Imaging Outcomes of Emergency MR Imaging in Dizziness and Vertigo: A Retrospective Cohort Study.

BACKGROUND AND PURPOSE: Patients exhibiting acute dizziness or vertigo often represent a diagnostic challenge, and many undergo neuroimaging for stroke detection. We aimed to demonstrate the imaging outcomes of first-line emergency MR imaging among patients with acute dizziness or vertigo and to determine the clinical risk factors for stroke and other acute pathology. MATERIALS AND METHODS: This retrospective study included consecutive patients with acute dizziness or vertigo referred for emergency MR imaging in a tertiary hospital during 5 years. We recorded and analyzed patient characteristics, relevant clinical information, and imaging outcomes. Risk score models were derived to predict which patients were more likely to present with positive MR imaging findings. RESULTS: A total of 1169 patients were included. Acute stroke was found in 17%; other clinically significant pathology, in 8% of patients. In 75% of the patients, emergency MR imaging showed no significant abnormalities. Risk factors for acute stroke included older age, male sex, and a prevalence of cardiovascular risk factors and neurologic signs. Isolated dizziness had no discriminative power on imaging outcomes, and 14% of these patients showed acute stroke. Risk scores had only moderate performance in predicting acute ischemic stroke (receiver operating characteristic area under curve = 0.75) or any significant pathology (receiver operating characteristic area under curve = 0.70). CONCLUSIONS: Acute dizziness and vertigo remain challenging even when emergency MR imaging is readily available. One in 4 patients had acute pathology on MR imaging. Predictors for acute pathology (older age, male sex, cardiovascular risk factors, and neurologic signs) may aid in patient selection for MR imaging, optimizing the yield and clinical impact of emergency neuroimaging. Low diagnostic yields of CT and internal acoustic canal MR imaging may offer an opportunity to reduce health care expenditures in the future.

Utility of brain imaging in pediatric patients with a suspected accidental spinal injury but no brain injury-related symptoms.

PURPOSE: Imaging is the gold standard in diagnosing traumatic brain injury, but unnecessary scans should be avoided, especially in children and adolescents. Clinical decision-making rules often help to distinguish the patients who need imaging, but if spinal trauma is suspected, concomitant brain imaging is often conducted. Whether the co-occurrence of brain and spine injuries is high enough to justify head imaging in patients without symptoms suggesting brain injury is unknown. OBJECTIVE: This study aims to assess the diagnostic yield of brain MRI in pediatric patients with suspected or confirmed accidental spinal trauma but no potential brain injury symptoms. METHODS: We retrospectively reviewed the medical and imaging data of pediatric patients (under 18 years old) who have undergone concomitant MRI of the brain and spine because of acute spinal trauma in our emergency radiology department over a period of 8 years. We compared the brain MRI findings in patients with and without symptoms suggesting brain injury and contrasted spine and brain MRI findings. RESULTS: Of 179 patients (mean age 11.7 years, range 0-17), 137 had symptoms or clinical findings suggesting brain injury, and 42 did not. None of the patients without potential brain injury symptoms had traumatic findings in brain MRI. This finding also applied to patients with high-energy trauma (n = 47) and was unrelated to spinal MRI findings. CONCLUSION: Pediatric accidental trauma patients with suspected or confirmed spine trauma but no symptoms or clinical findings suggesting brain injury seem not to benefit from brain imaging.

Outcomes of Follow-up Imaging After Pediatric Spinal Trauma Confirmed With Magnetic Resonance Imaging.

