Safety of Gadoxetate Disodium for Hepatobiliary MRI in Children and Adolescents.

Background Despite a proven role in the characterization of liver lesions, use of the gadolinium-based contrast agent (GBCA) gadoxetate disodium at MRI is limited in children due to a lack of comparative safety data. Purpose To evaluate the safety of the GBCA gadoxetate disodium (a linear ionic hepatobiliary contrast agent [HBA]) in children and adolescents, compared with extracellular contrast agents (ECA). Materials and Methods A retrospective analysis was conducted in children and adolescents aged 18 years or younger who underwent HBA-enhanced MRI at one of three tertiary hospitals from January 2010 to December 2022. The incidence of GBCA-associated acute adverse events was compared between MRI examinations with a HBA and those with ECA. Severity was categorized according to American College of Radiology guidelines (mild, moderate, or severe). (a) Propensity score matching using multivariable logistic regression models and (b) inverse probability of treatment weighting analysis based on nine covariates (age, sex, asthma, allergic rhinitis, chronic urticaria or atopy, food allergy, drug allergy, premedication, and history of GBCA-associated adverse events) were used for confounder adjustment. Results A total of 1629 MRI examinations (ECA, n = 1256; HBA, n = 373) in 1079 patients were included (mean age, 8.6 years ± 6.5; 566 girls). The per-examination incidence of GBCA-associated acute adverse events showed no evidence of a difference, with rates of 0.9% (11 of 1256 examinations) for ECA and 1.3% (five of 373 examinations) for HBA (odds ratio [OR], 1.55 [95% CI: 0.54, 4.46]; P = .42). Acute adverse events were all mild with ECA, whereas with HBA, they were mild for four patients and moderate for one patient. There was no evidence of a difference in the incidence of acute adverse events, even in propensity score matching (OR, 1.33 [95% CI: 0.30, 5.96]; P = .71) and inverse probability of treatment weighting analysis (OR, 0.84 [95% CI: 0.25, 2.86]; P = .78). Conclusion Gadoxetate disodium showed no difference in acute adverse events compared with ECA in children and adolescents, with further large-scale pediatric studies required to confirm its safety. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Otero in this issue.

MS4A3 promotes differentiation in chronic myeloid leukemia by enhancing common ß-chain cytokine receptor endocytosis.

The chronic phase of chronic myeloid leukemia (CP-CML) is characterized by the excessive production of maturating myeloid cells. As CML stem/progenitor cells (LSPCs) are poised to cycle and differentiate, LSPCs must balance conservation and differentiation to avoid exhaustion, similar to normal hematopoiesis under stress. Since BCR-ABL1 tyrosine kinase inhibitors (TKIs) eliminate differentiating cells but spare BCR-ABL1-independent LSPCs, understanding the mechanisms that regulate LSPC differentiation may inform strategies to eliminate LSPCs. Upon performing a meta-analysis of published CML transcriptomes, we discovered that low expression of the MS4A3 transmembrane protein is a universal characteristic of LSPC quiescence, BCR-ABL1 independence, and transformation to blast phase (BP). Several mechanisms are involved in suppressing MS4A3, including aberrant methylation and a MECOM-C/EBPε axis. Contrary to previous reports, we find that MS4A3 does not function as a G1/S phase inhibitor but promotes endocytosis of common ß-chain (ßc) cytokine receptors upon GM-CSF/IL-3 stimulation, enhancing downstream signaling and cellular differentiation. This suggests that LSPCs downregulate MS4A3 to evade ßc cytokine-induced differentiation and maintain a more primitive, TKI-insensitive state. Accordingly, knockdown (KD) or deletion of MS4A3/Ms4a3 promotes TKI resistance and survival of CML cells ex vivo and enhances leukemogenesis in vivo, while targeted delivery of exogenous MS4A3 protein promotes differentiation. These data support a model in which MS4A3 governs response to differentiating myeloid cytokines, providing a unifying mechanism for the differentiation block characteristic of CML quiescence and BP-CML. Promoting MS4A3 reexpression or delivery of ectopic MS4A3 may help eliminate LSPCs in vivo.

Chirality-matched catalyst-controlled macrocyclization reactions.

