Is It Growth or Natural History? Increasing Spinal Deformity After Sanders Stage 7 in Females With AIS.

BACKGROUND: Accurate prognosis and treatment decisions in adolescent idiopathic scoliosis (AIS) demand a reliable radiographic marker of growth cessation. Specifically, Sanders Stage 7 (SS7) is a useful marker of spine growth cessation in females and is proposed as a bracing endpoint. The purpose of this study was to determine the amount of curve progression noted in female individuals with AIS after achieving SS7. We hypothesize that a subset of patients continues to progress at a greater rate than the natural history at SS7. METHODS: This retrospective review included female patients with AIS treated at a single institution from May 2008 to 2018. Patients required a hand radiograph demonstrating SS7 and concurrent spine radiograph measuring <50 degrees, plus 2-year follow-up spine radiograph. Curve types were categorized by the modified Lenke Classification. Risser grade, menarche, height, weight, and bracing data were collected. Progression was defined as an increase of the main curve ≥5 degrees. Comparison between groups was analyzed using independent t tests and χ or Fisher exact tests as appropriate. Binary logistic regressions were used to construct a model predictive of progressing beyond 50 degrees or undergoing surgery. RESULTS: A total of 89 patients met inclusion criteria, average main curve magnitude 33 degrees (SD 9) at SS7 and 38 degrees (SD 11) at 2-year follow-up. Forty-five (51%) patients progressed ≥5 degrees and 17 (19%) progressed at least 10 degrees. Seventy patients had curves <40 degrees at SS7 and 22 (31%) progressed to >40 degrees at 2 years. Eleven (12%) patients progressed to >50 degrees or had surgery at 2-year follow-up. Receiver operating characteristic curve analysis identified a threshold of 39.5 degrees curvature at SS7 associated with progression to >50 degrees or surgery (area under the curve=0.94, P<0.001, sensitivity=100%, specificity=87%). Patients with initial curves >40 degrees did have additional height gained (2.1 cm; SD 1.5), but this was not different than those <40 degrees, P>0.05. In addition, no other variables had statistically significant association with those that progressed (P>0.05). CONCLUSIONS: A curve >40 degrees at SS7 is at high risk for progressing to a curve measuring >50 degrees or requiring surgery. Those with curves below this threshold still have potential to make clinically significant progression after skeletal maturity. Follow-up of patients beyond SS7 is essential for curves measuring >40 degrees. Reaching SS7 with a curve <50 degrees may not be the endpoint for curve progression, even if predictive of the end of spinal growth. LEVEL OF EVIDENCE: Level III-retrospective research study.

Pediatric Forearm Fractures Are Effectively Immobilized With a Sugar-Tong Splint Following Closed Reduction.

INTRODUCTION: Following closed reduction and initial casting of pediatric forearm fractures, loss of reduction (LOR) occurs in ∼5% to 75% of fractures. Sugar-tong splinting has been shown to maintain acceptable reduction in pediatric distal radius fractures while potentially avoiding issues associated with circumferential casting. We hypothesized that the sugar-tong splint would be an acceptable method for initial immobilization to prevent LOR in distal, mid-shaft, and proximal pediatric forearm fractures. METHODS: This is an IRB-approved, retrospective study. Inclusion criteria included pediatric patients age 4 to 16 years old, open growth plates, with a displaced forearm fracture (radius, ulna, or both bone) that underwent closed reduction. The clinical protocol involved closed reduction and application of a sugar-tong splint by an orthopaedic resident under conscious sedation in the emergency room. Clinical follow-up occurred at 1, 2, 4, and 6-week intervals with a long-arm cast overwrap applied at the initial clinic visit. Primary outcome was radiographic LOR which was defined as a change of >10 degrees of angulation on anterior posterior/lateral projections from initial postreduction radiograph or previous follow-up radiograph. The secondary outcome was the need for further intervention. RESULTS: Sixty-four (38%) patients demonstrated radiographic LOR with 90% of LORs occurring in the first 2 weeks. LOR was significantly more common in distal radius fractures [48/110 (44%)] than with either proximal [2/14 (14%), P=0.04] or mid-shaft radius fractures [7/41 (17%), P=0.004]. There was no difference in LOR by location for ulna fractures [proximal=2/13 (15%), middle=4/38 (11%), distal=20/77 (26%), P>0.08]. There was no difference in radial LOR in patients with isolated radius fractures compared with both bone forearm fracture (17/40 vs. 40/125, P=0.22), or ulnar LOR between isolated ulna and both bone forearm fracture (0/3 vs. 26/125, P>0.99). CONCLUSION: The sugar-tong splint is effective at maintaining reduction of pediatric forearm fractures similar to published rates for casting. While effective at all levels of the forearm, the sugar-tong splint performed best in proximal and mid-shaft forearm fractures. LEVEL OF EVIDENCE: Level IV.

