Attention fusion network with self-supervised learning for staging of osteonecrosis of the femoral head (ONFH) using multiple MR protocols.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) is characterized as bone cell death in the hip joint, involving a severe pain in the groin. The staging of ONFH is commonly based on Magnetic resonance imaging and computed tomography (CT), which are important for establishing effective treatment plans. There have been some attempts to automate ONFH staging using deep learning, but few of them used only MR images. PURPOSE: To propose a deep learning model for MR-only ONFH staging, which can reduce additional cost and radiation exposure from the acquisition of CT images. METHODS: We integrated information from the MR images of five different imaging protocols by a newly proposed attention fusion method, which was composed of intra-modality attention and inter-modality attention. In addition, a self-supervised learning was used to learn deep representations from a large amount of paired MR-CT dataset. The encoder part of the MR-CT translation network was used as a pretraining network for the staging, which aimed to overcome the lack of annotated data for staging. Ablation studies were performed to investigate the contributions of each proposed method. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the performance of the networks. RESULTS: Our model improved the performance of the four-way classification of the association research circulation osseous (ARCO) stage using MR images of the multiple protocols by 6.8%p in AUROC over a plain VGG network. Each proposed method increased the performance by 4.7%p (self-supervised learning) and 2.6%p (attention fusion) in AUROC, which was demonstrated by the ablation experiments. CONCLUSIONS: We have shown the feasibility of the MR-only ONFH staging by using self-supervised learning and attention fusion. A large amount of paired MR-CT data in hospitals can be used to further improve the performance of the staging, and the proposed method has potential to be used in the diagnosis of various diseases that require staging from multiple MR protocols.

A Fibroma of Tendon Sheath Causing Carpal Tunnel Syndrome: A Case Report of an Atypical Clinical Presentation.

Fibroma of the tendon sheath is a benign slow-growing fibrous tumor. Although rare, cases occurring in the upper extremities usually involve the fingers. It appears as a well-defined, roundor oval-shaped mass originating from the flexor tendon. Abundant fibrous stroma makes fibromas appear as a low intensity mass in all MRI sequences. Most of the fibromas manifest as painless soft tissue masses. Herein, we report a case of fibroma of the tendon sheath with an unusual clinical presentation, triggering carpal tunnel syndrome during wrist movement.

Community-Based Pre-Hospital Electrocardiogram Transmission Program for Reducing Systemic Time Delay in Acute ST-Segment Elevation Myocardial Infarction.

BACKGROUND AND OBJECTIVES: In acute ST-segment elevation myocardial infarction (STEMI), on-site transmission of electrocardiogram (ECG) has been shown to reduce systemic time delay to reperfusion and improve outcomes. However, it has not been adopted in community-based emergency transport system in Korea. METHODS: Busan Regional Cardio-cerebrovascular Center and Busan Metropolitan City Fire and Safety Headquarters (BMFSH) jointly developed and conducted a pre-hospital ECG transmission program. Seven tertiary hospitals and 22 safety stations of BMFSH participated. Systemic time delay to reperfusion of STEMI patients in the program was compared with that of 95 patients transported by 119 emergency medical system (EMS) before the program was implemented. RESULTS: During the study period, 289 ECG transmissions were made by 119 EMS personnel, executed within 5 minutes in 88.1% of cases. Of these, 42 ECGs were interpreted as ST-segment elevation. Final diagnosis of STEMI was made in 20 patients who underwent primary percutaneous coronary intervention. With the program, systemic time delay to reperfusion was significantly reduced (median [interquartile range; IQR], 76.0 [62.2-98.7] vs. 90.0 [75.0-112.0], p<0.01). Significant reduction of door-to-balloon time was also observed (median [IQR], 45.0 [34.0-69.5] vs. 58.0 [51.0-68.0], p=0.03). The proportion of patients with systemic time delay shorter than 90 minutes rose (51.6% vs. 75.0%, p=0.08) with pre-hospital ECG transmission. CONCLUSIONS: We developed and implemented a community-based pre-hospital ECG transmission program for expeditious triage of STEMI patients. Significant reductions of systemic time delay and door-to-balloon time were observed. The expanded use of pre-hospital ECG transmission should be encouraged to realize the full potential of this program.

Clinical outcomes of a novel presbyopia-correcting soft contact lens with a small aperture.