Macrocycles, formally defined as compounds that contain a ring with 12 or more atoms, continue to attract great interest due to their important applications in physical, pharmacological, and environmental sciences. In syntheses of macrocyclic compounds, promoting intramolecular over intermolecular reactions in the ring-closing step is often a key challenge. Furthermore, syntheses of macrocycles with stereogenic elements confer an additional challenge, while access to such macrocycles are of great interest. Herein, we report the remarkable effect peptide-based catalysts can have in promoting efficient macrocyclization reactions. We show that the chirality of the catalyst is essential for promoting favorable, matched transition-state relationships that favor macrocyclization of substrates with preexisting stereogenic elements; curiously, the chirality of the catalyst is essential for successful reactions, even though no new static (i.e., not "dynamic") stereogenic elements are created. Control experiments involving either achiral variants of the catalyst or the enantiomeric form of the catalyst fail to deliver the macrocycles in significant quantity in head-to-head comparisons. The generality of the phenomenon, demonstrated here with a number of substrates, stimulates analogies to enzymatic catalysts that produce naturally occurring macrocycles, presumably through related, catalyst-defined peripheral interactions with their acyclic substrates.

Clinical and radiographic results of locking plate with medial support screw in Proximal Humerus fracture - the more, the better?

BACKGROUND: The calcar of the proximal humerus is a fundamental structure for medial humeral column support. This study aimed to assess the outcome of osteosynthesis across cases of unstable proximal humerus fractures (PHFs) with medial calcar comminution, following treatment with a PHILOS locking plate and medial support screw (MSS). METHODS: Between January 2010 and December 2018, we retrospectively analyzed the outcomes of 121 cases of osteosynthesis for PHFs with medial column disruption. For the medial support, at least one oblique screw was inserted within 5 mm of the subchondral bone in the inferomedial quadrant of the humeral head. All patients were categorized into two groups: 26 patients in the single MSS group, and 95 in the multiple MSS group. Follow-up after at least an year involved clinical and radiographic outcome evaluations, and correspondingly measuring the Constant-Murley score, University of California, Los Angeles (UCLA) shoulder scale, pain visual analogue scale (VAS), major complications, neck-shaft angle (NSA), humeral head height (HHH), and the eventual time to bone union. Risk factors for the major complications were assessed by multivariate logistic regression analyses. RESULTS: The cohort's mean age was 64.4 ± 15.4 years, and the mean follow-up duration was 19.5 ± 7.6 months. At the final follow-up, between the single MSS and multiple MSS groups, no significant differences in the Constant-Murley score (p = 0.367), UCLA score (p = 0.558), VAS (p = 0.571), time to bone union (p = 0.621), NSA loss (p = 0.424), and HHH loss (p = 0.364) were observed. The incidence of complications (p = 0.446) based on the number of MSS were not significantly different. The initial insufficient reduction after surgery (of NSA < 125°) was found to be a significant risk factor for post-surgical complications. CONCLUSIONS: To treat unstable PHFs, the use of at least one MSS along with a locking plate system is sufficient to achieve satisfactory outcomes. Successful operative treatment using a locking plate for PHF treatment is inherent in anatomical fracture reduction, coupled with medial column support.

Deep learning-based fully automatic Risser stage assessment model using abdominal radiographs.

BACKGROUND: Artificial intelligence has been increasingly used in medical imaging and has demonstrated expert level performance in image classification tasks. OBJECTIVE: To develop a fully automatic approach for determining the Risser stage using deep learning on abdominal radiographs. MATERIALS AND METHODS: In this multicenter study, 1,681 supine abdominal radiographs (age range, 9-18 years, 50% female) obtained between January 2019 and April 2022 were collected retrospectively from three medical institutions and graded manually using the United States Risser staging system. A total of 1,577 images from Hospitals 1 and 2 were used for development, and 104 images from Hospital 3 for external validation. From each radiograph, right and left iliac crest patch images were extracted using the pelvic bone segmentation model DeepLabv3 + with the EfficientNet-B0 encoder trained with 90 digitally reconstructed radiographs from pelvic computed tomography scans with a pelvic bone mask. Using these patch images, ConvNeXt-B was trained to grade according to the Risser classification. The model's performance was evaluated using accuracy, area under the receiver operating characteristic curve (AUROC), and mean absolute error. RESULTS: The fully automatic Risser stage assessment model showed an accuracy of 0.87 and 0.75, mean absolute error of 0.13 and 0.26, and AUROC of 0.99 and 0.95 on internal and external test sets, respectively. CONCLUSION: We developed a deep learning-based, fully automatic segmentation and classification model for Risser stage assessment using abdominal radiographs.

