Two-stage approach for risk estimation of fetal trisomy 21 and other aneuploidies using computational intelligence systems.

OBJECTIVE: To estimate the risk of fetal trisomy 21 (T21) and other chromosomal abnormalities (OCA) at 11-13 weeks' gestation using computational intelligence classification methods. METHODS: As a first step, a training dataset consisting of 72 054 euploid pregnancies, 295 cases of T21 and 305 cases of OCA was used to train an artificial neural network. Then, a two-stage approach was used for stratification of risk and diagnosis of cases of aneuploidy in the blind set. In Stage 1, using four markers, pregnancies in the blind set were classified into no risk and risk. No-risk pregnancies were not examined further, whereas the risk pregnancies were forwarded to Stage 2 for further examination. In Stage 2, using seven markers, pregnancies were classified into three types of risk, namely no risk, moderate risk and high risk. RESULTS: Of 36 328 unknown to the system pregnancies (blind set), 17 512 euploid, two T21 and 18 OCA were classified as no risk in Stage 1. The remaining 18 796 cases were forwarded to Stage 2, of which 7895 euploid, two T21 and two OCA cases were classified as no risk, 10 464 euploid, 83 T21 and 61 OCA as moderate risk and 187 euploid, 50 T21 and 52 OCA as high risk. The sensitivity and the specificity for T21 in Stage 2 were 97.1% and 99.5%, respectively, and the false-positive rate from Stage 1 to Stage 2 was reduced from 51.4% to ∼1%, assuming that the cell-free DNA test could identify all euploid and aneuploid cases. CONCLUSION: We propose a method for early diagnosis of chromosomal abnormalities that ensures that most T21 cases are classified as high risk at any stage. At the same time, the number of euploid cases subjected to invasive or cell-free DNA examinations was minimized through a routine procedure offered in two stages. Our method is minimally invasive and of relatively low cost, highly effective at T21 identification and it performs better than do other existing statistical methods. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Dural sac cross-sectional area and morphological grade show significant associations with patient-rated outcome of surgery for lumbar central spinal stenosis.

PURPOSE: Lumbar central spinal stenosis (LSS) is one of the most common reasons for spine surgery in the elderly patient. Magnetic resonance imaging (MRI) represents the gold standard for the assessment of LSS and can be used to obtain quantitative measures of the dural sac cross-sectional area (DCSA) or qualitative measures (morphological grades A-D) of the rootlet/cerebrospinal fluid ratio. This study investigated the intercorrelation between these two MRI evaluation methods and explored their respective relationships with the patient baseline clinical status and outcome 12 months after surgery. METHODS: This was a retrospective analysis of prospectively collected data from 157 patients (88 male, 69 female; age 72 ± 7 years) who were undergoing first-time surgery for LSS. Patients with foraminal or isolated lateral stenosis were excluded. The Core Outcome Measures Index (COMI) was completed before and 12 months after surgery. Preoperative T2 axial MRIs were blinded and independently evaluated for DCSA and morphological grade. Spearman rank correlation coefficients described the relationship between the two MRI measures of stenosis severity and between each of these and the COMI baseline and change-scores (pre to 12 months' postop). Multiple logistic regression analysis (controlling for baseline COMI, age, gender, number of operated levels, health insurance status) was used to analyse the influence of stenosis severity on the achievement of the minimum clinically important change (MCIC) score for COMI and on global treatment outcome (GTO). RESULTS: There was a correlation of ρ = -0.69 (p < 0.001) between DCSA and morphological grade. There was no significant correlation between COMI baseline scores and either DCSA or morphological grades (p > 0.85). However, logistic regression revealed significant (p < 0.05) associations between stenosis ratings and 12-month outcome, whereby patients with more severe stenosis (as measured using either of the methods) benefited more from the surgery. Patients with a DCSA <75 mm2 or morphological grade D had a 4-13-fold greater odds of achieving the MCIC for COMI or a "good" GTO, compared with patients in the least severe categories of stenosis. CONCLUSIONS: Postoperative outcome was clearly related to the degree of preoperative radiological LSS. The two MRI methods appeared to deliver similar information, as given by the relatively strong correlation between them and their comparable performance in relation to baseline and 12-month outcomes. However, the qualitative morphological grading can be performed in an instant, without measurement tools, and does not deliver less clinically useful information than the more complex and time-consuming measures; as such, it may represent the preferred method in the clinical routine for assessing the extent of radiological stenosis and the likelihood of a positive outcome after decompression.

Relationship between sedimentation sign and morphological grade in symptomatic lumbar spinal stenosis.

