendations.

Backgrounds Trigonometric formulae have been derived to correlate the distraction angle (height) and tibial specifications. However, the assumption-induced simplifications are inherent in the formulae such as the rigid tibia and the specific orientations of cutting plane and lateral hinge. This study aimed to evaluated the accuracy of the trigonometric formulae. Methods The 3D printed tibiae were used as the specimens for which the hinge orientations and distraction sites were systematically varied. Hinge orientation was determined by wedge inclination of the bone saw into the medial tibia and saw progression near the lateral cortex. The specimens were distracted at different distraction sites to measure the distraction angles that were compared with literature formulae. Findings In cases of the same distraction height, the wedge inclination, saw progression, and distraction site had various impacts on the coronal angles, indicating that the ideal formula should consider these parameters. Averagely, the predicted angles of the literature formulae were 15% higher than the testing results. The differences in these results may be attributed to the deformable property of the specimen material, non-ideal hinge orientation, and differences in distraction sites. Saw progression and distraction site had greater impacts than wedge inclination on the distraction angle. Interpretation Variations in three surgical indices constitute a complicated mechanism that affects the 3D hinged rotation of the distracted plateau. The non-middle distraction further deforms the tibial rotation and reduces the accuracy of the trigonometric formulae. The trigonometric formulae might underestimate the distraction angle; thus. Appropriate corrections are necessary for clinical application.

This study investigated the influence of spatial overlap and radiographic length (RL) on the effective dose (ED) and organ dose for pediatric patients undergoing whole spine radiography using an auto-stitching digital radiography (DR) system.First, the system parameters were tested on a 10-year-old pediatric anthropomorphic phantom with a Shimadzu DR system, and the effects of the spatial overlap and RL on radiation doses were validated. The ED and organ dose were calculated on the basis of a Monte Carlo simulation program. Subsequently, 82 patients with adolescent idiopathic scoliosis were recruited. The spatial overlap and RL for each patient were modified to further investigate the dose reduction feasibility.RL and ED were appropriately correlated on the basis of patients' height. For a patient measuring 158 cm, the Shimadzu DR system was equipped with a 17-inch detector with a cut-off RL of 75 cm. The phantom simulations indicated that ED was reduced to a minimum value of 0.188 ± 0.001 mSv with a high RL for RL 75 cm. The minimum value increased to 0.300 ± 0.002 mSv for an RL of 75 cm and dropped to 0.222 ± 0.001 mSv for the maximum RL. By employing optimized RLs for patients, EDs were significantly reduced (p 0.05). Moreover, ED reductions were higher when longer RLs were employed.A decrease in the spatial overlap and number of radiographic acquisitions by adjusting RLs when possible could reduce ED and almost all organ doses. This study emphasized the effects of RL on the radiation dose and provided useful guidance for modifying the RL for patients to reduce the whole spine radiography dose using a modern auto-stitching DR system.

Lung cancer screening aims to detect small pulmonary nodules and decrease the mortality rate of those affected. However, studies from large-scale clinical trials of lung cancer screening have shown that the false-positive rate is high and positive predictive value is low. To address these problems, a technical approach is greatly needed for accurate malignancy differentiation among these early-detected nodules. We studied the clinical feasibility of an additional protocol of localized thin-section CT for further assessment on recalled patients from lung cancer screening tests. Our approach of localized thin-section CT was integrated with radiomics features extraction and machine learning classification which was supervised by pathological diagnosis. Localized thin-section CT images of 122 nodules were retrospectively reviewed and 374 radiomics features were extracted. In this study, 48 nodules were benign and 74 malignant. There were nine patients with multiple nodules and four with synchronous multiple malignant nodules. Different machine learning classifiers with a stratified ten-fold cross-validation were used and repeated 100 times to evaluate classification accuracy. Of the image features extracted from the thin-section CT images, 238 (64%) were useful in differentiating between benign and malignant nodules. These useful features include CT density (p = 0.002 518), sigma (p = 0.002 781), uniformity (p = 0.032 41), and entropy (p = 0.006 685). The highest classification accuracy was 79% by the logistic classifier. The performance metrics of this logistic classification model was 0.80 for the positive predictive value, 0.36 for the false-positive rate, and 0.80 for the area under the receiver operating characteristic curve. Our approach of direct risk classification supervised by the pathological diagnosis with localized thin-section CT and radiomics feature extraction may support clinical physicians in determining truly malignant nodules and therefore reduce problems in lung cancer screening.

