Adolescent hallux valgus: a systematic review of outcomes following surgery

PurposeThe management of adolescent hallux valgus (AHV) remains controversial, with reservations about both conservative and surgical treatments. Non-operative management has a limited role in preventing progression. Surgical correction of AHV has, amongst other concerns, been associated with a high prevalence of recurrence of deformity after surgery. We conducted a systematic review to assess clinical and radiological outcomes following surgery for AHV.MethodsA comprehensive literature search was performed in the Cochrane Library, CINAHL, EMBASE, Google Scholar and PubMed. The study was performed in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Demographic data, radiographic parameters and results of validated clinical scoring systems were analysed.ResultsThe published literature on AHV is largely heterogeneous and retrospective. Nine contemporary studies reporting on 140 patients (201 osteotomies) were included. The female to male ratio was 10:1. The mean age at operation was 14.5 years (range 10.5–22). The mean follow-up was 41.6 months (range 12–134). The mean post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score was 85.8 (standard deviation, SD ±7.38). The mean AOFAS patient satisfaction showed that 86 % (SD ±11.27) of patients were satisfied or very satisfied with their outcome. On the duPont Bunion Rating Score (BRS), 90 % rated their outcome as good or excellent. There was a statistically significant improvement in the inter-metatarsal angle (IMA, p = 0.0003), hallux valgus angle (HVA, p < 0.0001) and distal metatarsal articular angle (DMAA, p = 0.019).ConclusionBased on the most current published evidence, contemporary surgical interventions for AHV show excellent clinical and radiological outcomes, with high patient satisfaction. The rates of recurrence and other complications are lower than the historically reported figures. There is a need for high-level, multi-centre collaborative studies with prospective data to establish the long-term outcomes and optimal surgical procedure(s).     

Cervical Spinal Cord DTI Is Improved by Reduced FOV with Specific Balance between the Number of Diffusion Gradient Directions and Averages

BACKGROUND AND PURPOSE:Reduced-FOV DTI is promising for exploring the cervical spinal cord, but the optimal set of parameters needs to be clarified. We hypothesized that the number of excitations should be favored over the number of diffusion gradient directions regarding the strong orientation of the cord in a single rostrocaudal axis.MATERIALS AND METHODS:Fifteen healthy individuals underwent cervical spinal cord MR imaging at 3T, including an anatomic 3D-Multi-Echo Recombined Gradient Echo, high-resolution full-FOV DTI with a NEX of 3 and 20 diffusion gradient directions and 5 sets of reduced-FOV DTIs differently balanced in terms of NEX/number of diffusion gradient directions: (NEX/number of diffusion gradient directions = 3/20, 5/16, 7/12, 9/9, and 12/6). Each DTI sequence lasted 4 minutes 30 seconds, an acceptable duration, to cover C1–C4 in the axial plane. Fractional anisotropy maps and tractograms were reconstructed. Qualitatively, 2 radiologists rated the DTI sets blinded to the sequence. Quantitatively, we compared distortions, SNR, variance of fractional anisotropy values, and numbers of detected fibers.RESULTS:Qualitatively, reduced-FOV DTI sequences with a NEX of ≥5 were significantly better rated than the full-FOV DTI and the reduced-FOV DTI with low NEX (N = 3) and a high number of diffusion gradient directions (D = 20). Quantitatively, the best trade-off was reached by the reduced-FOV DTI with a NEX of 9 and 9 diffusion gradient directions, which provided significantly fewer artifacts, higher SNR on trace at b = 750 s/mm² and an increased number of fibers tracked while maintaining similar fractional anisotropy values and dispersion.CONCLUSIONS:Optimized reduced-FOV DTI improves spinal cord imaging. The best compromise was obtained with a NEX of 9 and 9 diffusion gradient directions, which emphasizes the need for increasing the NEX at the expense of the number of diffusion gradient directions for spinal cord DTI contrary to brain DTI.