PURPOSE: To investigate the efficacy and safety of a newly developed pinhole soft contact lens (Eyelike Pinhole II; Koryo Eyetech Co. Ltd.) for presbyopia correction. METHODS: This prospective clinical study enrolled 29 patients with presbyopia between October 2018 and December 2018. All participants wore the Eyelike Pinhole II in the non-dominant eye for >3 h/day for a period of 1 week. Binocular and monocular uncorrected near visual acuities, distance-corrected near visual acuity (DCNVA), uncorrected distance visual acuity, and corrected distance visual acuity (CDVA) were measured before and after the intervention. All visual acuities were measured in logarithm of the minimal angle of resolution (logMAR) units. In addition, binocular defocus curves were generated, and contrast sensitivity values were obtained under photopic and mesopic conditions before and after lens wear. RESULTS: The mean DCNVA of the treated eye and the mean binocular DCNVA improved from 0.34 ± 0.12 to 0.15 ± 0.14 (P < 0.001) and 0.31 ± 0.13 to 0.11 ± 0.10 (P < 0.001) logMAR, respectively, after pinhole contact lens wear. Although the mean CDVA of the treated eye deteriorated from -0.04 ± 0.05 to 0.02 ± 0.11 logMAR (P = 0.015), there was no significant change in the mean binocular CDVA (P = 0.79). The binocular defocus curve showed a significant improvement from -5.0 dioptres (D) to -1.0 D after pinhole contact lens wear. CONCLUSIONS: The newly developed Eyelike Pinhole II soft contact lens showed safe and effective outcomes; thus, it could be a promising option for the treatment of presbyopia.

Effects of Preservative-free 3% Diquafosol in Patients with Pre-existing Dry Eye Disease after Cataract Surgery: A Randomized Clinical Trial.

Dry eye disease (DED) after cataract surgery has become a critical concern, and various therapeutic options have been developed. Recently, preservative-free diquafosol ophthalmic solution has been introduced; however, its therapeutic effect on DED after cataract surgery has not been reported. We investigated the efficacy of preservative-free diquafosol in patients with pre-existing DED after cataract surgery. We divided subjects who were diagnosed with DED and scheduled to undergo cataract surgery, into 3 groups (preservative-free diquafosol, group 1; preservative-containing diquafosol, group 2; preservative-free hyaluronate, group 3), and each eye drops was administered 6 times daily after surgery. Tear break up time (TBUT), Ocular Surface Disease Index (OSDI), corneal staining score, lid margin abnormality, and meibum quality improved over time in group 1. Groups 1 and 2 had significantly superior TBUT, meibomian gland dysfunction grade, and meibomian gland expressibility throughout the study period than group 3. Meibum quality of group 1 was significantly better than group 2 at 1 and 3 months after surgery. Preservative-free diquafosol showed better efficacy in treating DED after cataract surgery than preservative-containing diquafosol or preservative-free hyaluronate. Preservative-free diquafosol may serve as a reliable option for the management of patients with pre-existing DED after phacoemulsification.

Lunate subchondral cysts: Are there specific radiologic findings for patients with symptomatic ulnocarpal impaction?

BACKGROUND: There are few clinical studies evaluating the relationship between lunate cysts and symptomatic ulnar impaction syndrome (UIS). The purpose of this study was to investigate the prevalence and relationship between lunate cysts and UIS by comparing data from patients with UIS against those without. MATERIALS AND METHODS: From March 2012 to January 2015, 375 patients who had undergone MRI or CT for reasons other than ulnar-sided wrist pain were classified into the 'asymptomatic group' (Group I). Thirty three patients who had been diagnosed with UIS were classified in the 'UIS group' (Group II). We determined whether any differences were present between the two groups and evaluated prognostic factors for lunate cysts. RESULTS: The prevalence of lunate cysts was significantly higher in Group II but only reached just above 50% (10.4% vs. 57.6%, p < 0.001]. Dorsal-side lunate cysts were more frequent than palmar side in Group I, while Group II had more cysts on the palmar side (74.4% vs. 52.6%, p = 0.001). Logistic regression analysis revealed that UIS and patient age was a significant factor for the presence of lunate cysts (odds ratio: 11.692, p < 0.001; odds ratio: 1.063, p < 0.001, respectively). However, positive ulnar variance or duration of symptom in Group II was not a predisposing factor for lunate cysts (odds ratio: 1.035, p = 0.598; odds ratio: 1.007, p = 0.877, respectively). CONCLUSION: Since positive ulnar variance or duration of symptom did not affect the formation of the lunate cyst and only slightly more than 50% (57.6%) of patients with UIS had a lunate cyst, it seems unlikely that these cysts are a pathognomonic finding. Surgeons can obtain some evidence from lunate cysts on radiographic exams, but care must be taken that this diagnosis is not made hastily or without due consideration.

Anterolateral ligament injury has a synergic impact on the anterolateral rotatory laxity in acute anterior cruciate ligament-injured knees.