Intermittent theta burst stimulation (iTBS), a patterned repetitive transcranial magnetic stimulation, was applied over the posterior superior temporal sulcus (pSTS) or dorsolateral prefrontal cortex (DLPFC) to explore its impact in adults with autism spectrum disorder (ASD). Among 25 adults with ASD, 19 (mean age: 20.8 years) completed the randomized, sham-controlled, crossover trial. Every participant received iTBS over the bilateral DLPFC, bilateral pSTS and inion (as a sham control stimulation) in a randomized order with a 1-week interval. Neuropsychological functions were assessed using the Conners' Continuous Performance Test (CCPT) and the Wisconsin Card Sorting Test (WCST). Behavioral outcomes were measured using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Social Responsiveness Scale (SRS). In comparison to that in the sham stimulation, the reaction time in the CCPT significantly decreased following single DLPFC session (p = 0.04, effect size = 0.71) while there were no significant differences in the CCPT and WCST following single pSTS session. Besides, the results in behavioral outcomes were inconsistent and had discrepancy between reports of parents and patients. In conclusion, a single session of iTBS over the bilateral DLPFC may alter the neuropsychological function in adults with ASD. The impacts of multiple-sessions iTBS over the DLPFC or pSTS deserve further investigations.

Mechanical ventilation used in patients with acute respiratory distress syndrome (ARDS) can damage pulmonary epithelial cells by producing inflammatory cytokines and depositing excess collagen. Src participates in plasminogen activator inhibitor-1 (PAI-1) and transforming growth factor-β1(TGF-β1) production during the fibroproliferative phase of ARDS, which involves a process of epithelial–mesenchymal transition (EMT). The mechanisms regulating interactions between mechanical ventilation and EMT are unclear. We hypothesized that EMT induced by high-tidal volume (VT) mechanical stretch-augmented lung inflammation occurs through upregulation of the Src pathway. Five days after administering bleomycin to simulate acute lung injury (ALI), male C57BL/6 mice, either wild-type or Src-deficient, aged 3 months, weighing between 25 and 30 g, were exposed to low-VT (6 ml/kg) or high-VT (30 ml/kg) mechanical ventilation with room air for 1–5 h. Nonventilated mice were used as control subjects. We observed that high-VT mechanical ventilation increased microvascular permeability, PAI-1 and TGF-β1 protein levels, Masson’s trichrome staining, extracellular collagen levels, collagen gene expression, fibroblast accumulation, positive staining of α-smooth muscle actin and type I collagen, activation of Src signaling and epithelial apoptotic cell death in wild-type mice (P

We retrospectively assessed the computed tomography (CT) features of 31 intrapulmonary lymph nodes (IPLNs) with histopathologic correlations. CT scans revealed that the IPLNs are located in the subpleural region, frequently below the level of the carina, and angular in shape. Most of the IPLNs are solid in texture but occasionally present with a ground-glass appearance. For pleura-attached and pleura-separated IPLNs, one or more and 3 or more linear opacities extending from the nodules can be identified, respectively. Histologically, the IPLNs are located either at the junction of the pleura and lung lobules or at the junction of adjacent lung lobules.

The purpose of this study was to determine which clinical information or computed tomography (CT) features can distinguish perforated from nonperforated appendicitis. We collected data from 102 patients (62 men, 40 women; mean age, 49.6 years; age range, 16-85 years) who presented to the emergency department with acute abdominal pain or suspicion of acute appendicitis and underwent appendectomy. In the clinical information, there was no significant factor to predict appendiceal perforation. As for CT features, significant imaging factors for predicting appendiceal perforation included abscess, phlegmon, and thickening of lateroconal fascia. The treatment strategy of acute appendicitis varies according to the integrity of the appendiceal wall. Besides clinical findings, CT features can distinguish perforated from nonperforated appendicitis, facilitating proper decision making in ER.

Chondroblastoma is a relatively uncommon but benign bone tumor that is typically found in a long-bone epiphysis. Reports of this type of tumor in the carpals have been rare, and even fewer cases of such tumors in the triquetrum have been reported. Here, we present classical findings of a chondroblastoma at an unusual location, the triquetrum, in an adolescent. Fat-suppressed T2*-weighted imaging revealed a hyperintense tumor matrix replacing the bony trabecula of the triquetrum, which had not been addressed in previous literature. Radiography-based differential diagnosis of a bubbly lesion in the hand of an adolescent, even in the small carpal bones, should include chondroblastoma.

Background. To retrospectively compare the accuracies of ultrasound-guided fine-needle aspiration (USFNA) and ultrasound-guided core needle biopsy (USCNB) in the diagnosis of parotid masses. Methods. A total of 171 patients (aged 17–86 years, mean 54 years) with parotid masses (35 malignant and 136 benign lesions) underwent either USFNA (n = 107) or USCNB (n = 64). The diagnostic accuracies for differentiating benign from malignant lesions of both examinations were compared. Surgical histopathology (n = 104) and clinical diagnosis (n = 67) were used to establish the final diagnoses. Results. USCNB had a significantly higher sensitivity (94.1%) than USFNA (55.6%) (p < 0.05) in differentiating benign lesions from malignant conditions. The specificity and overall accuracy of USCNB were higher than those of USFNA (100% and 98.4% versus 93.3% and 86.9%, respectively). USCNB provided more specific diagnosis than USFNA (100% versus 93.3%, p < 0.05). All six patients with lymphomas who underwent USCNB were accurately diagnosed, whereas all four patients with lymphomas who underwent USFNA were not. Conclusions. USCNB should be preferred to USFNA when a definite diagnosis of a parotid solid mass is needed. © 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011