Clinical characteristics of tetralogy of Fallot with left pulmonary artery acute angulation on computed tomography.

Left pulmonary artery (LPA) stenosis with acute angulation commonly necessitates surgical revision in the treatment of tetralogy of Fallot (TOF). We investigated the clinical characteristics of acute angulation of the LPA in patients with TOF via computed tomography (CT). Between 2011 and 2022, 160 patients were diagnosed with TOF using CT. After excluding 28 patients due to insufficient records or age, 132 patients were included in the present analysis. The patients were divided into two groups according to the presence or absence of acute angulation of the LPA: group I (TOF with an acute angle of the LPA, n = 53) and group II (TOF without an acute angle of the LPA, n = 79). We retrospectively collected clinical data from electronic medical records. T-tests were used to analyze continuous variables (i.e., age, sex, weight, right ventricular outflow tract [RVOT] pressure on echocardiography, and distance to bifurcation), and Fisher's exact and chi-square tests were used to analyze categorical data (i.e., presence of the right aortic arch, pulmonary arterial atresia/hypoplasia, atrial septal defect [ASD], patent ductus arteriosus [PDA], and pulmonary valve). The groups did not differ significantly in terms of sex, weight, presence of the right aortic arch, pulmonary arterial atresia/hypoplasia, ASD, or distance to the bifurcation. Moreover, there was no significant difference between the presence and absence of PDA (P = 0.057); however, patients in group I were significantly older (143.2 ± 97.8 days) than those in group II (91.1 ± 76.0 days, P = 0.002). Furthermore, RVOT pressure was significantly higher among patients in group I (45.1 ± 22.5 mmHg) than in group II (25.0 ± 12.4 mmHg, P < 0.001). In the current study, acute angulation of the LPA in patients with TOF, as observed on CT, was associated with older age and higher RVOT pressure on echocardiography.

Biportal endoscopic discectomy versus tubular microscopic discectomy for treating single-level lumbar disc herniation in obese patients: a multicenter, retrospective analysis.

PURPOSE: In microscopic lumbar discectomy in obese patients, a correlation is found between the operation time and increase in estimated blood loss according to the increase in body mass index; however, no studies have investigated the outcomes of biportal endoscopic lumbar discectomy in obese patients. Therefore, this study aimed to compare the clinical and radiographic outcomes of microscopic and endoscopic discectomy in obese patients with lumbar herniated discs. METHODS: In this multicenter, retrospective study, clinical and radiological data were compared and analyzed in 73 obese patients with a body mass index of > 30 kg/m2 who underwent microscopic or biportal endoscopic lumbar discectomy. Clinical data on the visual analog scale (VAS), Oswestry disability index (ODI), and EuroQol-5D (EQ-5D) scores were measured, and radiological data were obtained using magnetic resonance imaging (MRI). RESULTS: This study enrolled 43 patients who underwent microscopic discectomy and 30 who underwent biportal endoscopic discectomy. The VAS, ODI, and EQ-5D scores in both groups improved after surgery compared with those before surgery, although there was no difference between the two groups. Although there was a difference in the incidence of recurrent disc herniation confirmed by MRI after surgery, no difference was found in the number of patients requiring surgery between the two groups. CONCLUSION: In obese patients with lumbar disc herniation that was not improved with conservative treatment, no significant clinical or radiological differences in outcomes were noted between microscopic and biportal endoscopic surgery methods. In contrast, minor complications were less common in the biportal group.

Publisher Correction: Complete reconstitution of the diverse pathways of gentamicin B biosynthesis.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A Case Report of Postinfectious Bronchiolitis Obliterans After Coronavirus Disease 2019 in a 10-Year-Old Child.

