Morphology and Prevalence of the Inferior Transverse Scapular Ligament: Systematic Review, Meta-Analysis, and Proposal for Classification.

Background/Objectives: The suprascapular nerve is most vulnerable to entrapment at the suprascapular and spinoglenoid notches, causing neuropathy. Numerous studies have examined the suprascapular notch and ligament and its relationship with suprascapular nerve entrapment, but few have examined the spinoglenoid notch and the inferior transverse scapular ligament (ITSL). This study summarizes all existing ITSL morphology studies and presents a simple and comprehensive classification system for different ITSL subtypes. Methods: A systematic review of the literature was conducted according to the PRISMA guidelines, searching the online databases PubMed and Embase. The references of each relevant article were further screened to find more eligible studies. The Anatomical Quality Assessment tool was used in order to further evaluate the quality of the records extracted. STATA MP 14 was used for the analysis in this study. Results: In total, 14 studies (995 scapulae; minimum: 1 and maximum: 268) were included in the present study. The overall ITSL prevalence was 5.8 (95% CI: 4.5-7.1) and the estimated odds for ligamentous vs. membranous type was 0.5 (95% CI: 0.3-0.7). The basic different morphological subtypes of the ITSL reported in the included studies are the band-like ligament, the fan-shaped ligament, the membranous ITSL, and the perforated membranous types. Conclusions: The ITSL represents an anatomical structure of mostly ligamentous nature. A single ITSL definition and standardization of its basic morphological subtypes along with an easy-to-remember and thus widely used classification system could greatly facilitate the comprehensive description, identification, and proper handling of this element across many surgical procedures.

Pediatric osteochondral fractures: clinical insights associate early diagnosis to early rehabilitation via arthroscopy.

PURPOSE: This retrospective observational cohort analysis aims to address diagnostic and therapeutic challenges in managing osteochondral fractures (OCFs) resulting from acute patella dislocation and ankle sprains in children. METHODS: The study includes 15 children treated for OCFs between January 2020 and July 2022. Data were obtained from medical records and analyzed using logistic regression. RESULTS: The diagnostic and treatment algorithm involves detailed history, clinical examination, and imaging, with MRI guiding therapeutic decisions. Arthroscopic or mini open fixation led to successful rehabilitation, with 93% achieving full mobility at 9 months. Age was identified as a slight risk factor for free fragments in MRI, and arthroscopic management correlated with faster recovery at 3 months. CONCLUSION: This study underscores the importance of immediate diagnosis and minimally invasive intervention for OCFs in children. Timely treatment, guided by a diagnostic algorithm, facilitates joint restoration and prevents degenerative consequences, ensuring a return to regular activities within a year postoperatively. LEVEL OF EVIDENCE: IV.

Gender equality challenges in orthopaedic surgery: a systematic review.

PURPOSE: Several studies have examined gender-equality challenges and ways to improve women's representation and management. Orthopaedic surgeons and patients are less gender equitable than them of other surgical disciplines. This systematic review summarizes these findings and highlights orthopaedic surgery gender inequality. METHODS: Search of the PubMed, Embase, and Cochrane databases was carried out to extract human studies investigating the gender gap in orthopaedics, trying to highlight the equality challenges orthopaedic surgery faces. Studies incorporating patients with comorbidities in which gender is a proven risk factor, and pregnant women were excluded. RESULTS: This systematic review included 59 studies involving 692,435 people (mean females/males ratio: 4.44), spanning the years 1987-2023. Regarding the targeted population, 35 (59.32%) studies focused on patients, while 24 (40.68%) on physicians. Orthopaedic surgery is described as an unfriendly career field for women as surgeons or sports leading physicians while women are generally under represented in the academic field of orthopaedics. Regarding patients, female gender consists both a risk and prognostic factor influencing the prevalence of degenerative disease and the outcome of the operative treatment in reconstructive orthopaedics. Female gender is a risk factor for multiple sports injuries and influences the pathogenetic mechanisms resulting in ACL reconstruction. Regarding spine surgery, women are less likely to have surgery suggested, and such suggestion underlines severe disease's progression. CONCLUSIONS: Gender differences affect orthopaedic patient-physician-healthcare system interactions. Recognizing biases and their patterns is useful to improve the actual situation. By preventing those an unbiased, tolerant, and egalitarian workplace for physicians and a healthcare system that provides the best treatment to patients could be created.