BACKGROUND: Imaging plays a crucial role in the diagnostic workup of pediatric spinal trauma. Computed tomography and conventional radiographs are widely used as the primary imaging methods. Magnetic resonance imaging (MRI) is a radiation-free alternative with high sensitivity for bony and soft tissue injuries. There is no consensus on the optimal use of follow-up imaging in pediatric spinal trauma without immediate surgical treatment, especially if the injury is primarily confirmed with MRI. This study aimed to assess the diagnostic value of follow-up imaging after MRI-confirmed spinal trauma in children. METHODS: The medical records and the imaging data of children and adolescents with emergency spinal MRI and follow-up imaging over 8 years were retrospectively reviewed. The primary study outcome was the outcome of follow-up imaging and its effect on management. RESULTS: The study population consisted of 127 patients. The follow-up imaging did not alter the management in any patient with presumably stable injury in emergency MRI. Short-term follow-up imaging showed no clinically significant progression in thoracolumbar compression fractures. Flexion-extension radiographs had no additional value in cases with stable cervical spinal injury on emergency MRI. CONCLUSIONS: The clinical utility of short-term follow-up imaging is low in children with stable spinal injury on emergency MRI. LEVEL OF EVIDENCE: Level III-retrospective observational study.

Diagnostic performance of short noncontrast biparametric 3-T MRI for tonsillar infections: comparison with a full protocol including contrast-enhanced sequences.

BACKGROUND: We investigated whether a short, 5-min magnetic resonance imaging (MRI) protocol consisting of only axial T2-weighted and diffusion-weighted imaging (DWI) sequences can discriminate between tonsillar infections, peritonsillar abscesses and deeply extending abscesses in a retrospective, blinded, multireader setting. METHODS: We included patients sent by emergency physicians with suspected pharyngotonsillar infections who underwent emergency neck 3-T MRI from April 1 2013 to December 31 2018. Three radiologists (with 10-16 years of experience) reviewed the images for abscesses and their extension into deep neck spaces. Data were reviewed first using only axial T2-weighted Dixon images and DWI (short protocol) and second including other sequences and contrast-enhanced T1-weighted Dixon images (full protocol). Diagnostic accuracy, interobserver agreement, and reader confidence were measured. Surgical findings and clinical course served as standard of reference. RESULTS: The final sample consisted of 52 patients: 13 acute tonsillitis with no abscesses, 19 peritonsillar abscesses, and 20 deeply extending abscesses. Using the short protocol, diagnostic accuracy for abscesses across all readers was good-to-excellent: sensitivity 0.93 (95% confidence interval 0.87-0.97), specificity 0.85 (0.70-0.93), accuracy 0.91 (0.85-0.95). Using the full protocol, respective values were 0.98 (0.93-1.00), 0.85 (0.70-0.93), and 0.95 (0.90-0.97), not significantly different compared with the short protocol. Similar trends were seen with detecting deep extension. Interobserver agreement was similar between protocols. However, readers had higher confidence in diagnosing abscesses using the full protocol. CONCLUSIONS: Short MRI protocol showed good-to-excellent accuracy for tonsillar abscesses. Contrast-enhanced images improved reader confidence but did not affect diagnostic accuracy or interobserver agreement. RELEVANCE STATEMENT: Short protocol consisting only of T2-weighted Dixon and DWI sequences can accurately image tonsillar abscesses, which may improve feasibility of emergency neck MRI. KEY POINTS: • The short 3-T MRI protocol (T2-weighted images and DWI) was faster (5 min) than the full protocol including T1-weighted contrast-enhanced images (24 min). • The short 3-T MRI protocol showed good diagnostic accuracy for pharyngotonsillar abscesses. • Contrast-enhanced sequences improved reader confidence but did not impact diagnostic accuracy or interobserver agreement.

Emergency MRI in Spine Trauma of Children and Adolescents-A Pictorial Review.

Severe spinal trauma is uncommon in the pediatric population, but due to the potentially devastating consequences of missed injury, it poses a diagnostic challenge in emergency departments. Diagnostic imaging is often needed to exclude or confirm the injury and to assess its extent. Magnetic resonance imaging (MRI) offers an excellent view of both bony and soft tissue structures and their traumatic findings without exposing children to ionizing radiation. Our pictorial review aims to demonstrate the typical traumatic findings, physiological phenomena, and potential pitfalls of emergency MRI in the trauma of the growing spine.

Clinical outcome following magnetic resonance imaging as first-line imaging in low-impact pediatric spine trauma: a single-center retrospective observational study.