Coronavirus disease 2019 (COVID-19) is usually less severe in children and adolescents than in adults. However, it can cause severe respiratory illness in a small proportion of children with risk factors. Here, we report a rare case of a 10-year-old boy with postinfectious bronchiolitis obliterans that developed after pneumonia caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This patient was previously healthy apart from a high body mass index (BMI, 30.13; 99.6th percentile for the age bracket), history of preterm birth (35 weeks), and low birth weight (1,850 g). He had persistent exertional dyspnea after recovering from SARS-CoV-2-related pneumonia. Spirometry revealed obstructive lung disease with the following results: predicted forced vital capacity (FVC%pred), 71%; forced expiratory volume in 1 second (FEV1%pred), 63%; FEV1/FVC, 0.81; and forced expiratory flow25-75%pred, 55%. Chest computed tomography showed multifocal areas of parenchymal hyperlucency and mosaic attenuation in both lungs. This case suggests that careful observation of children with obesity and low birth weight is necessary after recovery from SARS-CoV-2-related pneumonia.

Author Correction: Complete reconstitution of the diverse pathways of gentamicin B biosynthesis.

In the version of this article originally published, reference to another structure of GenB1 was omitted (Dow, G. T., Thoden, J. B., & Holden, H. M. The three-dimensional structure of NeoB: an aminotransferase involved in the biosynthesis of neomycin. Protein Sci. 27, 945-956 (2018)). This paper is now cited as reference 32, and "Another structure of GenB1 was also reported independently during the revision of this article32" was added to the text in the Discussion section. This error has been corrected in the PDF and HTML versions of the article.

Complete reconstitution of the diverse pathways of gentamicin B biosynthesis.

Gentamicin B (GB), a valuable starting material for the preparation of the semisynthetic aminoglycoside antibiotic isepamicin, is produced in trace amounts by the wild-type Micromonospora echinospora. Though the biosynthetic pathway to GB has remained obscure for decades, we have now identified three hidden pathways to GB production via seven hitherto unknown intermediates in M. echinospora. The narrow substrate specificity of a key glycosyltransferase and the C6'-amination enzymes, in combination with the weak and unsynchronized gene expression of the 2'-deamination enzymes, limits GB production in M. echinospora. The crystal structure of the aminotransferase involved in C6'-amination explains its substrate specificity. Some of the new intermediates displayed similar premature termination codon readthrough activity but with reduced toxicity compared to the natural aminoglycoside G418. This work not only led to the discovery of unknown biosynthetic routes to GB, but also demonstrated the potential to mine new aminoglycosides from nature for drug discovery.

CT iterative vs deep learning reconstruction: comparison of noise and sharpness.

OBJECTIVES: To compare image noise and sharpness of vessels, liver, and muscle in lower extremity CT angiography between "adaptive statistical iterative reconstruction-V" (ASIR-V) and deep learning reconstruction "TrueFidelity" (TFI). METHODS: Thirty-seven patients (mean age, 65.2 years; 32 men) with lower extremity CT angiography were enrolled between November and December 2019. Images were reconstructed with two ASIR-V (blending factor of 80% and 100% (AV-100)) and three TFI (low-, medium-, and high-strength-level (TF-H) settings). Two radiologists evaluated these images for vessels (aorta, femoral artery, and popliteal artery), liver, and psoas muscle. For quantitative analyses, conventional indicators (CT number, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR)) and blur metric values (indicating the degree of image sharpness) of selected regions of interest were determined. For qualitative analyses, the degrees of quantum mottle and blurring were assessed. RESULTS: The higher the blending factor in ASIR-V or the strength in TFI, the lower the noise, the higher the SNR and CNR values, and the higher the blur metric values in all structures. The SNR and CNR values of TF-H images were significantly higher than those of AV-80 images and similar to those of AV-100 images. The blur metric values in TFI images were significantly lower than those in ASIR-V images (p < 0.001), indicating increased sharpness. Among all the investigated image procedures, the overall qualitative image quality was best in TF-H images. CONCLUSION: TF-H was the most balanced image in terms of image noise and sharpness among the examined image combinations. KEY POINTS: • Deep learning image reconstruction "TrueFidelity" is superior to iterative reconstruction "ASIR-V" regarding image noise and sharpness. • The high-strength "TrueFidelity" approach generated the best image quality among the examined image reconstruction procedures. • In iterative and deep learning CT image reconstruction, the higher the blending and strength factors, the lower the image noise and the poorer the image sharpness.