Students' perspective on the interactive online anatomy labs during the COVID-19 pandemic.

PURPOSE: New training methods sprung up using communication technologies after the suspension imposed on Greek Universities due to restrictive measures against the COVID-19 pandemic. The current questionnaire-based study evaluates the efficacy and utility of the interactive online anatomy labs (ONALs) in assisting the assimilation of anatomy and substituting dissection labs during the pandemic. METHODS: ONALs consisting of video recorded demonstrations of dissected cadavers were developed so that real-time dialogue and interaction between tutor and students was feasible. First- and second-year medical students who were taught neuroanatomy and splanchnology and first-year dental students who were taught head and neck anatomy evaluated the ONALs. RESULTS: One hundred and sixty students participated. The 61 students (38.13%) attended the splanchnology, 58 (36.25%) the neuroanatomy, and 41 (25.63%) the head and neck anatomy course. 86.9% of the participants found the ONALs beneficial for their study. The 75.5% with previous experience of a "face-to-face" dissection replied that the ONALs cannot substitute satisfactorily "face-to-face" dissections. 63.8% replied positively to the ONALs maintenance after the pandemic. CONCLUSIONS: The study's novelty is based on the maintenance of the greater possible interaction between tutors and students during the ONALs, in contrast to the previously described usage of dissection educational videos in anatomy. Our findings reinforce the established statement that "a teaching dissection is an irreplaceable tool in anatomy education". However, the ONALs were well-received by the students and can be kept on as a supplementary teaching modality and can be proven quite useful in Medical Schools that lack cadavers.

Interpretation and Natural History of Asymmetric Skin Folds in Infants With Developmental Dysplasia of the Hip.

The association between asymmetric skin folds (ASFs) of the gluteal, groin, or thigh regions and ipsilateral developmental dysplasia of the hip (DDH) has not been elucidated yet. Why are ASFs formed in some infants with DDH? Do DDH-associated ASFs persist during childhood and adulthood? Is it possible for ASFs to emerge without DDH pathology? Three cases of acute and chronic hip pathology in adults are presented in an attempt to explain the formation and the natural history of ASFs in infants with DDH. It is suggested that ASFs are formed when the excess soft tissues of the thigh shrink over a short femur. On the other hand, ASFs disappear after the length of the thigh is restored and the soft tissues of the thigh are re-stretched. This telescoping mechanism of the formation and disappearance of ASFs is applicable regardless of the underlying hip pathology or the age of the patient.

Exploring Parental Attitudes and Perceptions Regarding Childhood Vaccinations in Greece: A Study Within the Framework of the National Health Examination Survey (EMENO).

AIM: Vaccinations have reduced illnesses and mortality rates globally, yet negative attitudes and uncertainty about them hinder their acceptability and efficacy. The study aims to document Greek parents' immunization perceptions and risk factors. METHODS: Spanning 2014-2017, 447 parents (68% mothers) who participated in the Greek Health Examination Survey EMENO (National Survey of Morbidity and Risk Factors) completed an interview-delivered questionnaire. Attitudes were categorized into three groups: absolutely positive, positive, and negative. Absolutely positive attitudes included positive responses to all five statements in favor of vaccination and negative responses to the two statements against vaccination. Negative attitudes included positive responses to either one or both statements against vaccination and negative responses to all five statements in favor of vaccination.. All other participants were categorized as having a positive attitude. Skepticism towards vaccinations was classified into skeptical and non-skeptical groups based on responses to five statements implying uncertainty or skepticism. Participants were considered skeptical if they provided positive responses to at least three of these statements, and non-skeptical if they had none or up to two positive responses. The statistical analysis accounted for the study design whereas inverse probability weighting was used to adjust for non-response and multiple imputations were employed to impute missing values. The components of parental attitude and vaccine skepticism were identified using weighted multinomial logistic regression and logistic regression, respectively. RESULTS: In total, 16.6% were classified as having absolutely positive attitudes towards vaccinations whereas 42.1% were skeptical of vaccines. Of all participants, 96.0% agreed that vaccinations are essential for their child's well-being and adhere to scientific recommendations. However, concerns were also mentioned, with 26.2% worrying about potential adverse effects, and 21.6% believing it is better to acquire immunity through illness rather than vaccination. Positive participants, compared to absolutely positive ones, were more likely to be of Greek origin (adjusted relative rate ratio (aRRR): 3.35; 95% CI: 1.53-7.30) and living in semi-urban areas (aRRR: 4.84; 95% CI: 1.77-13.29). Negative participants, in contrast, were more likely to have higher education (aRRR: 2.98; 95% CI: 1.05-8.44) but also to live in semi-urban areas (aRRR: 6.43; 95% CI: 1.69-24.56). Furthermore, parents of Greek origin had significantly higher odds of being skeptical towards vaccination (adjusted Odds Ratio (aOR): 2.86; 95% CI: 1.36-5.98), while married or cohabiting parents had lower odds of being skeptical compared to single parents (aOR: 0.60; 95% CI: 0.35-1.06). CONCLUSIONS: While parents in this study recognize the importance of childhood immunizations, there is a widespread presence of negative attitudes and skepticism that can have a detrimental impact on vaccination rates.