PURPOSE: To investigate the prevalence of the anterolateral ligament (ALL) injuries and its role in rotatory laxity in acute anterior cruciate ligament (ACL)-injured knees. METHODS: Two-hundred and ninety-six consecutive patients with acute ACL injuries were evaluated retrospectively, excluding those with other ligament injury and undetectable path of ALL in MRI. Patients were divided into two groups based on the degree of ACL injury in arthroscopy (complete versus partial group). Logistic regression and discriminant analysis were performed to assess the risk of pivot shift test. RESULTS: A total of 169 patients were included (128 with complete and 41 with partial ACL rupture). Overall, 106/169 (62.7%) of ALL injuries were characterized, 87/128 (67.9%) in complete group, and 19/41 (46.3%) in partial group. The incidence of pivot shift was 120/128 (93.8%) and 14/41 (34.1%) in the complete and partial groups, respectively. The odds ratio in the pivot shift of combined ALL injury was found as 3.8 (95% CI 1.8-8.4) with the overall ACL injury, but higher as 17.1 (95% CI 3.1-96.4) with partial group. Higher grade of pivot shift showed a greater incidence of injury of ALL. Degree of ACL injury and ALL injury allowed 87.0% of correct classification of subsequent anterolateral rotatory laxity. CONCLUSION: Injury to the ALL could have a synergetic effect on anterolateral rotatory laxity in acute ACL-injured knee, however, its effect might be minor in case of complete tear. Careful assessment about combined ALL injury should be considered, especially in knees with high-grade pivot shift in acute ACL-injured knees. LEVEL OF EVIDENCE: Retrospective prognostic study, Level IV.

Fast and Scalable Hydrodynamic Synthesis of MnO2/Defect-Free Graphene Nanocomposites with High Rate Capability and Long Cycle Life.

The integration of metal oxides and carbon materials provides a great potential for enhancing the high energy and power densities of supercapacitors, but the rational design and scalable fabrication of such composite materials still remain a challenge. Herein, we report a fast, scalable, and one-pot hydrodynamic synthesis for preparing ion conductive and defect-free graphene from graphite and MnO2/graphene nanocomposites. The use of this hydrodynamic method using Taylor-Couette flow allows us to efficiently fast shear-exfoliate graphite into large quantities of high-quality graphene sheets. Deposition of MnO2 on graphene is subsequently performed in a fluidic reactor within 10 min. The prepared MnO2/graphene nanocomposite shows outstanding electrochemical performances, such as a high specific capacitance of 679 F/g at 25 mV/s, a high rate capability of 74.7% retention at an extremely high rate of 1000 mV/s, and an excellent cycling characteristic (∼94.7% retention over 20 000 cycles). An asymmetric supercapacitor device is fabricated by assembling an anode of graphene and a cathode of MnO2/graphene, which resulted in high energy (35.2 W h/kg) and power (7.4 kW/kg) densities (accounting for the mass of both electrodes and the electrolyte) with a high rate capability and long cycle life.

An intra-articular synovial lipoma of the hip, possibly causing osteoarthritis: a case report and review of the literature.

In this report, we present the case of an intra-articular synovial lipoma in a 58-year-old female with a coincident marked unilateral hip osteoarthritis. This patient suffered from right hip pain that developed gradually over 2 years. Physical examination noted decreased range of motion and evidence of impingement. MR and CT images showed an intra-articular fat-intense mass in the hip joint that was excised and confirmed as a synovial lipoma on histology. This case reveals that an intra-articular lipoma of the hip could be accompanied by pain or impingement and followed by hip osteoarthritis even in the absence of trauma.

Long-term efficacy and safety of ExPress implantation for treatment of open angle glaucoma.

AIM: To compare the long-term efficacy and safety of ExPress implantation and standard trabeculectomy in patients with primary open angle glaucoma (POAG). METHODS: In this retrospective study, we compared 17 eyes treated by ExPress implantation with 23 eyes treated by trabeculectomy. Efficacy was assessed according to the relevant intraocular pressure (IOP) values and success rates during the first year of follow-up. Postoperative corneal endothelial cell loss was also compared. RESULTS: The number of antiglaucoma medications and the IOP reduction were similar between the 2 groups during the follow-up period. Although the mean IOP was similar, the IOP-fluctuation rate during the early postoperative period was significantly lower in the ExPress group than in the trabeculectomy group (P=0.038). A Kaplan-Meier survival curve analysis showed no significant success-rate difference between the groups (P=0.810). The corneal endothelial cell loss rate, moreover, was significantly lower in the ExPress group (P=0.05). CONCLUSION: ExPress implantation compared with trabeculectomy showed similar IOP-reduction and success rates along with lower IOP fluctuation and endothelial cell loss rates. For this reason, it can be considered to be the treatment of choice for patients with advanced glaucoma or low corneal endothelial cell density.

Choroidal Thickness Variation According to Refractive Error Measured by Spectral Domain-optical Coherence Tomography in Korean Children.