BACKGROUND: Pediatric spinal trauma is rare, but the consequences of a missed injury can be devastating. Medical imaging is often needed in addition to physical examination. Conventional radiographs are widely recommended, but their negative predictive value is limited. Computed tomography (CT) is more sensitive but has a higher radiation dose. Magnetic resonance imaging (MRI) has superior soft tissue contrast and lacks ionizing radiation, but it is more expensive and time-consuming. Thus, the debate regarding the most suitable imaging method is still ongoing. OBJECTIVE: This study examined the ability of MRI to exclude injuries requiring surgical treatment as a first-line imaging method in low-impact pediatric spine trauma. MATERIALS AND METHODS: We retrospectively reviewed the medical records and imaging data of children (under 18 years old) who had suspected spinal trauma and were scanned using MRI in our emergency radiology department over a period of 8 years. We assessed the ability of MRI to detect unstable injuries by searching for later occurrences of primarily missed injuries requiring surgery. RESULTS: Of 396 patients (median age 12 years, range 0-17), 114 (29%) had MRI findings suggesting an acute injury. Bony injuries were detected in 78 patients (20%) and ligamentous or other soft tissue injuries in 82 patients (21%). In the subgroup of 376 patients (median age 12 years, range 0-17) with at least 6 months of clinical follow-up, no missed injuries demanding surgical intervention or immobilization occurred after spinal MRI as  first-line imaging. No adverse events related to MRI or anesthesia occurred. CONCLUSION: MRI can detect injuries requiring surgical treatment as a first-line imaging method in suspected low-impact pediatric spinal trauma and is safe to use in this selected population.

Imaging Outcomes of Emergency MRI in Patients with Suspected Cerebral Venous Sinus Thrombosis: A Retrospective Cohort Study.

Cerebral venous sinus thrombosis (CVST) is a rare neurological emergency condition with non-specific symptoms. Imaging options to rule out CVST are computed tomography (CT) and magnetic resonance imaging (MRI). This study aimed to determine the imaging outcomes of emergency MRI as a first-line imaging method in patients with suspected CVST. In this retrospective cohort study, we analyzed emergency brain MRI referrals from a five-year period in a tertiary hospital for suspicion of CVST. We recorded patient characteristics, risk factors mentioned in the referrals, and imaging outcomes. Altogether 327 patients underwent emergency MRI on the grounds of suspected CVST. MRI showed evidence of CVST among five patients (1.5%). Imaging showed other clinically significant pathology in 15% of the patients and incidental findings in 5% of the patients. Despite clinical suspicion, the diagnostic yield of emergency MRI for CVST is low and similar to that previously reported for CT. MRI is an alternative imaging method devoid of ionizing radiation in patients with suspected CVST.

Pictorial Review of MRI Findings in Acute Neck Infections in Children.

Pediatric neck infections and their complications, such as abscesses extending to deep neck compartments, are potentially life-threatening acute conditions. Medical imaging aims to verify abscesses and their extensions and exclude other complications. Magnetic resonance imaging (MRI) has proven to be a useful and highly accurate imaging method in acute neck infections in children. Children and adults differ in terms of the types of acute infections and the anatomy and function of the neck. This pictorial review summarizes typical findings in pediatric patients with neck infections and discusses some difficulties related to image interpretation.

MRI of acute neck infections: evidence summary and pictorial review.

Infection of the deep neck spaces is a life-threatening acute illness that requires prompt diagnosis and treatment. Magnetic resonance imaging (MRI) offers unsurpassed soft tissue discrimination and is therefore well suited for imaging neck infections. Recently, the feasibility, diagnostic accuracy, and clinical significance of this method have been documented in patients with acute neck infections. This review article summarizes the scientific evidence, provides a practical guide to image acquisition and interpretation, reviews the most common imaging findings, and discusses some difficult diagnoses and pitfalls in acute neck infections, to help both radiologists and clinicians in managing these critically ill patients.

Elastic Lumbar Support Versus Rigid Thoracolumbar Orthosis for Acute Pediatric Spondylolysis: A Prospective Controlled Study.