Preoperative Symptoms in Femoroacetabular Impingement Patients Are More Related to Mental Health Scores Than the Severity of Labral Tear or Magnitude of Bony Deformity.

BACKGROUND: The purpose of this study was to determine the relationships between patient factors, mental health status, the condition of the local tissue, magnitude of bony deformity, and preoperative symptoms in a series of femoroacetabular impingement (FAI) patients. METHODS: From our prospective outcomes registry, we identified 64 patients with arthroscopically-treated labral tears and cam deformities. We assessed the correlations between patient factors (age, sex, body mass index, level of education), surgical findings (size of labral tear, presence of chondral lesions), mental health factors (VR-12 mental component score [MCS], depression, and preoperative use of psychotropic and/or opioid drugs), magnitude of FAI deformity (alpha and lateral center edge angles), and preoperative hip dysfunction and osteoarthritis outcome score (HOOS) subscales. Patient factors, surgical and radiographic findings, and preoperative HOOS scores were compared between patients with low and high MCS. RESULTS: Neither hip pathology nor patient-related factors significantly correlated with HOOS scores. On the contrary, MCS significantly correlated with HOOS symptom (ρ = 0.45, P < .001) and pain scores (ρ = 0.52, P < .001). Low MCS patients had significantly lower preoperative scores for all 5 HOOS subscales (P ≤ .002) and more frequent chondral lesions and comorbid depression (P ≤ .01). CONCLUSION: Symptom severity was significantly more related to mental health status than either the size of labral tear or FAI deformity. Patients with low MCS had significantly worse preoperative pain and self-reported function, and a greater prevalence of concomitant chondral lesions. Future studies are necessary to determine if earlier surgical treatment or preoperative psychological and/or pain coping interventions may improve outcomes for those with low MCS.

Assessing landscape scale wildfire exposure for highly valued resources in a Mediterranean area.

We used a fire simulation modeling approach to assess landscape scale wildfire exposure for highly valued resources and assets (HVR) on a fire-prone area of 680 km(2) located in central Sardinia, Italy. The study area was affected by several wildfires in the last half century: some large and intense fire events threatened wildland urban interfaces as well as other socioeconomic and cultural values. Historical wildfire and weather data were used to inform wildfire simulations, which were based on the minimum travel time algorithm as implemented in FlamMap. We simulated 90,000 fires that replicated recent large fire events in the area spreading under severe weather conditions to generate detailed maps of wildfire likelihood and intensity. Then, we linked fire modeling outputs to a geospatial risk assessment framework focusing on buffer areas around HVR. The results highlighted a large variation in burn probability and fire intensity in the vicinity of HVRs, and allowed us to identify the areas most exposed to wildfires and thus to a higher potential damage. Fire intensity in the HVR buffers was mainly related to fuel types, while wind direction, topographic features, and historically based ignition pattern were the key factors affecting fire likelihood. The methodology presented in this work can have numerous applications, in the study area and elsewhere, particularly to address and inform fire risk management, landscape planning and people safety on the vicinity of HVRs.

Three-dimensional, digital, and gross anatomy of the Lisfranc ligament.