Comparison of noise-optimized linearly blended images and noise-optimized virtual monoenergetic images evaluated by dual-source, dual-energy CT in cardiac vein assessment.

BACKGROUND: The coronary venous system is frequently used as an entry route to the heart and treatment modalities for many cardiac diseases and many procedures. Consequently, evaluation of the coronary venous system and understanding cardiac vein anatomy is crucial. PURPOSE: To determine the optimal image set in a comparison of noise-optimized linearly blended images (F_0.6) and noise-optimized virtual monoenergetic images (VMI+) evaluated by dual-energy computed tomography (DECT) for cardiac vein assessment. MATERIAL AND METHODS: Thirty-four patients (mean age 58.2 ± 14.2 years) who underwent DECT due to chest pain were enrolled. Images were post-processed with the F_0.6, and VMI+ algorithms at energy levels in the range of 40-100 keV in 10-keV increments. Enhancement (HU), noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were objectively measured at two points in the great cardiac vein by consensus of two radiologists. Two blinded observers evaluated the subjective image quality of the great cardiac vein on a 4-point scale. RESULTS: HU, noise, and SNR peaked at 40 keV VMI+ (P < 0.05) among 50-100 keV VMI+. CNR peaked at 100 keV VMI+; however, there were no significant differences compared to CNR images processed at 40-90 keV VMI+. HU and noise were significantly higher in 40 keV VMI+ than F_0.6 images; however, both SNR and CNR were significantly higher in F_0.6 images. An assessment of subjective vein delineation revealed that F_0.6 images had the highest scores. CONCLUSION: F_0.6 images were superior to VMI+ and provided the optimal image set for cardiac vein assessment.

Application of High-Throughput Competition Experiments in the Development of Aspartate-Directed Site-Selective Modification of Tyrosine Residues in Peptides.

Herein we report a Cu-catalyzed, site-selective functionalization of peptides that employs an aspartic acid (Asp) as a native directing motif, which directs the site of O-arylation at a proximal tyrosine (Tyr) residue. Through a series of competition studies conducted in high-throughput reaction arrays, effective conditions were identified that gave high selectivity for the proximal Tyr in Asp-directed Tyr modification. Good levels of site-selectivity were achieved in the O-arylation at a proximal Tyr residue in a number of cases, including a peptide-small molecule hybrid.

Extracerebral choroid plexus papilloma in the pharynx with airway obstruction in a newborn: a case report.

BACKGROUND: Choroid plexus papillomas (CPPs) are rare, usually benign, neoplasms originating in the central nervous system. In this study, we present the first case of a giant airway-obstructing CPP in the pharynx of a newborn. CASE PRESENTATION: A cystic mass located in the pharynx was noted in a fetus at the 29th week of gestation. Elective cesarean section was performed at the 38th week of gestation with successful intubation and ex utero intrapartum treatment. On computed tomography, there was a huge airway-obstructing cystic mass in the choana and pharynx. Elective surgery with total excision was performed, and histological examination confirmed the diagnosis of CPP. CONCLUSION: We report the first case of an extracerebral airway-obstructing CPP in the pharynx of a newborn. Radiologic examinations are not enough for the diagnosis of CPPs, and complete excision of the tumor with histological confirmation is indispensable for accurate diagnosis and treatment.

A ribosome profiling study of mRNA cleavage by the endonuclease RelE.

