Radiological-pathological correlation of the British Thyroid Association ultrasound classification of thyroid nodules: a real-world validation study.

AIM: To evaluate the real-world performance of the British Thyroid Association (BTA) U classification, specifically focusing on radiology-pathology correlation and to glean learning points. METHODS AND MATERIALS: Adults undergoing a neck ultrasound for thyroid nodules were reviewed over a period of 1-year. Data including demographics, nodule characteristics, BTA grading, and cytology/histopathology were retrieved with a minimum 24-month follow-up. RESULTS: Of 1,225 graded nodules in 964 patients, cytology and/or histology were available for 300 (24%). 57 cancers were detected. Of 24 (2%) U5 nodules, 14 were malignant, of 51 (4%) U4, 22 were malignant, of 256 (21%) U3, 20 were malignant, and from 894 (73%) U2 nodules, one cancer was discovered. BTA U grading with fine-needle aspiration (FNA)/core biopsy achieved 96.5% sensitivity, 93.7% specificity, and 93.9% accuracy compared to excision. There was no association between nodule size and rate of malignancy. CONCLUSION: This is the first study to validate the use of the BTA U-grading system in UK clinical practice. The BTA U-grading system is a robust and reliable method of evaluating the risk of malignancy in thyroid nodules with a high negative predictive value. Key learning points gleaned from the study were accurate assessment of nodule echogenicity, careful evaluation of solid-cystic nodules, optimising ultrasound technique, and the low-risk nature of U3 nodules.

Feasibility of a streamlined imaging protocol in technetium-99m-Tektrotyd somatostatin receptor SPECT/CT.

AIM: To assess the feasibility and efficacy of a streamlined single time-point 99mTc-HYNIC-Tyr3-octreotide (Tektrotyd) somatostatin receptor scintigraphy (SRS) protocol to differentiate pathological uptake by neuroendocrine tumours (NETs) from physiological activity. METHODS AND MATERIALS: Tektrotyd imaging in 50 consecutive patients with NETs was reviewed retrospectively. Imaging was independently assessed by two experienced reporters with dual-certification in radiology and nuclear medicine and agreed in consensus. The presence of physiological bowel activity and/or further sites of equivocal uptake on 4-hour planar imaging and whether combined single-photon-emission computed tomography (SPECT)/computed tomography (CT) assessment allowed accurate diagnosis was tabulated. A judgement was also made in each case on whether 2-hour planar imaging was necessary for accurate diagnostic interpretation. RESULTS: Thirty-six patients (72%) had positive findings on Tektrotyd SPECT/CT. Eight patients (16%) had bowel activity on 4-hour planar imaging, which could be considered to have hampered interpretation without access to SPECT/CT. Eleven studies in 10 patients (20%) demonstrated areas of indeterminate uptake on planar imaging; five in the uncinate process of the pancreas, three in the nasal cavity or paranasal sinuses, one in the adrenal glands, one in a focus of inflammation on the posterior abdominal wall, and one at the tip of a central venous line. In all cases, accurate interpretation of findings was possible with SPECT/CT, without the 2-hour planar image. CONCLUSION: Two-hour planar imaging could be safely omitted from Tektrotyd SRS incorporating SPECT/CT imaging without reducing the accuracy of diagnostic interpretation. Streamlined imaging has the potential to reduce patient inconvenience and improve scanner and staff efficiency.

Robotic colorectal surgery: previous laparoscopic colorectal experience is not essential.

A background in minimally invasive colorectal surgery (MICS) has been thought to be essential prior to robotic-assisted colorectal surgery (RACS). Our aim was to determine whether MICS is essential prior to starting RACS training based on results from our initial experience with RACS. Two surgeons from our centre received robotic training through the European Academy of Robotic Colorectal Surgery (EARCS). One surgeon had no prior formal MICS training. We reviewed the first 30 consecutive robotic colorectal procedures from a prospectively maintained database between November 2014 and January 2016 at our institution. Fourteen patients were male. Median age was 64.5 years (range 36-82) and BMI was 27.5 (range 20-32.5). Twelve procedures (40%) were performed by the non-MICS-trained surgeon: ten high anterior resections (one conversion), one low anterior resection and one abdomino-perineal resection of rectum (APER). The MICS-trained surgeon performed nine high and four low anterior resections, one APER and in addition three right hemicolectomies and one abdominal suture rectopexy. There were no intra-operative complications and two patients required re-operation. Median post-operative stay was five days (range 1-26). There were two 30-day re-admissions. All oncological resections had clear margins and median node harvest was 18 (range 9-39). Our case series demonstrates that a background in MICS is not essential prior to starting RACS training. Not having prior MICS training should not discourage surgeons from considering applying for a robotic training programme. Safe and successful robotic colorectal services can be established after completing a formal structured robotic training programme.