BACKGROUND: There are inconsistencies in the descriptive anatomy of the Lisfranc ligament. No information is available on orientation of fibers or presence of bundles, nor are there 3-dimensional anatomic data on the ligaments or their attachments. This study assessed the 3-dimensional anatomy of the Lisfranc ligament and its attachment sites. METHODS: A total of 37 cadaver feet were dissected to expose the ligament attachments at the Lisfranc joint. The Lisfranc ligament and plantar ligament attachments were outlined separately and then removed with the attachment outlines preserved. A 3-dimensional digitizer was used to digitize bony and articular surfaces, as well as ligament attachment sites, at approximately 1 mm intervals; the positional accuracy was 0.23 mm. The surface areas of the entire bone, articular regions, and Lisfranc and plantar ligament attachment regions were determined and anatomic details were noted. RESULTS: The Lisfranc ligament had a single bundle in 73% of the specimens and 2 bundles in 27%. Both variations had a single attachment to the second metatarsal (M2; mean attachment surface area, 135 mm(2)). The single-bundle variation attached to the medial cuneiform (C1; mean attachment surface area, 140 mm(2)). The plantar ligament, C1-M2-M3, attached to the anterior plantar surface of the lateral aspect of C1 (mean attachment surface, 64 mm(2)) and had attachment sites at the bases of M2 and M3. Its fibers ran anteriorly and inferiorly, with attachments to the proximal inferomedial aspect of M2 (mean attachment surface, 63 mm(2)) and fibers extending to a smaller attachment at the plantar aspect of M3 (mean attachment surface area, 26 mm(2)). CONCLUSION: The Lisfranc ligament is variable in anatomy and can have a single- or double-bundle arrangement. Its area of attachment is larger than that of the plantar ligament. CLINICAL RELEVANCE: Anatomic descriptions of location, dimensions, and variability in the position and surface area of the ligament attachment sites and of orientation of the bundles provide information for future attempts at repair or reconstruction of the Lisfranc ligament.

Accuracy of citation and quotation in foot and ankle surgery journals.

BACKGROUND: A recent review of technical editing of research suggests that over one third of references cited in articles in medical journals have some inaccuracies and one fifth of quotations to references in these articles are not accurate. METHODS: Two hundred and forty-nine citation references and 408 quotes from 25 articles published in 5 orthopaedic journals were randomly selected to determine referencing accuracy. The presence of citation errors was examined by 1 of the authors while the presence of quotation errors was determined by 2 of the authors. Full copies of articles as well as the references were obtained to compare the accuracies. RESULTS: The total citation error rate was 41% (103 out of 249 references), and the total quotation error rate was 20% (80 out of 408 quotes) for the 5 orthopaedic journals. CONCLUSION: Citation and quotation errors were still relatively common in orthopaedic journals. While we did not identify any factors associated with citation and quotation errors, the use of technical editing may reduce the amount of citation errors. CLINICAL RELEVANCE: Readers and authors should be aware that many citations of studies are inaccurate and one should review the original source if it is to be used in another publication or to guide clinical treatment.

CT density analysis of the medial cuneiform.

BACKGROUND: A cannulated lag screw inserted through the medial cuneiform into the base of the second metatarsal is often utilized to reduce the diastasis and aid healing of Lisfranc injuries. Also procedures such as a midfoot or a Lapidus arthrodesis require adequate implant-bone purchase in the medial cuneiform. The medial cuneiform contains cancellous bone of varying density. Knowledge of density variation may be helpful for implant usage and manufacturing of area specific implants. METHODS: In 60 randomly selected patients, mean computed tomography (CT) intensity in Hounsfield units was measured at 12 sampled locations within the medial cuneiform and served as a proxy for bone density. The patients' age, gender, and race were recorded. An analysis of variance (ANOVA) assessed the effect of age, gender, race, and sample site on bone density. Statistical testing assumed 95% level of confidence. RESULTS: ANOVA showed age, gender, and sample site had significant effects (P < .001) on bone density, though race had no significant effect (P = .28). The distal-dorsal-lateral (DDL) site was significantly denser than all other sites (P < .001) except the middle-dorsal-lateral (MDL) (P = .53). The proximal-plantar-lateral (PPL) site was significantly less dense than all other sites (P < .001) except the middle-plantar-lateral/medial and the proximal-plantar-medial sites (P < .14). A general trend of density increasing in the distal and dorsal directions was evident, and within the dorsal sites there was a trend of increasing density in the lateral direction. CONCLUSION: This is the first study to date to measure density of the medial cuneiform using living subjects. The sample size of 60 patients was also the largest of any study measuring density of this bone. We conclude that the densest area of the medial cuneiform is the most anterior, dorsal, and lateral portion. CLINICAL RELEVANCE: The findings of this study may indicate the most optimal area for implant purchase in the medial cuneiform when reducing the diastasis between the base of the second metatarsal and medial cuneiform and for stabilization of the medial column.