PURPOSE: We aimed to study the relationship between two morphological parameters recently described on MRI images in relation to lumbar spinal stenosis (LSS): the first is the sedimentation sign (SedS) and the second is the morphological grading of lumbar stenosis. MATERIALS AND METHODS: MRIs from a total of 137 patients were studied. From those, 110 were issued from a prospective database of symptomatic LSS patients, of whom 73 were treated surgically and 37 conservatively based on symptom severity. A third group consisting of 27 subjects complaining of low back pain (LBP) served as control. Severity of stenosis was judged at disc level using the four A to D grade morphological classification. The presence of a SedS was judged at pedicle level, above or below the site of maximal stenosis. RESULTS: A positive SedS was observed in 58, 69 and 76% of patients demonstrating B, C and D morphology, respectively, but in none with grade A morphology. The SedS was positive in 67 and 35% of the surgically and conservatively treated patients, respectively, and in 8% of the LBP group. C and D morphological grades were present in 97 and 35% of patients in the surgically and conservatively treated group, respectively, and in 18% of the LBP group. Presence of a positive SedS carried an increased risk of being submitted to surgery in the symptomatic LSS group (OR 3.5). This risk was even higher in the LSS patients demonstrating grade C or D morphology (OR 65). DISCUSSION AND CONCLUSION: One-third of surgically treated LSS patients do not present a SedS. This sign appears to be a lesser predictor of treatment modality in our setting of symptomatic LSS patients compared to the severity of stenosis judged by the morphological grade.

Electronic Health Record Application Support Service Enablers.

There is a huge need for open source software solutions in the healthcare domain, given the flexibility, interoperability and resource savings characteristics they offer. In this context, this paper presents the development of three open source libraries - Specific Enablers (SEs) for eHealth applications that were developed under the European project titled "Future Internet Social and Technological Alignment Research" (FI-STAR) funded under the "Future Internet Public Private Partnership" (FI-PPP) program. The three SEs developed under the Electronic Health Record Application Support Service Enablers (EHR-EN) correspond to: a) an Electronic Health Record enabler (EHR SE), b) a patient summary enabler based on the EU project "European patient Summary Open Source services" (epSOS SE) supporting patient mobility and the offering of interoperable services, and c) a Picture Archiving and Communications System (PACS) enabler (PACS SE) based on the dcm4che open source system for the support of medical imaging functionality. The EHR SE follows the HL7 Clinical Document Architecture (CDA) V2.0 and supports the Integrating the Healthcare Enterprise (IHE) profiles (recently awarded in Connectathon 2015). These three FI-STAR platform enablers are designed to facilitate the deployment of innovative applications and value added services in the health care sector. They can be downloaded from the FI-STAR cataloque website. Work in progress focuses in the validation and evaluation scenarios for the proving and demonstration of the usability, applicability and adaptability of the proposed enablers.

Decision-making in lumbar spinal stenosis: A survey on the influence of the morphology of the dural sac.

Surgical decision-making in lumbar spinal stenosis involves assessment of clinical parameters and the severity of the radiological stenosis. We suspected that surgeons based surgical decisions more on dural sac cross-sectional area (DSCA) than on the morphology of the dural sac. We carried out a survey among members of three European spine societies. The axial T2-weighted MR images from ten patients with varying degrees of DSCA and morphological grades according to the recently described morphological classification of lumbar spinal stenosis, with DSCA values disclosed in half the assessed images, were used for evaluation. We provided a clinical scenario to accompany the images, which were shown to 142 responding physicians, mainly orthopaedic surgeons but also some neurosurgeons and others directly involved in treating patients with spinal disorders. As the primary outcome we used the number of respondents who would proceed to surgery for a given DSCA or morphological grade. Substantial agreement among the respondents was observed, with severe or extreme stenosis as defined by the morphological grade leading to surgery. This decision was not dependent on the number of years in practice, medical density or specialty. Disclosing the DSCA did not alter operative decision-making. In all, 40 respondents (29%) had prior knowledge of the morphological grading system, but their responses showed no difference from those who had not. This study suggests that the participants were less influenced by DSCA than by the morphological appearance of the dural sac. Classifying lumbar spinal stenosis according to morphology rather than surface measurements appears to be consistent with current clinical practice.

An overview of recent end-to-end wireless medical video telemedicine systems using 3G.

Advances in video compression, network technologies, and computer technologies have contributed to the rapid growth of mobile health (m-health) systems and services. Wide deployment of such systems and services is expected in the near future, and it's foreseen that they will soon be incorporated in daily clinical practice. This study focuses in describing the basic components of an end-to-end wireless medical video telemedicine system, providing a brief overview of the recent advances in the field, while it also highlights future trends in the design of telemedicine systems that are diagnostically driven.