A survey of knowledge and awareness of Jordanian female university students of human papillomavirus infection and its vaccine.

OBJECTIVE: To assess the knowledge and awareness of Jordanian female university students regarding human papillomavirus (HPV) infection and its vaccine. MATERIALS AND METHODS: A self-administered, anonymous questionnaire was distributed to 450 participants at Jordan University of Science and Technology (JUST) in Jordan. The survey focused on three areas: knowledge and awareness of HPV infection, knowledge of HPV vaccine, and source of information about HPV infection and its vaccine. RESULTS: The survey response rate was 79.8%. Most of the respondents (about 68%) have heard about HPV and knew that the HPV is a virus in the genital area that is sexually transmitted, and 59% of them knew that persistent infection with PV virus can cause precancerous/cancerous diseases in the genital tract. Only 45% of the respondents have ever heard about HPV vaccine and 37.8% of them knew that HPV vaccine is very effective in preventing HPV infection and its related precancerous/cancerous diseases. Majority of the respondents, 78.7 % and 73.5%, who knew about HPV and HPV vaccine, respectively, had heard about it from healthcare providers. CONCLUSION: The study suggests that more health education and information about the HPV characteristics and HPV vaccine is needed for female university students.

How injuries affect rehabilitation workload in a National Team during an elite soccer event? An experience from the FIFA 2010 World Cup.

AIM: Many epidemiological studies have been performed in soccer but none of them investigated the incidence of injury in association with the utilization of clinical and rehabilitation services of the medical team. This study aims to examine such correlation in a National football team during the recent 2010 World Cup. METHODS: All injuries occurred to the Algerian National Team players during the pre competition stage and the World Cup were recorded, together with the exposure. Moreover, duration and frequency of each consultation performed by doctors, physiotherapists, masseurs and pitch rehabilitator was recorded. RESULTS: Incidence of injuries was 7.54 per 1000h exposure and six players were injured at the beginning of the stage but all players were available for official matches. Difference in the duration of rehabilitation sessions on the field is present among the players who joined the camp already injured and the players who were not injured at the commencement of the camp (8.83±10.63 vs. 2.00±4.46 hours, P<0.05) while there was no difference in rehabilitation between players that occurred in an injury during after the beginning of the camp and uninjured players. CONCLUSION: A medical team composed of two physicians, four physiotherapists, one pitch rehabilitator and two masseurs facilitated us to reasonably distribute this workload with good rehabilitation outcomes based on players' availability during competition. Moreover, the skills of a pitch rehabilitator appear to be useful, most evidently when starting the camp with previously injured athletes. Conversely, injuries occurring during the tournament didn't affect rehabilitation workload significantly.

The emerging role of cardiovascular MRI for suspected cardioembolic stroke.

Stroke is a leading cause of morbidity and long-term disability worldwide and is often the result of embolic material from the heart or proximal aorta. These are referred to as cardioembolic sources of stroke. The investigation of patients with suspected cardioembolic stroke has traditionally been the mainstay of echocardiography. Cardiac magnetic resonance imaging (MRI) is a powerful imaging technique that has rapidly evolved over the last decade and is playing an ever increasing role in clinical cardiovascular imaging. This review of the literature aims to furnish the reader with an understanding of the role of cardiac MRI across the spectrum of causes of cardioembolic sources of stroke by providing the reader with an overview of the indications, technical considerations, a proposed imaging algorithm, and capabilities of this technology with selected illustrated examples of disease entities.

Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular examinations: practical solutions for managing the diagnostic conundrum.

Preparticipation screening programmes for underlying cardiac pathologies are now commonplace for many international sporting organisations. However, providing medical clearance for an asymptomatic athlete without a family history of sudden cardiac death (SCD) is especially challenging when the athlete demonstrates particularly abnormal repolarisation patterns, highly suggestive of an inherited cardiomyopathy or channelopathy. Deep T-wave inversions of ≥ 2 contiguous anterior or lateral leads (but not aVR, and III) are of major concern for sports cardiologists who advise referring team physicians, as these ECG alterations are a recognised manifestation of hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC). Subsequently, inverted T-waves may represent the first and only sign of an inherited heart muscle disease, in the absence of any other features and before structural changes in the heart can be detected. However, to date, there remains little evidence that deep T-wave inversions are always pathognomonic of either a cardiomyopathy or an ion channel disorder in an asymptomatic athlete following long-term follow-up. This paper aims to provide a systematic review of the prevalence of T-wave inversion in athletes and examine T-wave inversion and its relationship to structural heart disease, notably HCM and ARVC with a view to identify young athletes at risk of SCD during sport. Finally, the review proposes clinical management pathways (including genetic testing) for asymptomatic athletes demonstrating significant T-wave inversion with structurally normal hearts.