STUDY DESIGN: A prospective study on clinical, radiographic, and health-related quality of life (HRQoL) outcomes in children with acute spondylolysis treated with a rigid thoracolumbar orthosis or with an elastic lumbar support. OBJECTIVE: To compare outcomes of pediatric spondylosysis treated with a hard brace or an elastic lumbar support. SUMMARY OF BACKGROUND DATA: The benefits of the use of a rigid orthosis in treatment of spondylolysis are not clear. MATERIALS AND METHODS: Fifty-seven consecutive children with acute spondylolysis (mean age: 14.1 yr, range: 9-17 yr) were prospectively enrolled. Patients were treated with a rigid thoracolumbar orthosis (Boston brace) or with a low-profile, elastic lumbar support. First 14 patients were randomized the remaining 43 chose brace type themselves. Treatment period was four months. Treatment outcomes included bony union of the spondylolysis assessed with a computed tomography at four months and HRQoL using the Scoliosis Research Society-24 outcome questionnaire filled out before and after the treatment. RESULTS: Of the 57 patients, 54 completed the treatment protocol. Twenty-nine patients were treated using the Boston brace and 25 patients the elastic lumbar support. Bony union was obtained in 69.0% (20/29) of the Boston brace and in 60.0% (15/25) of the elastic lumbar support group patients. Difference in union rates was not significant (relative risk=1.14, 95% confidence interval: 0.44-2.98, P =0.785). There was no difference in the Scoliosis Research Society-24 total or domain scores at the end of follow-up between the treatment groups ( P >0.159 for all comparisons). In the whole cohort, the bony union did not predict better HRQoL in the end of the treatment ( P =0.869), although the pain domain improved significantly in the whole cohort ( P <0.001). CONCLUSIONS: A rigid thoracolumbar orthosis did not provide any benefits over an elastic lumbar support in terms of bony union or HRQoL outcomes in children with acute spondylolysis. LEVEL OF EVIDEN: 2.

Diagnostic yield of emergency MRI in non-traumatic headache.

PURPOSE: Non-traumatic headache is one of the most common neurological complaints in emergency departments. A relatively low diagnostic yield of magnetic resonance imaging (MRI) among outpatients has been previously reported, but studies of emergency patients are lacking. We sought to determine the diagnostic yield of emergency MRI among outpatients presenting to the emergency department with non-traumatic headache. METHODS: In this retrospective cohort study, we analyzed emergency MRI referrals in a tertiary hospital for non-traumatic headache over a five-year period. We recorded patient characteristics, relevant clinical information from the referrals, and imaging outcomes. RESULTS: In total, 696 emergency patients with non-traumatic headache underwent MRI, most within 24 h of presentation. Significant findings related to headache were found in 136 (20%) patients, and incidental findings in 22% of patients. In a multivariate model, the predisposing factors of the significant findings were age, smoking, nausea, and signs/symptoms of infection. The protective factors were numbness and history of migraine. A predictive clinical score reached only moderate performance. CONCLUSION: Although emergency MRI shows headache-related findings in one in five patients, accurate prediction modeling remains a challenge, even with statistically significant predictors and a large sample size.

MRI of odontogenic maxillofacial infections: diagnostic accuracy and reliability.

OBJECTIVES: To determine the diagnostic accuracy of emergency magnetic resonance imaging (MRI) in odontogenic maxillofacial infections, the clinical and surgical significance of MRI findings, and whether MRI can identify the tooth responsible for the infection. METHODS: A retrospective cohort study reviewed 106 emergency neck MRI scans of patients with neck infections of odontogenic origin. The diagnostic accuracy of MRI in identifying abscesses was studied relative to surgical findings. Correlations were analyzed between various MRI findings and clinical results and outcomes, such as the surgical approach (intraoral vs. extraoral). The ability of MRI findings to predict the causative tooth was assessed in a blinded multi-reader setting. RESULTS: Of the 106 patients with odontogenic infections, 77 (73%) had one or more abscesses. Imaging showed a sensitivity, specificity, and accuracy of 0.95, 0.84, and 0.92, respectively, for MRI diagnosis of an odontogenic abscess. Among the imaging findings, mediastinal edema was the strongest predictor of extraoral surgery. MRI showed bone marrow edema in the majority of patients, and multi-reader assessment showed good reliability. MRI was also able to predict the causative tooth accurately. CONCLUSIONS: Emergency neck MRI can accurately detect odontogenic abscesses and reliably point to the causative tooth. These results can increase the utility and reliance on emergency MRI in clinical decision-making.