Pediatric Ankle Fractures: Successful Remodeling and Restoration Through Comprehensive Diagnosis and Conservative Management in a Diverse Context.

Diagnosing toddler ankle fractures, especially those that affect several bones, can be difficult. The infrequency of such complex injuries, particularly in household environments, emphasizes the importance of increased awareness in diagnosing and managing these types of injuries. We present a compelling case study of a 20-month-old toddler of a low socioeconomic background who sustained fractures in the ankle, calcaneus, tibia, and fibula after being trapped under furniture. The diagnostic process involved trauma guidelines, radiographic assessments, and axial CT scans. Conservative management, including an eight-week plaster cast, was chosen based on the careful consideration of the child's age, the nature of the fracture, and the absence of immediate surgical indications. The follow-up period involved radiographic assessments, as well as repeated regular clinical examinations, revealing consistent alignment and the absence of complications. The successful outcome underscores the importance of a comprehensive diagnostic approach, thoughtful treatment planning, and meticulous follow-up. Individualized care, considering both clinical and socioeconomic factors, proved crucial for optimal outcomes in pediatric orthopedics. The case contributes valuable insights into the evolving landscape of early childhood orthopedics, emphasizing the need for a discerning approach to diagnosing and managing complex fractures in this population. Conservative treatment could significantly assist when absolute surgical indications are lacking both in cases of minimal resources where multiple operations are not plausible and when the patient's social history raises awareness.

Gabapentin-Induced Adrenal Insufficiency: The Hypothalamic-Pituitary-Adrenal Axis Stress Misresponse and Risk of Infection: A Case Report and Literature Review.

This literature review, in light of the presented case report, explores the complex interplay between gabapentin (GBP), a gamma-aminobutyric acid (GABA) analog, and the hypothalamic-pituitary-adrenal (HPA) axis in patients undergoing major surgical procedures. It specifically investigates the potential impact of GBP on cortisol levels, stress responses, and infection risk, illustrated by a detailed clinical case. This review combines a comprehensive literature search with a case report of a 17-year-old male with osteosarcoma who experienced transient adrenal insufficiency and infections while receiving GBP. The case is analyzed in the context of the existing literature on GBP and the HPA axis. The findings highlight the intricate relationship between GBP use, adrenal insufficiency, and infection susceptibility. It underscores the need for further research and clinical vigilance when prescribing GBP to patients with underlying medical conditions, particularly in the context of major surgical procedures. The review underscores the need for further research and clinical vigilance when prescribing GBP, particularly in perioperative settings. In conclusion, GBP's effects on the HPA axis and immune responses are complex and multifaceted. Clinicians should exercise caution when prescribing GBP, especially for patients with underlying conditions undergoing major surgery. Further research is needed to elucidate the mechanisms of GBP's influence on cortisol levels and stress responses.

HCV Cascade of Care in HIV/HCV Co-Infected Individuals: Missed Opportunities for Micro-Elimination.