Implicated in persistence and stress response pathways in bacteria, RelE shuts down protein synthesis by cleaving mRNA within the ribosomal A site. Structural and biochemical studies have shown that RelE cuts with some sequence specificity, which we further characterize here, and that it shows no activity outside the context of the ribosome. We obtained a global view of the effect of RelE on translation by ribosome profiling, observing that ribosomes accumulate on the 5'-end of genes through dynamic cycles of mRNA cleavage, ribosome rescue and initiation. Moreover, the addition of purified RelE to cell lysates shows promise as a method for generating ribosome footprints. In bacteria, profiling studies have suffered from relatively low resolution and have yielded no information on reading frame due to problems inherent to MNase digestion, the method used to degrade unprotected regions of mRNA. In contrast, we find that RelE yields precise 3'-ends that for the first time reveal reading frame in bacteria. Given that RelE has been shown to function in all three domains of life, RelE has potential to improve reading frame and shed light on A-site occupancy in ribosome profiling experiments more broadly.

What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability?

BACKGROUND: The triangular fibrocartilage complex (TFCC) tear is a common cause of ulnar-side wrist pain; however, its natural course is not well understood. QUESTIONS/PURPOSES: We sought (1) to determine the natural course of TFCC tears without distal radioulnar joint (DRUJ) instability, and (2) to identify the factors associated with poor prognosis after nonsurgical treatment of TFCC tears. METHODS: Over a 3-year period, we treated 117 patients with TFCC tears who did not have DRUJ instability. The diagnosis was made on the basis of ulnar-sided wrist pain, a positive ulnocarpal stress test or ulnar grinding test, and identification of a tear on MRI or CT arthrography. Of those, 25 were excluded during the initial evaluation period because they met the previously defined indications of surgery on the basis of clinical history. Another 19 patients (20%) were lost to followup before 6 months, and one patient was excluded because of prior wrist surgery, leaving 72 wrists in 72 patients for analysis in this retrospective study, which drew data from a review of electronic medical records of one institution. The group consisted of 42 men and 30 women, with a mean age of 40 years (range, 18-70 years). The study group was followed for a mean of 16 months (range, 6 to 36 months). We evaluated the pain VAS and patient-rated wrist evaluation (PRWE) at the initial visit, at 4, 8, and 12 weeks, and at more than 6 months after the initial visit. A PRWE score ≤ 20 points indicated complete recovery, and a PRWE score more than 20 points was considered an incomplete recovery. We used Kaplan-Meier survival analysis and Cox regression modelling to estimate the time to complete recovery and to identify factors associated with incomplete recovery among the seven possible factors of older age (≥ 45 years), male, obesity (body mass index ≥ 30 kg/m), dominant-hand involvement, chronic symptoms (≥ 6 months), traumatic tear, and ulnar-plus variance. RESULTS: The Kaplan-Meier survival analysis showed that estimated cumulative incidence of complete recovery was 30% (95% confidence interval [CI], 20-40) at 6 months and 50% (95% CI, 39-61) at 1 year. We could not find any risk factors among the seven candidate factors, including older age (hazard ratio [HR], 0.608; 95% CI, 0.34-1.087; p = 0.093), male (HR, 1.152; 95% CI, 0.667-1.991; p = 0.612), obesity (HR, 1.433; 95% CI, 0.603-3.402; p = 0.415), dominant hand involvement (HR, 1.808; 95% CI, 0.927-3.527; p = 0.082), chronic symptoms (HR, 0.763; 95% CI, 0.443-1.922; p = 0.133), traumatic tear (HR, 0.756; 95% CI, 0.432-1.32; p = 0.325), and ulnar plus variance (HR, 0.804; 95% CI, 0.461-1.404; p = 0.443). CONCLUSIONS: This study demonstrates that nonsurgical treatment is moderately successful for treating patients with TFCC tears without DRUJ instability. We recommend a minimum of 6 months nonsurgical treatment as the first-line treatment for this injury. Future studies are necessary to clarify predictors of persistent pain with nonsurgical treatment to avoid an unnecessary surgical delay. LEVEL OF EVIDENCE: Level III, prognostic study.

Does use of the 70° arthroscope improve the outcomes of arthroscopic débridement for chronic recalcitrant tennis elbow?