The natural course of bridging osteophyte formation on MRI-A pictorial illustration.

Diffuse skeletal hyperostosis is a common spinal disorder, but its pathophysiology is mostly unclear. The disorder can lead to a variety of symptoms, but many patients remain relatively asymptomatic. We present a case demonstrating the development of bridging osteophytes on a series of magnetic resonance images. An elderly person's spine was scanned repeatedly due to non-specific back pain during the last 4 years and the consecutive images revealed the formation of a bony bridge in the lumbar spine. Extensive bone marrow edema was seen during the formation of the osteophyte, suggestive of an ongoing inflammatory process. This case underlines that the inflammatory reaction in diffuse skeletal hyperostosis can be intense and prolonged, and its role might be worth studying further.

Diagnostic accuracy of contrast-enhanced CT for neck abscesses: A systematic review and meta-analysis of positive predictive value.

OBJECTIVES: To review the diagnostic accuracy of contrast-enhanced computed tomography (CT) in differentiating abscesses from cellulitis in patients with neck infections, using surgical findings as the reference standard. MATERIALS AND METHODS: Previous studies in the last 32 years were searched from PubMed and Embase. Because of partial verification bias (only positive abscess findings are usually verified surgically), sensitivity and specificity estimates are unreliable, and we focused on positive predictive value (PPV). For all studies, PPV was calculated as the proportion of true positives out of all positives on imaging. To estimate pooled PPV, we used both the median with an interquartile range and a model-based estimate. For narrative purposes, we reviewed the utility of common morphological CT criteria for abscesses, such as central hypodensity, the size of the collection, bulging, rim enhancement, and presence of air, as well as sensitivity and specificity values reported by the original reports. RESULTS: 23 studies were found reporting 1453 patients, 14 studies in children (771 patients), two in adults (137 patients), and seven including all ages (545 patients). PPV ranged from 0.67 to 0.97 in individual studies, had a median of 0.84 (0.79-0.87), and a model-based pooled estimate of 0.83 (95% confidence interval 0.80-0.85). Most morphological CT criteria had considerable overlap between abscesses and cellulitis. CONCLUSIONS: The pooled estimate of PPV is 0.83 for diagnosing neck abscesses with CT. False positives may be due to limited soft tissue contrast resolution. Overall, none of the morphological criteria seem to be highly accurate for differentiation between abscess and cellulitis.

Magnetic resonance imaging findings in pediatric neck infections-a comparison with adult patients.

BACKGROUND: Differences in the functioning of the immune system and the anatomical proportions of the neck between children and adults lead to different manifestations of deep neck infections. Magnetic resonance imaging (MRI) may serve as an alternative to computed tomography (CT) as the primary imaging modality. OBJECTIVE: To study characteristic MRI findings and the diagnostic accuracy of MRI in pediatric deep neck infections. MATERIALS AND METHODS: We retrospectively studied a cohort of pediatric patients who underwent a neck 3-tesla MRI study over a five-year period. Inclusion criteria were: 1) emergency MRI findings indicating an infection, 2) infection as the final clinical diagnosis, 3) diagnostic image quality verified by the radiologist reading the study and 4) age under 18 years. Patient record data, including surgery reports, were compared with the MRI findings. RESULTS: Data of 45 children were included and analysed. Compared to adults, children had a higher incidence of retropharyngeal infection and lymphadenitis, and a lower incidence of peritonsillar/parapharyngeal infection. MRI showed evidence of an abscess in 34 children. Of these 34 patients, 24 underwent surgery, which confirmed an abscess in 21 but no abscess in three patients. In addition, three patients underwent surgery without MRI evidence of abscess, and an abscess was found in one of these cases. The measures of diagnostic accuracy among the children were sensitivity 0.96, specificity 0.77, positive predictive value 0.89, negative predictive value 0.91 and accuracy 0.89. Compared with adults, children had lower C-reactive protein, but a similar proportion of them had an abscess, and abscess size and rate of surgery were similar. CONCLUSION: Despite the differences in the infection foci, emergency MRI in children had equal diagnostic accuracy to that in adults.

