Methods and Reproducibility of Liver Fat Measurement Using 3-Dimensional Liver Segmentation From Noncontrast Computed Tomography in EVAPORATE Cohort.

OBJECTIVE: Nonalcoholic fatty liver disease not only shares multiple risk factors with cardiovascular disease but also independently predicts its increased risk and related outcomes. Here, we evaluate reproducibility of 3-dimensional (3D) liver volume segmentation method to identify fatty liver on noncontrast cardiac computed tomography (CT) and compare measures with previously validated 2-dimensional (2D) segmentation CT criteria for the measurement of liver fat. METHODS: The study included 68 participants enrolled in the EVAPORATE trial and underwent serial noncontrast cardiac CT. Liver attenuation < 40 Hounsfield units (HU) was used for diagnosing fatty liver, as done in the MESA study. Two-dimensional and 3D segmentation of the liver were performed by Philips software. Bland-Altman plot analysis was used to assess reproducibility. RESULTS: Interreader reproducibility of 3D liver mean HU measurements was 96% in a sample of 111 scans. Reproducibility of 2D and 3D liver mean HU measurements was 93% in a sample of 111 scans. Reproducibility of change in 2D and 3D liver mean HU was 94% in 68 scans. Kappa, a measure of agreement in which the 2D and 3D measures both identified fatty liver, was excellent at 96.4% in 111 scans. CONCLUSIONS: Fatty liver can be reliably diagnosed and measured serially in a stable and reproducible way by 3D liver segmentation of noncontrast cardiac CT scans. Future studies need to explore the sensitivity and stability of measures for low liver fat content by 3D segmentation, over the current 2D methodology. This measure can serve as an imaging biomarker to understand mechanistic correlations between atherosclerosis, fatty liver, and cardiovascular disease risk.

Staying Out of Trouble: Complications of Supracondylar Humerus Fractures.

Supracondylar fractures are among the most common fractures in children that require surgery. These fractures are also associated with some of the most serious complications of all fractures seen in children. Timely recognition and careful management can mitigate the potentially poor outcomes of these complications. Pin-site irritation and superficial infections are the most common complications seen. Cubitus varus remains another common complication, even with the use of closed reduction and pinning for management of most displaced fractures. Neurapraxias are seen in almost 10% of patients, with most resolving spontaneously. The worst complications are those that may be catastrophic for patients, causing substantial loss of function or even amputation of the limb; for example, vascular injury and compartment syndrome. Diagnosis and management of these complications should focus on strategies to ensure the best possible outcomes.

Prefrontal cortical circuit for depression- and anxiety-related behaviors mediated by cholecystokinin: role of ΔFosB.

Decreased medial prefrontal cortex (mPFC) neuronal activity is associated with social defeat-induced depression- and anxiety-like behaviors in mice. However, the molecular mechanisms underlying the decreased mPFC activity and its prodepressant role remain unknown. We show here that induction of the transcription factor ΔFosB in mPFC, specifically in the prelimbic (PrL) area, mediates susceptibility to stress. ΔFosB induction in PrL occurred selectively in susceptible mice after chronic social defeat stress, and overexpression of ΔFosB in this region, but not in the nearby infralimbic (IL) area, enhanced stress susceptibility. ΔFosB produced these effects partly through induction of the cholecystokinin (CCK)-B receptor: CCKB blockade in mPFC induces a resilient phenotype, whereas CCK administration into mPFC mimics the anxiogenic- and depressant-like effects of social stress. We previously found that optogenetic stimulation of mPFC neurons in susceptible mice reverses several behavioral abnormalities seen after chronic social defeat stress. Therefore, we hypothesized that optogenetic stimulation of cortical projections would rescue the pathological effects of CCK in mPFC. After CCK infusion in mPFC, we optogenetically stimulated mPFC projections to basolateral amygdala or nucleus accumbens, two subcortical structures involved in mood regulation. Stimulation of corticoamygdala projections blocked the anxiogenic effect of CCK, although no effect was observed on other symptoms of social defeat. Conversely, stimulation of corticoaccumbens projections reversed CCK-induced social avoidance and sucrose preference deficits but not anxiogenic-like effects. Together, these results indicate that social stress-induced behavioral deficits are mediated partly by molecular adaptations in mPFC involving ΔFosB and CCK through cortical projections to distinct subcortical targets.

Pre-operative prone radiographs can reliably determine spinal curve flexibility in adolescent idiopathic scoliosis (AIS).