Disc degeneration: current surgical options.

Chronic low back pain attributed to lumbar disc degeneration poses a serious challenge to physicians. Surgery may be indicated in selected cases following failure of appropriate conservative treatment. For decades, the only surgical option has been spinal fusion, but its results have been inconsistent. Some prospective trials show superiority over usual conservative measures while others fail to demonstrate its advantages. In an effort to improve results of fusion and to decrease the incidence of adjacent segment degeneration, total disc replacement techniques have been introduced and studied extensively. Short-term results have shown superiority over some fusion techniques. Mid-term results however tend to show that this approach yields results equivalent to those of spinal fusion. Nucleus replacement has gained some popularity initially, but evidence on its efficacy is scarce. Dynamic stabilisation, a technique involving less rigid implants than in spinal fusion and performed without the need for bone grafting, represents another surgical option. Evidence again is lacking on its superiority over other surgical strategies and conservative measures. Insertion of interspinous devices posteriorly, aiming at redistributing loads and relieving pain, has been used as an adjunct to disc removal surgery for disc herniation. To date however, there is no clear evidence on their efficacy. Minimally invasive intradiscal thermocoagulation techniques have also been tried, but evidence of their effectiveness is questioned. Surgery using novel biological solutions may be the future of discogenic pain treatment. Collaboration between clinicians and basic scientists in this multidisciplinary field will undoubtedly shape the future of treating symptomatic disc degeneration.

[Non fusion techniques in spinal surgery]. / Techniques de "non-fusion" en chirurgie rachidienne.

In order to prevent adjacent segment degeneration following spinal fusion new techniques are being used. Lumbar disc arthroplasty yields mid term results equivalent to those of spinal fusion. Cervical disc arthroplasty is indicated in the treatment of cervicobrachialgia with encouraging initial results. The ability of arthroplasty to prevent adjacent segment degeneration has yet to be proven. Although dynamic stabilization had not been proven effective in treating chronic low back pain, it might be useful following decompression of lumbar spinal stenosis in degenerative spondylolisthesis. Interspinal devices are useful in mild lumbar spinal stenosis but their efficacy in treating low back pain is yet to be proven. Confronted with a growing number of new technologies clinicians should remain critical while awaiting long term results.

An intramedullary alignment guide lodging within the femoral canal during total knee arthroplasty: a case report.

The usual complications of total knee arthroplasty include thrombo-embolism, infection, and loosening. We report an unusual and potentially serious complication of an intramedullary guide lodging within the femoral canal during the procedure. Considering the risk of fracture and additional exposure, the guide was not removed and was cut in situ. The rest of the operation was completed successfully and the patient made an uneventfully recovery.

Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis.

Patients undergoing spinal surgery are at risk of developing thromboembolic complications even though lower incidences have been reported as compared to joint arthroplasty surgery. Deep vein thrombosis (DVT) has been studied extensively in the context of spinal surgery but symptomatic pulmonary embolism (PE) has engaged less attention. We prospectively followed a consecutive cohort of 270 patients undergoing spinal surgery at a single institution. From these patients, only 26 were simple discectomies, while the largest proportion (226) was fusions. All patients received both low molecular weight heparin (LMWH) initiated after surgery and compressive stockings. PE was diagnosed with spiral chest CT. Six patients developed symptomatic PE, five during their hospital stay. In three of the six patients the embolic event occurred during the first 3 postoperative days. They were managed by the temporary insertion of an inferior vena cava (IVC) filter thus allowing for a delay in full-dose anticoagulation until removal of the filter. None of the PE patients suffered any bleeding complication as a result of the introduction of full anticoagulation. Two patients suffered postoperative haematomas, without development of neurological symptoms or signs, requiring emergency evacuation. The overall incidence of PE was 2.2% rising to 2.5% after exclusion of microdiscectomy cases. The incidence of PE was highest in anterior or combined thoracolumbar/lumbar procedures (4.2%). There is a large variation in the reported incidence of PE in the spinal literature. Results from the only study found in the literature specifically monitoring PE suggest an incidence of PE as high as 2.5%. Our study shows a similar incidence despite the use of LMWH. In the absence of randomized controlled trials (RCT) it is uncertain if this type of prophylaxis lowers the incidence of PE. However, other studies show that the morbidity of LMWH is very low. Since PE can be a life-threatening complication, LMWH may be a worthwhile option to consider for prophylaxis. RCTs are necessary in assessing the efficacy of DVT and PE prophylaxis in spinal patients.