Prevalence of electrocardiographic abnormalities in West-Asian and African male athletes.

OBJECTIVES: To evaluate the electrocardiographic (ECG) characteristics of West-Asian, black and Caucasian male athletes competing in Qatar using the 2010 recommendations for 12-lead ECG interpretation by the European Society of Cardiology (ESC). DESIGN: Cardiovascular screening with resting 12-lead ECG analysis of 1220 national level athletes (800 West-Asian, 300 black and 120 Caucasian) and 135 West-Asian controls was performed. RESULTS: Ten per cent of athletes presented with 'uncommon' ECG findings. Black African descent was an independent predictor of 'uncommon' ECG changes when compared with West-Asian and Caucasian athletes (p<0.001). Black athletes also demonstrated a significantly greater prevalence of lateral T-wave inversions than both West-Asian and Caucasian athletes (6.1% vs 1.6% and 0%, p<0.05). The rate of 'uncommon' ECG changes between West-Asian and Caucasian athletes was comparable (7.9% vs 5.8%, p>0.05). Seven athletes (0.6%) were identified with a disease associated with sudden death; this prevalence was two times higher in black athletes than in West-Asian athletes (1% vs 0.5%), and no cases were reported in Caucasian athletes and West-Asian controls. Eighteen West-Asian and black athletes were identified with repolarisation abnormalities suggestive of a cardiomyopathy, but ultimately, none were diagnosed with a cardiac disease. CONCLUSION: West-Asian and Caucasian athletes demonstrate comparable rates of ECG findings. Black African ethnicity is positively associated with increased frequencies of 'uncommon' ECG traits. Future work should examine the genetic mechanisms behind ECG and myocardial adaptations in athletes of diverse ethnicity, aiding in the clinical differentiation between physiological remodelling and potential cardiomyopathy or ion channel disorders.

Injury epidemiology in a national football team of the Middle East.

Many football epidemiological studies have been performed but only two of them have investigated injury risk in a national football team. In the present study, the senior male Qatar national football team was followed prospectively for two seasons. All injuries that were incurred during training and matches were recorded, together with match and training exposure time. Principal findings were (i) a higher injury incidence during matches than during training, (65.9 vs 4.3/1000 h, P<0.001), (ii) a high incidence of muscular strain during matches (23.2/1000 h) and (iii) a greater severity of injury in games than in regular training or camp situations (19.5 vs 8.4 vs 6.7 days, P<0.05). Despite the unique environmental, social and cultural setting in the Middle East, these findings are consistent with previous data from European football, suggesting that international guidelines on injury prevention and management may be applied in this region.

Differences in markers of cardiovascular disease between professional football players of West-Asian and Black African descent.

OBJECTIVES: To examine the cardiovascular risk factors of professional football players of West-Asian and Black African descent competing in the 2010/11 Qatar Stars League. DESIGN: Ten out of twelve professional football clubs attended pre-participation screening. 100 West-Asian males from seven Gulf States and six Middle-Eastern countries and 90 Black males from seven African countries. METHODS: All players were screened using the FIFA pre-competition medical assessment, incorporating a physical examination, resting 12-Lead ECG, echocardiogram, with determination of total cholesterol, high and low density lipoprotein (HDL/LDL) and triglycerides. RESULTS: West-Asian football players had a higher prevalence of a family history (FH) of coronary heart disease (CHD) (25% vs. 12%, p = 0.025) compared to Black African players predominantly due to CHD in their fathers (14% vs. 6%, p<0.05). West-Asian players had higher total cholesterol levels (4.4 vs. 4.2 mmol/L, p = 0.025) and lower HDL levels (1.3 vs. 1.4 mmol/L, p = 0.004) than Black African players; remaining significant after adjusting for a FH of CHD. Positively, all lipid levels were clinically acceptable for both ethnicities. Finally, one in eight West-Asian and one in eleven Black African football players were regular smokers. CONCLUSIONS: The prevalence of cardiovascular disease in West-Asia is increasing. This study observed clinically acceptable blood lipid profiles for both West-Asian and Black African football players. However, West-Asian players had a greater number of markers for CVD than their Black African counterparts despite being matched for physical activity levels. Targeted education with regards to diet, lifestyle and tobacco use is required for both ethnicities.