Brote epidémico de meningoencefalitis eosinofílica en una comunidad rural / Eosinophilic meningoencephalitis outbreak in a rural community

La infección por el nematodo Angiostrongylus cantonensis es la causa mßs frecuente de meningoencefalitis eosinofílica. La mayoría de los casos aparecen de forma aislada aunque se han descrito numerosos brotes epidémicos. Describir las manifestaciones clínicas y las características del líquido cefalorraquídeo y otros exámenes complementarios de 11 pacientes con diagnóstico de meningoencefalitis eosinofílica. Se trata de un estudio de serie de casos, de 11 enfermos admitidos en el Hospital General Universitario Dr Gustavo Aldereguía Lima con el diagnóstico de meningoencefalitis eosinofílica. Estos pacientes provenían de un mismo centro de trabajo, situado en un área rural, y sus síntomas clínicos coincidieron en el tiempo (enero-febrero 2006). Los síntomas predominantes fueron cefalea persistente (100 por ciento), parestesias e hiperestesias cutáneas (100 por ciento), mialgias (45 por ciento), trastornos visuales (45 por ciento), rigidez nucal (18 por ciento), parálisis facial periférica en 2 casos (18 por ciento). Solo un enfermo refirió fiebre. El diagnóstico de meningoencefalitis por A. cantonensis debe sospecharse en todo enfermo con cefalea persistente, parestesias e hiperestesias, aun en ausencia de fiebre y rigidez nucal. La presencia de eosinofilia en sangre periférica asociada a los síntomas anteriores sugiere el diagnóstico. La pleocitosis con un porcentaje elevado de eosinófilos es característico de esta enfermedad, pero la ausencia de eosinófilos en el líquido cefalorraquídeo no niega el diagnóstico. Es frecuente que ocurra en alguna etapa un predominio de linfocitos. Con la descripción de esta serie de casos se presenta el primer reporte de un brote epidémico de meningoencefalitis eosinofílica ocurrido en Cuba.

The infection by nematode Angiostrongylus cantonensis is the most frequent cause of eosinophilic meningoencephalitis. Most of cases occur in isolation although numerous outbreaks have been described. To describe the clinical manifestations and the characteristics of the cerebrospinal fluid and other supplementary exams from 11 patients diagnosed as eosinophilic meningoencephalitis carriers. A case study of eleven patients diagnosed with eosinophilic meningoencephalitis and admitted to Dr Gustavo Aldereguía Lima general university hospital. These patients worked at the same workplace located in a rural area and their clinical symptoms appeared in the same period of time (january to february, 2006). Predominant symptoms were persistent headache (100 percent of cases 9, cutaneous paresthesia and hyperesthesia (100 percent), myalgias (45 percent), impaired vision (45 percent), neck rigidity (18 percent), peripheral facial paralysis in two cases (18 percent). One single patient said that he had got fever. Meningoencephalitis caused by A. cantonensis should be suspected whenever a person suffers from persistent headache, paresthesias and hyperesthesias, even when neither fever nor neck rigidity is declared. Eosinophilia in peripheral blood associated to previous symptoms may indicate such a diagnosis. Pleocytosis, in which the percentage of eosinophils is high, is a characteristic of this disease; however, the lack of eosinophils in the cerebrospinal fluid does not reject this diagnosis. It is frequent that at some stage, lymphocytes will be predominant. The description of this case study allows us to present the first report of an outbreak of eosinophilic meningoencephalitis occurred in Cuba.

Meningoencefalitis eosinofílica: presentación y enseñanzas del primer caso de un brote / Eosinophilic meningoencephalitis: presentation and teachings of the first case of an outbreak

Paciente masculino, de 35 años de edad, procedente de la comunidad rural 5 de Septiembre, Rodas, admitido en el hospital Dr Gustavo Aldereguía Lima, por cefalea pulsátil persistente, con proyección ocular de 5 sem de evolución, hiperestesia cutánea en regiones occipital, lateral derecha del cuello, dorsal izquierda y muslo derecho. Se realizó examen físico que sólo mostró ligero dolor a la flexión del cuello. Se constató eosinofilia de 11 por ciento. Se halló líquido cefalorraquídeo de 950 leucocitos x mm3, con predominio de linfocitos y 10 por ciento de eosinófilos. Se planteó el diagnóstico de meningitis eosinofílica por Angiostrongylus cantonensis. Se conoció que varios compañeros de trabajo del enfermo tenían síntomas parecidos y que existía alarma en la comunidad. Se estudió el caso, con el planteamiento de una entidad que no se piensa en ella en la práctica cotidiana, por lo cual se pudo desenredar la madeja tejida alrededor de varios casos cuyo origen inicialmente no estaba muy claro.