People living with HIV-HCV co-infection comprise a target group for HCV-micro-elimination. We conducted an HCV cascade of care (CoC) for HIV-HCV co-infected individuals living in Greece and investigated factors associated with different HCV-CoC stages. We analyzed data from 1213 participants from the Athens Multicenter AIDS Cohort Study. A seven-stage CoC, overall and by subgroup (people who inject drugs (PWID), men having sex with men (MSM), men having sex with women (MSW), and migrants], was constructed, spanning from HCV diagnosis to sustained virologic response (SVR). Logistic/Cox regression models were employed to identify factors associated with passing through each CoC step. Among 1213 anti-HCV-positive individuals, 9.2% died before direct-acting antiviral (DAA) availability. PWID exhibited higher mortality rates than MSM. Of 1101 survivors, 72.2% remained in care and underwent HCV-RNA testing. Migrants and PWID showed the lowest retention rates. HCV-RNA was available for 79.2% of those in care, with 77.8% diagnosed with chronic HCV. Subsequently, 71% initiated DAAs, with individuals with very low CD4 counts (<100 cells/µL) exhibiting lower odds of DAA initiation. SVR testing was available for 203 individuals, with 85.7% achieving SVR. The SVR rates did not differ across risk groups. In 2023, significant gaps and between-group differences persisted in HCV-CoC among HIV-HCV co-infected individuals in Greece.

Assessment of De-Escalation of Empirical Antimicrobial Therapy in Medical Wards with Recognized Prevalence of Multi-Drug-Resistant Pathogens: A Multicenter Prospective Cohort Study in Non-ICU Patients with Microbiologically Documented Infection.

Antimicrobial resistance poses a major threat to human health worldwide and the implementation of antimicrobial stewardship programs (ASPs), including antimicrobial de-escalation (ADE), is a multifaceted tool for minimizing unnecessary or inappropriate antibiotic exposure. This was a prospective observational study of 142 non-Intensive Care Unit (ICU) patients with microbiologically documented infection who were initially administered empirical antimicrobial therapy and admitted to the medical wards of 6 tertiary-care hospitals in Greece from January 2017 to December 2018. Patients were divided into two groups, the ADE and non-ADE group, based on whether ADE was applied or not, respectively. Exploratory end-points were ADE feasibility, safety and efficacy. ADE was applied in 76 patients at a median time of 4 days (IQR: 3, 5). An increased likelihood of ADE was observed in patients with urinary tract (OR: 10.04, 95% CI: 2.91, 34.57; p < 0.001), skin and soft tissue (OR: 16.28, 95% CI: 1.68, 158.08; p = 0.016) and bloodstream infections (OR: 2.52, 95% CI: 1, 6.36; p = 0.05). Factors significantly associated with higher rates of ADE were clarithromycin administration, diagnosis of urinary tract infection (UTI), isolation of E. coli, age and symptoms type on admission. Mortality was lower in the ADE group (18.4% vs. 30.3% p < 0.1) and ADE was not significantly associated with the probability of death (p = 0.432). ADE was associated with favorable clinical outcomes and can be performed even in settings with high prevalence of multi-drug resistant (MDR) pathogens without compromising safety.

A Simplified Three-Layered Suturing Training Pad for Undergraduate Medical Students: A Technical Note.

Surgical training is a long process that requires a lot of commitment and effort. Basic surgical techniques are the foundation of every procedure, with suturing being one of them. Hence, it is of great importance for aspiring young surgeons to practice and develop their suturing skills. Quite many kinds of suturing training models have been used and proposed worldwide, ranging from commercial silicone pads to meat leftovers and various fruits. We have developed our own, simplified, and low-cost suturing training pad that consists of three layers and is based on the combined use of silicone sponge sheet and polyurethane foam. It is quite durable and elastic and has been applied in three suturing training workshops so far. For this reason, we would like to present our experience of a low-cost but effective way of promoting and achieving further surgical excellence.

The Burden of COVID-19 in Adult Patients With Hematological Malignancies: A Single-center Experience After the Implementation of Mass-vaccination Programs Against SARS-CoV-2.