Popliteo-pedal bypass surgery for critical limb ischemia.

BACKGROUND: Critical limb ischaemia due to distal arterial disease represents a significant challenge. Randomised controlled evidence suggests that open surgery may be superior to endovascular intervention but there is limited data on the specific clinical cohort with exclusively infra-popliteal disease. AIM: We analysed indications for, and outcome from all, popliteo-pedal bypass procedures performed between July 1998 to November 2008. PATIENTS AND METHODS: Twenty-eight bypass procedures were performed in 24 patients. Autologous vein was used exclusively. The proximal anastomosis was to the below-knee popliteal artery in all the patients; the distal anastomosis was to plantar artery (n = 15) or dorsalis pedis artery (n = 13). Mean patient age was 63.Eight years of age (range 37-92 years). Indications for surgery were tissue loss (n = 21) and rest pain (n = 7). Ultrasound graft surveillance was performed every 6-months. RESULTS: Using life table analysis, primary graft patency was 63.3% at 1-, 3- and 5-years and secondary patency (after three interventions) was 74.6% at 1-, 3- and 5-years. Limb salvage rate was 81.8% after 1-, 3- and 5-years as all five limb amputations were performed in the first 3-months following the surgery. Overall survival was 75, 75 and 47.1% at 1-, 3- and 5-years, respectively. The major amputation free survival rate was 54.2, 54.2 and 21.3% at 1-, 3- and 5-years, respectively. Seventy-nine percent (n = 19) patients were diabetic. CONCLUSION: Our data supports popliteo-pedal bypass as an effective treatment for distal vascular disease. Comparison with endovascular treatment in a randomised trial needs to be performed.

Pilonidal sinus of the penis.

Pilonidal sinus is a well recognised chronic inflammatory condition which commonly affects the natal cleft and finger web space. Pilonidal sinus of the penis is a rare clinical entity; few cases have been reported previously. The treatment strategy is almost the same as treating any pilonidal sinus and involves total excision of the sinus. Our diagnosis was established on the histopathological findings rather than a clinical-based diagnosis, Follow-up is advisable since the recurrence rate is high. Our case report is one of few cases reported on pilonidal sinus all over the world. Our patient had total excision of the sinus with complete recovery.

Does the number of previous caesarean deliveries affect maternal outcome and complication rates?

We evaluated maternal complications in relation to number of previous caesarean sections in Princess Badea Teaching Hospital, Irbid, Jordan. Analysis of the medical records of 1739 patients delivered by caesarean section was conducted. It revealed a 14-fold increase in the risk of caesarean hysterectomy in patients with placenta praevia and previous caesarean section compared to patients with placenta praevia and no previous caesarean section. The risk of caesarean hysterectomy increased with increasing number of previous caesarean sections. Those with 3 or more previous caesarean sections were at significantly higher risk of blood transfusion. Post-operative pyrexia was commoner in women with 3 or more previous caesarean sections compared to those undergoing their first one

Submandibular gland stones, a clinical review.

The purpose of this study is to highlight the role of per-oral extraction of submandibular calculi in the management of salivary sialadenitis. This study was based on a retrospective review of patients presenting with submandibular sialadenitis over a 5-year period. 26 patients presented with a history of sialadenitis, with a palpable stone in the floor of the mouth and were considered candidates for surgery. 21 (80%) underwent per-oral extraction using marsupialization of the duct to maintain duct patency. 4 (15%) were deemed unsuitable when assessed under general anaesthesia due to inaccessible calculi. 2 (9%) of the 21 patients that underwent per-oral extraction required gland excision, due to persistence of symptoms. The remaining 19 (91%) are symptom free with a mean follow-up of 18 months. There were no neurological post-operative sequelae in the group. 1 patient had no surgical intervention at the end. In conclusion, per-oral extraction of submandibular salivary calculi is a safe method of relieving symptoms due to sialadenitis in patients with palpable accessible calculi in the floor of the mouth.

Variation in repeat caesarean section complication rates among 3 hospitals in northern Jordan

We investigated the complication rates of repeat caesarean deliveries in 3 hospitals [national health, military, university] in Irbid by examining the obstetric records of 989 women from 1 December 1999 to 30 March 2004. There was a statistically significant difference between the number of previous caesarean sections and hospital. In total, 579 [58.5%] patients underwent elective caesarean section. There were statistically significant differences between hospitals for "failure to progress in labour" and "other" indications for caesarean section. After adjusting for the number of caesarean sections, regression analysis revealed that women from the military and university hospitals were more likely to have placenta praevia. There were no statistically significant differences between hospitals as regards post- operative complications

[Sports activities and declared health status]. / Activités sportives et état de santé déclaré.