The case of a 35-year-old male from 5 de Septiembre rural community, Rodas, admitted in Dr Gustavo Aldereguía Lima Hospital due to persistent pulsatile headache, with ocular projection of 5 weeks of evolution, cutaneous hyperesthesia in occipital region, right lateral region of the neck, left dorsal region and right thigh, was presented. The physical examination only showed mild pain on flexing the neck. 11 percent of eosinophilia was confirmed. CSF of 950 leukocytes x mm3, with predominance of lymphocytes and 10 percent of eosinophiles was found. The diagnosis of eosinophilic meningitis caused by Angiostrongylus cantonensis was established. It was known that several work mates of the patient had similar symptoms and that there was alarm in the community. The case was studied with the presentation of an entity that is not considered in the daily practice, which made possible to clarify some cases whose origin was not very clear at the beginning.

Dos casos de meningitis crónica por Angiostrongylus cantonensis / Two patients with chronic meningitis due to Angiostrongylus cantonensis

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Características epidemiológicas de la hepatitis C en donantes de sangre / Epidemiological characteristics of hepatitis C in blood donors

Se presentó un estudio de casos y controles (60 y 120 respectivamente) en donantes de sangre del Banco Provincial de Cienfuegos. Los casos fueron aquellos que se identificaron como positivos en la prueba de detección de anticuerpos contra el virus C de la hepatitis (VHC) y los controles, los donantes seleccionados con prueba negativa (test de ELISA de tercera generación). Se trató de estimar la prevalencia de factores de riesgo para adquirir hepatitis C en donantes de sangre y medir la fuerza de asociación entre factores de riesgo y aparición de infección por VHC. Se comprobó que las variables de riesgo con valores más altos de los odds ratio (con significación estadística) fueron las transfusiones recibidas, tratamientos parenterales y antecedentes de enfermedad de transmisión sexual (ETS). Se halló alta prevalencia de asma entre los pacientes seropositivos al VHC (23 por ciento) lo que pudiera estar relacionado con la vía de transmisión percutánea por tratamientos parenterales repetidos

Características clínicas y morfológicas de la hepatitis C en donantes / Clinical and morphological characteristics of hepatitis C in donors

Se estudió una serie de 60 sujetos donantes de sangre con presencia de anticuerpos contra el virus C de la hepatitis (Ac VHC). Se trató de identificar la expresión clínica de la enfermedad por VHC en donantes, de conocer los resultados laparoscópicos e histológicos y de evaluar la concordancia entre la visión endoscópica y los informes histológicos del hígado en los casos con biopsias. Se observó que la infección por VHC en donantes cursó de forma silente; sin embargo, el 62 porciento de ellos tenían alteraciones histológicas hepáticas las cuales probablemente estuvieron relacionadas con este agente viral. Se halló pobre concordancia entre diagnóstico laparoscópico y resultados histológicos. El análisis de la sensibilidad y la especificidad, así como el valor predictivo positivo y el negativo aplicados a la laparoscopia, demuestran las limitaciones de esta prueba para el diagnóstico de hepatitis crónica, el cual debe ser confirmado histológicamente

Influenza: actualidad y reto / Influenza: present time and challenge

El Consejo de Actividades Científicas del HPCQD Dr Gustavo aAldereguía Lima de Cienfuegos invita a mesa redonda a un epidemiólogo, dos internistas y un neumólogo, para dar respuesta a una serie de interrogantes sobre la influenza y un probable brote epidémico en el país y en la provincia. Se analizan entre otros aspectos relacionados con ésta enfermedad; cuales son las principales características epidemiológicas y la situación actual de la influenza en la provincia, como se transmite y produce la enfermedad, cuales son sus principales complicaciones, terapeútica a seguir y efectividad de la vacunación

Coma hiperosmolar: veinte años después / Hyperosmolar coma: after twenty years

Se analizan algunas variables clínicas, humorales y de tratamiento en 2 series de pacientes que fueron hospitalizados por coma hiperosmolar no cetoacidótico en 2 épocas diferentes, una de 1967 a 1973, con 14 enfermos y 6 fallecidos; otra de 1983 a 1988 con 15 pacientes y 6 fallecidos. Se precisa el resultado final al egreso y se comparan los datos principales en ambos grupos. Se comprueba en los enfermos que fallecieron una edad promedio superior y una mayor demora en el tiempo que media entre el ingreso en el hospital y el diagnóstico y tratamiento del coma hiperosmolar. Se comentan los resultados de ambas series y se hacen conclusiones