Cervical spinal cord (CSC) assessment in daily clinical routines still essentially relies on a qualitative evaluation of conventional MR imaging sequences. Nonetheless, additional sequences could provide more sensitive information about CSC alterations, notably in inflammatory, traumatic, and neurodegenerative diseases.^1–5 Among the sequences, diffusion tensor imaging, classically based on single-shot echo-planar imaging, could provide valuable qualitative information and quantitative surrogate biomarkers.While DTI has been widely investigated in the brain, its use for CSC imaging is still challenging and is restricted to preclinical and monocentric clinical studies. Several reasons for these limitations include the CSC being a small structure, prone to distortions; susceptibility artifacts, especially with a long echo-planar readout train; flow artifacts; and physiologic motion artifacts.Among the various methods that have been implemented on MR imaging systems to improve DTI quality, reduced field-of-view (r-FOV) is particularly promising. It consists of reducing the FOV in the phase- or frequency-encoding direction to shorten the echo-planar readout train and attenuate susceptibility- and motion-related artifacts.^6–11 Because the CSC is a small longitudinal structure, r-FOV is especially suitable for its exploration. One of the r-FOV techniques uses a 2D echo-planar radiofrequency pulse to excite a rectangular FOV, with contiguous multisections. The k-space is then more rapidly acquired for the same spatial resolution, which decreases single-shot EPI artifacts together with inherent fat suppression.⁶On qualitative analysis, this CSC r-FOV diffusion-weighted imaging method obtained from 3 orthogonal diffusion gradient directions has already demonstrated its ability to better detect anatomic details, with fewer ghosting and blurring artifacts,¹² while apparent diffusion coefficient values were stable compared with conventional full-FOV CSC DWI (f-FOV).However, there is no recommendation regarding the optimal set of parameters to perform r-FOV DTI in CSC. Some consensus has been reached (regarding the b-value, voxel size, number of excitations, number of diffusion gradient directions [NDGD], and bandwidth¹³), but these recommendations concern f-FOV DTI with parallel imaging, whose sequence scheme is different from the r-FOV scheme. The smaller voxel size in r-FOV inherently leads to a decrease of the signal-to-noise ratio. Classic strategies to recover SNR consist of increasing the NEX and/or the NDGD. Unlike brain DTI, for which the NDGD should be preferred over the NEX, there is no consensus about the best pair of NEX/NDGD for CSC DTI to handle with the complex fiber orientation. One might even hypothesize that the best trade-off of NEX/NDGD could be obtained by favoring NEX (unlike for brain DTI) because the CSC is particularly affected by artifacts and presents a single prominent orientation. It is difficult to rely on phantom studies or theoretic analyses for such optimization in the CSC, which could not take into account CSF pulsations, heartbeats, or patient respiratory motions.Therefore, the purpose of this study was to compare different sets of r-FOV CSC DTI, depending on different pairs of NEX and NDGD, and a standard f-FOV DTI. To do so, we used an empiric nonsequential optimization approach, in which both NEX and NDGD were modified simultaneously, with the only constraint being maintaining the same clinically acceptable scan duration. To evaluate image quality, we proposed a practical clinical approach with a standardized bench test for qualitative and quantitative evaluations derived from ROIs and tractography.     

Upscaling the recruitment and retention of human resources for health at primary healthcare centres in Lebanon: a qualitative study