Clinical and prognostic significance of emergency MRI findings in neck infections.

OBJECTIVES: Due to its superior soft-tissue contrast and ability to delineate abscesses, MRI has high diagnostic accuracy in neck infections. Whether MRI findings can predict the clinical course in these patients is unknown. The purpose of this study was to determine the clinical and prognostic significance of various MRI findings in emergency patients with acute neck infections. MATERIALS AND METHODS: We retrospectively reviewed the 3-T MRI findings of 371 patients with acute neck infections from a 5-year period in a single tertiary emergency radiology department. We correlated various MRI findings, including retropharyngeal (RPE) and mediastinal edema (ME) and abscess diameter, to clinical findings and outcomes, such as the need for intensive care unit (ICU) treatment and length of hospital stay (LOS). RESULTS: A total of 201 out of 371 patients (54%) with neck infections showed evidence of RPE, and 81 out of 314 patients (26%) had ME. Both RPE (OR = 9.5, p < 0.001) and ME (OR = 5.3, p < 0.001) were more prevalent among the patients who required ICU treatment than among those who did not. In a multivariate analysis, C-reactive protein (CRP) levels, RPE, and maximal abscess diameter were independent predictors of the need for ICU treatment, and CRP, ME, and maximal abscess diameter were independent predictors of LOS. CONCLUSION: In patients with an acute neck infection that requires emergency imaging, RPE, ME, and abscess diameter, as shown by MRI, are significant predictors of a more severe illness. KEY POINTS: • Two hundred one out of 371 patients (54%) with neck infection showed evidence of retropharyngeal edema (RPE), and 81 out of 314 patients (26%) had mediastinal edema (ME). • Maximal abscess diameter, RPE, and C-reactive protein (CRP) were independent predictors of the need for intensive care unit (ICU) treatment, and maximal abscess diameter, ME, and CRP were independent predictors of length of hospital stay. • Prognostic significance of MRI findings was evident also while controlling for CRP values.

Volumetric Bone Mineral Density in Cementless Total Hip Arthroplasty in Postmenopausal Women: Effects on Primary Femoral Stem Stability and Clinical Recovery.

BACKGROUND: In cementless total hip arthroplasty, femoral stems should preferably not migrate at all postoperatively. This goal is difficult to achieve in postmenopausal women with impaired bone quality. Here, we explored the clinical importance of initial stem migration, measured by radiostereometric analysis (RSA), in women who underwent quantitative computed tomography (CT) of the involved hip preoperatively. METHODS: A prospective cohort of 65 postmenopausal women (mean age, 69 years) with hip osteoarthritis and Dorr type-A or B femoral anatomy underwent total hip arthroplasty with implantation of a tapered, single-wedge femoral stem. Volumetric bone mineral density (BMD) was measured using quantitative CT. Femoral stem translation and rotation were measured using model-based RSA within 3 days after the surgical procedure and were repeated at 3, 5, and 11 months. Postoperative recovery parameters included walking speed, walking activity, and patient-reported outcome measures. Subjects were categorized into 2 groups according to the magnitude of initial 5-month stem subsidence (<2 mm or ≥2 mm); RSA outliers (n = 7) were analyzed separately. RESULTS: Subjects with stem subsidence of ≥2 mm (mean, 3.09 mm [95% confidence interval (CI), 2.70 to 3.47 mm]) had lower intertrochanteric volumetric BMD (p = 0.008). Subjects with subsidence of <2 mm (mean, 0.80 mm [95% CI, 0.51 to 1.09 mm]) had faster improvement of patient-reported outcome measures and exhibited faster walking speed (p = 0.007) and greater walking activity (p = 0.010) at 11 months as well as better Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (p = 0.002) and RAND 36-Item Health Survey mental component scores (p = 0.006) at 2 years. All cohort stems were osseointegrated at 2 years. CONCLUSIONS: Femoral stem stability and resistance to subsidence were sensitive to adequate intertrochanteric volumetric BMD. Low intertrochanteric volumetric BMD was associated with greater stem migration. With initial migration, clinical recovery was slower and patient-reported outcome measures were less satisfactory. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial.