BACKGROUND/AIM: Despite the widespread mass-vaccination programs worldwide and the continuing evolution of COVID-19 therapeutics, the burden of SARS-CoV-2 infection in patients with hematological malignancies (HM) remains elusive. The aim of the present study was to assess the clinical characteristics, outcomes and therapeutic strategies applied in HM patients hospitalized during the post-vaccine period in Greece. PATIENTS AND METHODS: From June 2021 to October 2022, 60 HM patients with COVID-19 were retrospectively analyzed. Exploratory end-points included the incidence of intubation, probability of recovery, mortality, and duration of remdesivir (RDV) administration. RESULTS: Overall, mechanical ventilation (MV) was required for five patients and crude mortality was 8.3%. HM of lymphocytic origin (p=0.035) and obesity (p=0.03) were the main determinants of the risk of intubation and among several laboratory markers, only LDH>520 IU/l was proven to be an independent MV predictor (p=0.038). The number of co-existing comorbidities (p=0.05) and disease severity on admission (p<0.001) were found to rule the probability of recovery, and dexamethasone was associated with worse prognosis, particularly in patients with mild/moderate COVID-19. RDV was administered to the entire cohort, of whom 38 were managed with an extended course. In the multivariate analysis, patients with HM of lymphocytic origin were more likely to receive RDV for more than five days (p=0.002). CONCLUSION: Our study emphasizes the frailty of HM patients, even in the era of Omicron-variant predominance, and underlines the need to optimize therapy.

Remdesivir: Effectiveness and Safety in Hospitalized Patients with COVID-19 (ReEs-COVID-19)-Analysis of Data from Daily Practice.

Remdesivir was the first antiviral approved for treating COVID-19. We investigated its patterns of use, effectiveness and safety in clinical practice in Greece. This is a retrospective observational study of hospitalized adults who received remdesivir for COVID-19 in September 2020-February 2021. The main endpoints were the time to recovery (hospital discharge within 30 days from admission) and safety. The "early" (remdesivir initiation within 24 h since hospitalization) and "deferred" (remdesivir initiation later on) groups were compared. One thousand and four patients (60.6% male, mean age 61 years, 74.3% with severe disease, 70.9% with ≥1 comorbidities) were included, and 75.9% of them were on a 5-day regimen, and 86.8% were in the early group. Among those with a baseline mild/moderate disease, the median (95% CI) time to recovery was 8 (7-9) and 12 (11-14) days for the early and deferred groups, respectively (p < 0.001). The corresponding estimates for those with a severe disease were 10 (9-10) and 13 (11-15) days, respectively (p = 0.028). After remdesivir initiation, increased serum transaminases and an acute kidney injury were observed in 6.9% and 2.1%, respectively. Nine (0.9%) patients discontinued the treatment due to adverse events. The effectiveness of remdesivir was increased when it was taken within 24 h since admission regardless of the disease severity. Remdesivir's safety profile is similar to that described in clinical trials and other real-world cohorts.

The prognostic role of micronutrient status and supplements in COVID-19 outcomes: A systematic review.

Micronutrients constitute an adjuvant treatment for respiratory viral infections. Since there is no effective antiviral therapy for COVID-19 yet, adjuvant intervention for the survival of critically ill patients may be significant. Search of the PubMed, CINAHL and Cochrane databases was carried out to find human studies investigating the prognostic role of micronutrient status and the effects of micronutrient supplementation intervention in COVID-19 outcomes of adult patients. Patients with certain comorbidities (diabetes mellitus type 2, obesity, renal failure, liver dysfunction etc.) or pregnant women were excluded. 31 studies (27 observational studies and 4 clinical trials) spanning the years 2020-2021, pertaining to 8624 COVID-19 patients (mean age±SD, 61 ± 9 years) were included in this systematic review. Few studies provided direct evidence on the association of serum levels of vitamin D, calcium, zinc, magnesium, phosphorus and selenium to patients' survival or death. Vitamin D and calcium were the most studied micronutrients and those with a probable promising favorable impact on patients. This review highlights the importance of a balanced nutritional status for a favorable outcome in COVID-19. Micronutrients' deficiency on admission to hospital seems to be related to a high risk for ICU admission, intubation and even death. Nevertheless, evidence for intervention remains unclear.