The sustainability of primary healthcare (PHC) worldwide has been challenged by a global shortage in human resources for health (HRH). This study is a unique attempt at systematically soliciting and synthesising the voice of PHC and community stakeholders on the HRH recruitment and retention strategies at the PHC sector in Lebanon, the obstacles and challenges hindering their optimisation and the recommendations to overcome such obstacles. A qualitative design was utilised, involving 22 semi‐structured interviews with PHC experts in Lebanon conducted in 2013. Nvivo qualitative data analysis software was employed for the thematic analysis of data collected from interviews. Five comprehensive themes emerged: understanding PHC scope, HRH recruitment issues, HRH retention challenges, rural areas' specific challenges and stakeholders' recommendations. Analysis of stakeholders' responses revealed a lack of a unified understanding of the PHC scope impacting the capacity for appropriate HRH planning. Identified impediments to recruitment included the suboptimal supply of HRH, financial constraints and poor management. Retention difficulties were attributed to poor working environments, financial constraints and lack of professional development. There was consensus that HRH challenges faced were aggravated in rural areas, jeopardising the equitable access to PHC services of quality. Equitable access was also jeopardised by the reported shortage of female HRH in a sociocultural context where many females prefer providers of the same gender. The study sets the path towards upscaling recruitment and retention policies and practices through the endorsement of a nationally acknowledged PHC definition and scope, the sustainable development of the PHC workforce and through the implementation of targeted recruitment and retention strategies addressing rural settings and gender equity. Decision‐makers and planners are urged to identify HRH as the most important input for the success of PHC programmes and interventions, especially in the growing fields of mental health and geriatric care.     

Association between mass media and body weight concern among Jordanian adolescents’ residents of Amman: the role of gender and obesity

Objectives

Body image in the mass media promotes an unrealistic picture of body shape that leads to body dissatisfaction among adolescentsQuery. Therefore, the study presented in this paper aimed to assess the association between mass media and adolescents’ weight concerns and perceptions of body weight and shape.

Methods

A cross-sectional survey was conducted on school adolescents aged between 15 and 18 years during the academic year 2013–2014. Multistage stratified sampling method was used. The number of participants in the study was 795 students: 400 boys and 395 girls.

Results

All participants have a common behavior in rarely reading magazines, but they spend more than 2 h in watching television or less than 3 h using the internet. However, most of obese/non-obese adolescents, boys or girls, have shown high influence (p < 0.05) of reading magazines on the subject of dieting to lose weight.

Conclusion

While obese students read more magazines on dieting to lose weight, other mass media did not show the same results on weight concerns and body shape among Jordanian adolescents.

     

A Pin1/PML/P53 axis activated by retinoic acid in NPM-1c acute myeloid leukemia

Retinoic acid (RA) was proposed to increase survival of chemotherapy- treated patients with nucleophosmin-1 (NPM-1c)-mutated acute myeloid leukemia. We reported that, ex vivo, RA triggers NPM-1c degradation, P53 activation and growth arrest. PML organizes domains that control senescence or proteolysis. Here, we demonstrate that PML is required to initiate RA-driven NPM-1c degradation, P53 activation and cell death. Mechanistically, RA enhances PML basal expression through inhibition of activated Pin1, prior to NPM-1c degradation. Such PML induction drives P53 activation, favoring blast response to chemotherapy or arsenic in vivo. This RA/PML/P53 cascade could mechanistically explain RA-facilitated chemotherapy response in patients with NPM-1c mutated acute myeloid leukemia.     

The use and yield of continuous EEG in critically ill patients: A comparative study of three centers

Objective

Continuous EEG (cEEG) monitoring of critically ill patients has gained widespread use, but there is substantial reported variability in its use. We analyzed cEEG and antiseizure drug (ASD) usage at three high volume centers.

Eating Disorders in Lebanon: Directions for Public Health Action

Research in the field of eating disorders (ED) is limited in the Middle East. The aim of the present study was to profile Lebanese ED outpatients. A mixed-method design was used. Clinicians across Lebanon filled individual questionnaires about their 2013 ED outpatients (n = 104) and participated in focus groups. Results showed that bulimia nervosa was the most prevalent ED (46.1 %) followed by anorexia nervosa (39.4 %) and binge eating (14.4 %). The emerging socio-demographic profile of the Lebanese ED patient was that of a single female young adult of middle to high socio-economic status with severe ED symptoms (amenorrhea, multiple purging behaviors) and depression. Also, there was a general delay in seeking help which made patient recovery more difficult. The present study emphasizes the critical need for a public health approach to ED awareness and could help in developing preventive and remedial educational programs targeting youth in Lebanon and the Middle East.