BACKGROUND: Nontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years. MATERIALS AND METHODS: One hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA). RESULTS: A total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P = .33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P = .85). There were no significant differences (P = .84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P = .74) and patient satisfaction (P = .83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P = .538) or CTA (P = .485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P = .0045). CONCLUSIONS: On the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.

Overstay and Readmission in Ear, Nose, and Throat Day Surgery-Factors Affecting Postanesthesia Course.

AIMS: Many procedures in ear, nose, and throat (ENT) day surgery are carried out under local anesthesia in Finland, whereas many other countries use general anesthesia. We investigated overstay and readmission rates in local and general anesthesia at Helsinki University Hospital. MATERIAL AND METHODS: We conducted a retrospective study on ENT (n = 1011) day surgery patients within a 3-month period using the hospital's surgery database to collect data pertaining to anesthesia, overstays, readmissions, and contacts within 30 days of surgery. OBJECTIVES: We examined the effect of American Society of Anesthesiologists (ASA) class, age, sex, type of procedure, and anesthesia type on overstay, contact, and readmission rates. RESULTS: A multivariable logistic regression model included ASA class, age, sex, type of procedure, and anesthesia (local vs general). Sex, age, and type of procedure had an effect on the outcomes of overstay, readmission, or contact. With general anesthesia, 3.2% (n = 23) had an overstay or readmission compared to 1.4% (n = 4) after local anesthesia. This was mainly explained by the number of study outcomes in tonsillar surgery that was performed only in general anesthesia. CONCLUSIONS: Day surgery could be done safely using local anesthesia, as the number of study outcomes was no greater than in general anesthesia. Sex, type of procedure, and age affected the rate of study outcomes, but ASA class and anesthesia form did not. Our overstay, contact, and readmission rates are on the same level, or lower, than in international studies.

The Characteristics of Postoperative Mediastinitis During the Changing Phases of Cardiac Surgery.

BACKGROUND: Mediastinitis is a serious complication of open heart surgery associated with high mortality, considerable health care costs, and prolonged hospital stay. We examined characteristics and incidence of mediastinitis during 29 years when indications and patient material have been in a process of change. METHODS: This was a retrospective population-based study comprising all mediastinitis patients more than 16 years of age after open heart surgery between 1990 and 2018 from a population of 1.7 million. Patient records of 50 mediastinitis patients from 2004 to 2014 were reviewed and compared with 120 patients from 1990 to 1999. RESULTS: Annual mediastinitis rate varied 0% to 1.5% with a decreasing trend-from a level exceeding 1.2% to approximately 0.3%-over the study period. In 2004 to 2014 patients with mediastinitis were older, more often smokers, and more often had diabetes mellitus and renal insufficiency than in 1990 to 1999. No difference in length of hospital treatment, antibiotic prophylaxis or treatment, intensive care unit treatment, or mortality was observed between 1990 to 1999 and 2004 to 2014. Coronary artery bypass graft surgery became less common and valve replacement and hybrid operations more common among operations leading to mediastinitis. Staphylococcus aureus increased (from 25% to 56%, p = .005) whereas coagulase-negative staphylococci (46% to 23%, P < .001) and gram-negative bacteria (18% to 12%, P = .033) decreased as causative agents. Surgery for mediastinitis remained similar except introduction of vacuum-assisted closure treatment. CONCLUSIONS: The rate of mediastinitis decreased during these 29 years. No difference in 30-day mortality in mediastinitis was seen: 0.9% in 1990 to 1999 and 2% in 2004 to 2014.