PURPOSE: The purpose of this study was to evaluate the correlation between non-effort prone and bending radiographs in determining curve flexibility in adolescent idiopathic scoliosis (AIS). METHODS: A retrospective review of AIS patients who underwent pre-operative full spine radiographic imaging from 2006 to 2019 was performed. The Cobb angle (CA) of proximal thoracic (PT), main thoracic (MT) and thoracolumbar/lumbar (TL/L) curves were measured and correlated on standing, prone and bending radiographs. Standing, bending, and prone measurements were correlated using Spearman's analysis, and intra-rater reliability was evaluated using intraclass correlation analysis. RESULTS: A total of 381 patients (74% female) with a mean age of 15.1 ± 2.5 years were identified. A strong correlation existed between the prone and bending CA for the PT (rs = 0.797, p < 0.01) and MT (rs = 0.779, p < 0.01) curve and a moderate correlation existed between the prone and bending TL/L curve (rs = 0.641, p < 0.01). For a non-structural PT curve, a prone CA < 25° correctly identified a bending CA < 25° 96.7% of the time (p < 0.005). For a non-structural MT curve, a prone CA < 35° correctly identified a bending CA < 25° 90.2% of the time (p < 0.005). For a non-structural TL/L curve, a prone CA < 35° correctly identified a bending CA < 25° 95% of the time (p < 0.005). CONCLUSION: Prone radiographs demonstrated a moderate to strong correlation with bending radiographs and may be used as a proxy for determining spinal flexibility, especially when bending films are deemed unreliable. LEVEL OF EVIDENCE: III.

Association of Bacterial Etiology With Rates of Reoperation in Patients With Septic Tenosynovitis of the Hand.

Background: The anatomy of the hand makes it uniquely sensitive to complications after bacterial infection. The causative organism has been implicated as a predictor of complications after surgery. We hypothesize that bacterial etiology is associated with different operation and reoperation rates in patients with flexor tenosynovitis. Methods: The Nationwide Inpatient Sample 2001-2013 database was queried for cases of tenosynovitis by using International Classification of Diseases, 9th Revision (ICD-9) diagnostic codes 727.04 and 727.05. The pathogen cultured was also identified with ICD-9 codes, and surgical intervention was determined using ICD-9 procedural codes. χ2 analysis and logistic regression were used to determine predictors of outcomes. Outcomes included initial surgery and the need for additional surgery, which was defined as records having ICD-9 procedural codes repeated for the same patient. Results: A total of 17,476 cases were included. The most common bacterial etiology was methicillin-sensitive Staphylococcus aureus followed by Streptococcus species. Infections with gram-positive organisms, including methicillin-sensitive and methicillin-resistant S aureus, unspecified Staphylococcus, and Streptococcus species were significantly associated with higher rates of initial surgery for tenosynovitis. Patients receiving Medicaid and Hispanic patients had a statistically significant lower likelihood of surgery. Higher rates of reoperation were reported in patients aged 30 to 50 years, 51 to 60 years, 61 to 79 years, and ≥80 years; other factors associated with higher reoperation rates were Streptococcus and Staphylococcus infections and use of Medicare. Conclusions: The data show that cultures of Streptococcus and certain species of Staphylococcus in patients with septic tenosynovitis are predictive of operation and reoperation rates. Patients with these infectious etiologies may have more severe presentations that warrant operative intervention. This data may allow for more informed decision-making in the preoperative period.

Synergistic effects of robotic surgery and IPACK nerve block on reduction of opioid consumption in total knee arthroplasty.

Background: There are numerous strategies to combat postoperative analgesia and expedite recovery after total knee arthroplasty (TKA). The purpose of this study was to determine opioid consumption, length of stay, and functional outcomes after robotic versus standard TKA in the setting of various regional pain modalities. Methods: A consecutive series of patients treated with unilateral primary robotic or standard TKA from January 2018-February 2021 were retrospectively identified. Regional pain modalities included peri-articular injection (PAI), adductor canal block (ACB), and infiltration between popliteal artery and capsule of knee (IPACK). Patient demographics, operative/perioperative variables, and postoperative function were recorded. Daily opiate consumption was calculated as morphine milligram equivalents (MME). Multivariate regression was performed to control for age, sex, and race. Results: After review, 283 patients (177 Females; 106 Males) were included. Robotic TKA patients received IPACK + ACB (36), while standard TKA patients received either ACB (45), IPACK + ACB (167), or PAI (35). Daily inpatient opioid consumption in the standard IPACK + ACB (p = 0.02) and robotic IPACK + ACB groups (p = 0.0001) was significantly lower compared to standard ACB. When combined with IPACK block, robotic procedures synergistically lowered opiate consumption (p = 0.004) compared to standard procedures and led to earlier discharge (p = 0.003). The robotic IPACK + ACB cohort also demonstrated improved early ambulation compared to standard ACB, (p = 0.05), whereas the same benefit was not seen for patients who received IPACK during standard TKA. Conclusions: The utilization of IPACK block decreases inpatient postoperative opioid requirements following TKA. Robotic TKA and IPACK block appeared to have a synergistic effect on opioid consumption and postoperative recovery.

A novel and easy technique for restoring grossly decayed mandibular molar with a modified cast-post.

The article addresses the difficulty of restoring a grossly carious molar tooth, where very little tooth structure is left after caries excavation. When enough sound tooth structure is missing for satisfying the ferrule effect, a clinician can follow this technique and easily restore such teeth. A step by step procedure, including instrumentation and materials and a new impression technique, is described in detail, with clinical photographs. This technique results in the fabrication of a robust and extremely retentive post and core on which to place fixed prosthodontic restorations. A 2 and half year study showed that the tooth well in function with no signs of any problem. The author has restored around many decayed molars using this technique. Over a period of three years, no failure was reported. With an increasing demand on the dentist for restoring a structurally compromised teeth, this technique provides the patients with a robust prosthodontic solution.