BACKGROUND: The use of a 70° arthroscope has been reported to provide better visualization of the extensor carpi radialis brevis origin at the lateral epicondyle. We aimed to compare the surgical outcomes of arthroscopic débridement using an additional 70° arthroscope with those using a 30° arthroscope alone in the treatment of chronic recalcitrant tennis elbow. METHODS: A total of 68 consecutive patients who received arthroscopic débridement for chronic recalcitrant tennis elbow were retrospectively reviewed. A 30° scope was used in 41 patients (mean age, 47 years; range, 26-61 years), whereas an additional 70° scope was used in 27 patients (mean age, 50 years; range, 34-61 years). Outcomes were assessed using a visual analog scale for pain and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire at the preoperative visit and at 3 months, 6 months, and 12 or more months after surgery. RESULTS: Both groups showed significant and progressive improvements in visual analog scale pain scores and Quick Disabilities of the Arm, Shoulder and Hand scores at 3 months, 6 months, and final follow-up (P < .05). However, no significant differences were found between the groups at all time points of measurement regarding those outcome measures (P > .05). In addition, the proportions of patients with excellent outcomes and those with clinically meaningful improvements were comparable between the groups (P = .397 and P = .558, respectively). CONCLUSION: The use of an additional 70° arthroscope did not provide a significant improvement in the outcomes of arthroscopic débridement for chronic recalcitrant tennis elbow.

Risk Estimation for Biliary Atresia in Patients with Neonatal Cholestasis: Development and Validation of a Risk Score.

Purpose To develop and validate a scoring system based on clinical and imaging features to predict the risk for biliary atresia in patients with neonatal cholestasis. Materials and Methods Patients with neonatal cholestasis who underwent both ultrasonography (US) and hepatobiliary scintigraphy (n = 480) were retrospectively identified from two tertiary referral hospitals from January 2000 to February 2017. Patients from one hospital were classified as the derivation cohort (n = 371), and those from the other hospital were classified as the validation cohort (n = 109). Clinical and imaging features associated with biliary atresia were assessed. Histopathologic or intraoperative cholangiographic findings served as the reference standard for biliary atresia. A prediction model was developed by using logistic regression and was then transformed into a scoring system. The scoring system was internally and externally validated. Results Among the 371 patients in the derivation cohort, 97 (26.15%) had biliary atresia. A scoring system was constructed with the following variables: full-term birth, presence of the triangular cord sign at US, abnormal gallbladder morphology at US, and failure of radioisotope excretion to the small bowel at hepatobiliary scintigraphy. The maximum possible score with this system is 7 points. This system enabled differentiation of biliary atresia in the derivation cohort (C statistic, 0.981; 95% confidence interval [CI]: 0.970, 0.992) and the validation cohort (C statistic, 0.995; 95% CI: 0.987, 1.000). The risk score also showed good calibration in both the derivation and the validation cohorts (P = .328 and P = .281, respectively). Conclusion A simple scoring system combining clinical and imaging features can help accurately estimate the risk for biliary atresia in patients with neonatal cholestasis.

Diagnostic Performance of Transient Elastography for Liver Fibrosis in Children: A Systematic Review and Meta-Analysis.

OBJECTIVE: We aimed to assess the diagnostic performance of transient elastography for evaluating liver fibrosis in children and adolescents. MATERIALS AND METHODS: A computerized search of Medline and Embase up to December 31, 2017, was performed to identify studies. Studies evaluating the diagnostic performance of transient elastography for the severity of liver fibrosis in children and adolescents were selected. Pooled sensitivity and specificity were calculated using hierarchic logistic regression modeling. Multiple subgroup analysis was performed. RESULTS: In this meta-analysis that included 11 original articles involving 723 patients, transient elastography showed a summary sensitivity of 95% (95% CI, 74-99%) and a specificity of 90% (95% CI, 81-95%) for the diagnosis of significant liver fibrosis (stage ≥ F2) in children. The hierarchic summary ROC AUC was 0.96 (95% CI, 0.94-0.98). Multiple subgroup analysis for the diagnosis of significant hepatic fibrosis showed clinically acceptable ranges of sensitivity and specificity across all subgroups. In additional subgroup analysis, the diagnostic accuracies of transient elastography according to the Metavir system were also within a clinically acceptable range, measured up to a sensitivity of 86% and specificity of 86% for diagnosing Metavir stage F4 fibrosis. CONCLUSION: Transient elastography showed highly accurate diagnostic performance for the diagnosis of liver fibrosis in children.