PURPOSE: To assess choroidal thickness (CT) variation according to refractive errors using enhanced-depth imaging optical coherence tomography. METHODS: Eighty-nine eyes (in 89 children) <±6 diopter were categorized into three groups: hyperopia, emmetropia, and myopia, according to refractive error, and underwent choroidal scans using enhanced-depth imaging-optical coherence tomography. CT was measured at the fovea and at 1 mm and 3 mm nasal (N1 and N3), temporal (T1 and T3), superior (S1 and S3), and inferior (I1 and I3) from the fovea. RESULTS: Mean foveal CTs were 346.86 µm, 301.97 µm, and 267.46 µm in the hyperopia, emmetropia, and myopia groups, respectively (p < 0.05). CTs at N3 and T3 were 214.59 µm and 318.68 µm, 163.92 µm and 320.79 µm, and 153.93 µm and 295.61 µm in the hyperopia, emmetropia, and myopia groups, respectively (p < 0.05). All CTs in the hyperopia group were thicker than those of other groups (p < 0.05). Fovea was thickest and was significantly thicker than at N3 and I3 in hyperopia (p < 0.05). T3 thickness in the emmetropia and myopia groups was greater than thickness at other areas, particularly the nasal and inferior choroids (p < 0.05). CT was positively correlated with spherical equivalent (p = 0.029). CONCLUSIONS: In Korean children, CTs were greater in the hyperopia group than in the emmetropia and myopia groups. The temporal choroid was thicker than the nasal choroid, regardless of the refractive error. The thickest location in the hyperopia group was the fovea; however, the temporal choroid was thickest in the emmetropia and myopia groups.

Comparative effectiveness of lumbar epidural steroid injections using particulate vs. non-particulate steroid: an intra-individual comparative study.

OBJECTIVES: To perform an intra-individual comparison for the effectiveness of lumbar epidural steroid injection (ESI) between injections using particulate (triamcinolone) and non-particulate (dexamethasone) steroid. MATERIALS AND METHODS: This study included 162 patients(M:F = 60:102, mean age 66.3 years) who underwent lumbar ESI using dexamethasone(ESI_DEXA) from April 2013 to May 2013 and who had previously underwent lumbar ESI using triamcinolone(ESI_TRIAM) within 1 year. Degree of relative satisfaction, injection-free interval and injection frequency were determined. Subgroup analyses were also done according to the diagnosis, approach-methods, patients' ages and sex. RESULTS: Eighty-seven of 139 patients (62.6 %) responded that the effect of ESI_TRIAM was better than that of ESI_DEXA (p = 0.004). In the four subgroups-patients with herniated intervertebral disc (HIVD), who underwent transforaminal ESI, were under age 70 and were male patients-the proportion of patients who preferred ESI_TRIAM was significantly greater than the proportion patients who preferred ESI_DEXA in terms of relative satisfaction (p < 0.05). The injection-free interval of ESI_TRIAM was significantly longer than that of ESI_DEXA (p = 0.01). In the subgroup analyses, the patient groups HIVD, who underwent transforaminal ESI, under age 70 and female patients with longer injection-free interval of ESI_TRIAM than ESI_DEXA were statistically significant (p < 0.05). Other factors were not significant. CONCLUSION: The relative satisfaction with ESI_TRIAM was significantly better than that with ESI_DEXA in the same patient, and the injection-free interval after ESI_TRIAM was significantly longer than that after ESI_DEXA.

Lumbar facet joint injection: feasibility as an alternative method in high-risk patients.

OBJECTIVE: To evaluate the effectiveness of therapeutic facet joint steroid injections for symptoms caused by lumbar spinal stenosis in patients who are at risk of bleeding. METHODS: We analysed 134 patients who had previously undergone one-level bilateral facet joint steroid injections for lumbar radiculopathy caused by spinal stenosis from January 2011 to December 2012. All patients had a bleeding tendency due to several medical conditions. A retrospective chart review was conducted by one radiologist. Response was measured by using a five-point patient satisfaction scale. Evaluations of the relationship between possible outcome predictors were made using the chi-squared or Fisher's exact test, as appropriate. RESULTS: Among the 42 enrolled patients (male/female = 14/28; mean age, 58 years; range, 41-88 years), 25 patients (59.5 %) were classified to have received effective treatment; in 17 patients treatment was classified as ineffective. Eighteen (72 %) of the 25 patients with mild-to-moderate central canal stenosis had symptom relief, and 7 of the 17 (41.2 %) patients with severe central canal stenosis had symptom relief (P < 0.05). Other outcome predictors were not statistically significant. CONCLUSION: Therapeutic facet joint steroid injection is potentially effective for lumbar radiculopathy caused by spinal stenosis. This could be helpful in patients at risk of bleeding. KEY POINTS: • Epidural injection of steroids is a conventional treatment for lumbar radiculopathy. • Facet joint steroid injections showed similar therapeutic effects in lumbar spinal stenosis. • No serious complications, including bleeding, occurred with facet joint injections. • Facet joint steroid injection offers an alternative therapy in patients with bleeding risk.