A cross-section study on sports and health was carried out among 8666 subjects from 15 to 49 years old, for a large range of practices. The analysis compared three groups, 2048 non-athletics, 5381 "moderately" athletic, and 1237 "highly" athletic. Compared to non-athletics, the "moderately" athletic group has a higher opinion of their state of health, with a similar frequency of declared health problems (hospitalisations, absences from work, traumatisms). The intensive practices are accompanied by an opinion of health status similar to the moderately athletic group, with a larger frequency of declared health problems. These results suggest a poor control of sports risks among those who practice the most.

Abruptio placentae: risk factors and perinatal outcome.

OBJECTIVE: It is a case control study, conducted in order to determine the risk factors, and to find out the perinatal outcome of abruptio placentae in women delivered at the Princess Badeea Teaching Hospital in North Jordan. METHODS: We reviewed all cases of placental abruption delivered between 15th April 1994 till 26 November 1995 and to compare that with pregnancies and deliveries not complicated by abruptio placentae. RESULTS: During the study period there were 108 cases of abruptio placentae and 108 cases of the control group. The total number of women delivered were 18,256, so the incidence of abruptio placentae was 5.9 per 1000 births. When compared to the control group, abruptio placentae occurred more in parous women (para > or = 5) (p < 0.0005), more preterm deliveries (p < 0.0001) with more birth weight < 2,500 g (p < 0.0001). Preeclampsia and pregnancy induced hypertension, intrauterine growth retardation, caesarean delivery, and intrauterine fetal death occurred more in patients with abruptio placentae. CONCLUSION: High parity, preeclampsia and hypertension are significant etiological determinants of abruptio placentae.

Is there a relationship between physical activity and dietary calcium intake? A survey in 10,373 young French subjects.

PURPOSE: The purpose of this study was to discuss, in the light of the results of a survey, the calcium ration of a sample of French youth and to determine whether various sports activities can be related to dietary calcium intake. METHODS: Physical activity was evaluated using Baecke's questionnaire. Calcium intake was evaluated using a food frequency oriented questionnaire. The survey was performed on a population of 10,373 subjects (6,966 males and 3,407 females) including three different groups of subjects: school children and college students, military personnel, and athletes registered in sports federations. The mean age of this population was 19 +/- 9 yr, ages ranging between 7 and 50 yr. RESULTS: The mean amount of declared calcium intake (DCI) for the total population was 1242 +/- 843 mg per 24 hr (mg x d(-1)). Fifty percent of this population consumed less than 1000 mg x d(-1) and 13% less than 500 mg x d(-1). There was no significant relationship between the index of activity and declared calcium intake. Calcium intake decreased with age and was lower in females compared to males. CONCLUSIONS: The subjects trained in individual endurance sports such as triathlon, biking, and road running have a lower DCI than subjects trained in team sports such as volley ball, handball, or basketball. This survey, performed on a large population, does indicate that for half of them daily calcium intake is below the threshold of 1,000 mg x d(-1) considered the daily requirement covering the needs of a population without age or gender distinction and that calcium intake is not related to the level of physical activity.

Alterations in muscular performance and orthostatic tolerance during Ramadan.

BACKGROUND: During Ramadan, physiological changes are expected to result from both long-term dietary restriction and partial sleep loss. HYPOTHESIS: We speculated that Ramadan fasting has deleterious effects on muscle performances and on orthostatic tolerance. METHODS: There were 11 senior fighter pilots tested on three occasions during the first week of Ramadan (Beg-R), during the fourth week (End-R) and during a control period, 2 mo after Ramadan (C). Each test session consisted of an assessment of the strength and endurance performances of the knee extensors and elbow flexors and of an analysis of the HR and BP responses to the orthostatic stress imposed by a 80 degrees head-up tilt. RESULTS: Body weight decreased by 2.7% at End-R in comparison with C period (p < 0.01). Maximum isometric strength (MVC) of elbow flexor muscles decreased immediately (by 10-12%; p < 0.05). Muscular endurance at both 35 and 70% MVC were lower at End-R in comparison with C period (-28%, -22%, respectively; p < 0.05). The head-up tilt test at End-R was accompanied by a higher increase in heart response than during orthostasis during C and Beg-R periods, and by a decrease in pulse pressures (p < 0.001). These alterations in responses to the head-up tilt were associated with a fall by about 7% in plasma volume. CONCLUSIONS: These data demonstrate that Ramadan fasting leads to an impairment in muscular performances and to a decrease in orthostatic tolerance. Further studies are needed to verify the impact of these changes on +Gz tolerance.