Color multiscale texture classification of hysteroscopy images of the endometrium.

The objective of this study was to investigate the diagnostic performance of a Computer Aided Diagnostic (CAD) system based on color multiscale texture analysis for the classification of hysteroscopy images of the endometrium, in support of the early detection of gynaecological cancer. A total of 416 Regions of Interest (ROIs) of the endometrium were extracted (208 normal and 208 abnormal) from 45 subjects. RGB images were gamma corrected and were converted to the YCrCb color system. The following texture features were extracted from the Y, Cr and Cb channels: (i) Statistical Features (SF), (ii) Spatial Gray Level Dependence Matrices (SGLDM), and (iii) Gray Level Difference Statistics (GLDS). The Probabilistic Neural Network (PNN), statistical learning and the Support Vector Machine (SVM) neural network classifiers were also applied for the investigation of classifying normal and abnormal ROIs in different scales. Results showed that the highest percentage of correct classification (%CC) score was 79% and was achieved for the SVM models trained with the SF and GLDS features for the 1x1 scale. This %CC was higher by only 2% when compared with the CAD system developed, based on the SF and GLDS feature sets computed from the Y channel only. Further increase in scale from 2x2 to 9x9, dropped the %CC in the region of 60% for the SF, SGLDM, and GLDS, feature sets, and their combinations. Concluding, a CAD system based on texture analysis and SVM models can be used to classify normal and abnormal endometrium tissue in difficult cases of gynaecological cancer. The proposed system has to be investigated with more cases before it is applied in clinical practise.

A new clinical test in diagnosing quadriceps tendon rupture.

INTRODUCTION: Extensor mechanism ruptures might be easily overlooked and misdiagnosed, and delayed diagnosis of quadriceps tendon rupture is frequent. However, the literature recommends early surgical repair within 72 h. PATIENTS AND METHODS: This paper describes a new simple clinical diagnostic test that directly evaluates the integrity of the distal 5 cm of the quadriceps tendon itself. It consists of inserting a needle in the tendon, proximal to the suspected rupture and mobilising the knee joint. RESULTS: The suspected ruptured quadriceps tendons with a positive 'needle' diagnostic test were confirmed intra-operatively. CONCLUSIONS: This minimally invasive and easily available technique should be considered in the diagnostic work-up and treatment planning of patients with suspected tears of the quadriceps tendon.

[Low back pain in 2006: back to the root]. / Approche de la lombalgie chronique en 2006: remonter à la source.

Low back pain is a major burden for health care. According to the International Classification of Function, it is a disability of complex origin. Risk factors for chronification are of psychosocial and not physical nature. Primary targets of treatment should be physical fitness and the self-management of problem by the patient. Awareness of the psychosocial factors (yellow, blue and black flags) which can disturb occupational reintegration should be developed. Rehabilitation is based on measures to modify patient's beliefs and fitness. The prescribed treatment should aim to relieve pain, correct disability, prevent relapses, inform and educate the patient. Every low back pain sufferer which does not improve in 1 month should be sent to a team skilled in handling this kind of problem.

Modified triangular posterior osteosynthesis of unstable sacrum fracture.

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22-41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.

[Percutaneous vertebroplasty]. / Vertébroplastie par voie percutanée.

Although vertebroplasty was initially a treatment of vertebral haemangioma or metastases, this procedure is now frequent option to the treatment of osteoporotic vertebral fractures. In this review article, we will discuss the indication, the techniques and the follow-up of the vertebroplasty. This is a risky procedure, which should be performed by experimented physicians working with high-resolution fluoroscopic equipments, by biplane fluoroscopy, to reduce the risk and irradiation to the patient. According to the available follow-up studies, there is clear evidence of a strong improvement of quality of life after vertebroplasty by rapid decreasing of back pain at least during the first six months. Other new studies will analyze the long-term follow-up after vertebroplasty.

[Surgical indications in spinal trauma]. / Lésions traumatiques rachidiennes et indications au traitement chirurgical.

Surgical indications in spinal trauma remain a controversial topic. In general, unstable cervical injuries such as displaced odontoid fractures, burst fractures or tear drop fractures require surgical intervention. Thoracolumbar compression injuries without posterior wall involvement or significant kyphosis can be treated conservatively. Surgery is indicated in fractures-dislocations and burst fractures with significant canal narrowing and/or major kyphosis. The role of emergency decompression as well as that of steroids remain uncertain since no study to date has convincingly proven their efficacy.