Clinical Circumstances Research Articles

Skin cancer: What happens in the laboratory?

Skin cancer specimen handling in Australian histopathology laboratories, while largely standardised, exhibits significant variations that affect clinical decision-making and patient outcomes. This article provides clinicians with an understanding of histopathological processes to enhance diagnostic precision, inform surgical margin evaluations and refine management approaches. Understanding specimen handling and protocols is vital for accurate interpretation of pathology reports and management of skin cancers. Variations in sampling, examination and sectioning can affect pathological diagnosis and margin assessment. Clinician insights into laboratory processes are crucial for best practice. Retention of specimens and reports allows for further evaluation if clinical circumstances evolve or additional investigations are required.

Access to Psychotherapy Notes: Review of Legal Standards for Mental Health Clinicians.

Patients' access to their psychotherapy records may be assumed to be well protected; however, the matter is intricately regulated. In fact, the statutes and rights pertaining to patient access to psychotherapy notes vary across states. Taken together, federal and state laws indirectly and inconsistently delineate lawful access-as well as clinical exceptions to providing access-to psychotherapy notes. Federal law defers to state laws when the latter afford individuals greater access to their notes. Both federal and individual state levels vary in providing for possible conditions under which access may be restricted. Right of access to psychotherapy notes is a matter of importance for all mental health clinicians in the United States. Awareness and integration of pertinent laws and regulations allow clinicians to manage such matters without a negative impact on their clinical care. Further consideration of how clinical practice interacts with other dimensions of health care administration (clinical, ethical, and legal) may serve to enhance the integrity of a clinician's work and the ability to adapt to difficult clinical circumstances with confidence.

A Meta-Analytical Way of Systematizing the Use of Hyaluronan Gels for the Relief of Osteoarthritis, Compared with New Treatment Alternatives.

Hyaluronic acid, in the form of a gel or viscoelastic colloidal solution, is currently used for the viscosupplementation of joints affected by osteoarthritis, but its effectiveness is under debate in relation to newer alternatives. Based on meta-analytical arguments, the present article reinforces the opinion that there are still no decisive arguments for its complete replacement but for its use adapted to the peculiarities of the disease manifestation and of the patients. A "broad" comparison is first made with almost all alternatives studied in the last decade, and then a meta-regression study is performed to compare and predict the effect size induced by viscosupplementation therapy and its main challenger of clinical interest, the platelet-rich plasma treatment. If they are computerized, the developed models can represent tools for clinicians in determining the appropriateness of the option or not for viscosupplementation in a manner adapted to the pain felt by the patients, to their age, or to other clinical circumstances. The models were generated using algorithms implemented in the R language and assembled in different R packages. All primary data and necessary R scripts are provided in accordance with the philosophy of reproducible research. Finally, we adhere in a documented way to the opinion that HA-based products, currently under circumspection, are still clinically useful.

Low dose of morphine to relieve dyspnea in acute respiratory failure: the OpiDys double-blind randomized controlled trial

BackgroundMorphine relieves dyspnea in various clinical circumstances. Whether or not this applies to patients admitted to intensive care units (ICUs) for acute respiratory failure (ARF) is unknown. We evaluated the efficacy and safety of low-dose morphine on dyspnea in patients admitted to the ICU for ARF.MethodsIn this single-center, double-blind, phase 2, randomized, controlled trial, we assigned non-intubated adults admitted to the ICU for ARF with severe dyspnea, defined by a visual analog scale for dyspnea (dyspnea-VAS) from zero (no dyspnea) to 100 mm (worst imaginable dyspnea) ≥40 mm, to receive a low dose of Morphine Hydrochloride (intravenous titration followed by subcutaneous relay) or Placebo. All patients received standard therapy, including etiological treatment and non-invasive respiratory support.ResultsTwenty-two patients were randomized, 11 in each group. The average dyspnea (median [interquartile range]) over 24 hours did not significantly differ between the two groups (40 [25 – 43] mm in the Morphine group vs. 40 [36 – 49] mm in the Placebo group, p=0.411). Dyspnea-VAS was lower in the Morphine group than in the Placebo group at the end of intravenous titration (30 [11 – 30] vs. 35 [30 – 44], p=0.044) and four hours later (18 [10 – 29] vs. 50 [30 – 60], p=0.043). The cumulative probability of intubation was higher in the Morphine group than in the Placebo group (p=0.046)ConclusionIn this phase 2 pilot trial, morphine did not improve 24-hour average dyspnea in adult patients with ARF, even though it had a statistically significant immediate effect. Of concern, Morphine use was associated with a higher intubation rate.Trial registrationThe protocol was declared on the ClinicalTrial.gov database (no. NCT04358133) and was published in September 2022.

Treatment of acute high risk sub-massive pulmonary embolism with balloon angioplasty and thrombolysis simultaneously

Background: Acute sub-massive pulmonary embolism is a common clinical condition, and it is associated with high mortality and morbidity. This condition is commonly associated with various co-morbidities and clinical circumstances. Methods: This is a case report series of 4 patients, wherein the thrombolysis and balloon angioplasty was performed simultaneously using a Cordis 6F diagnostic catheter and later exchanged with a 6F guide catheter in the respective pulmonary artery when a larger balloon was required. Results: All these four patients achieved successful revascularization of the respective pulmonary artery. One patient expired 30 hours after the procedure with a significant reduction in the symptoms suddenly, which was likely a second episode of pulmonary embolism. No bleeding manifestations were observed in any of the patients. The other three patients are on follow-up. Conclusion: Simultaneous coronary balloon dilatation and thrombolysis is a useful method in the treatment of high risk submassive acute pulmonary embolism. If needed, higher caliber balloons can be used for the same technique using guide catheters.

Clinical Spectrum of Upper Gastrointestinal Bleeding in Pediatric Age Group: An Experience From a Tertiary Care Hospital of Bangladesh

Background: The bleeding occurring proximal to the ligament of the treitz is known as Upper GI bleeding. The patient may present with hematemesis or melena. Upper gastrointestinal bleeding in children can result in complex and perhaps fatal clinical circumstances. It fluctuates significantly depending on changes in the patient’s demographics and other diseases. Methods: This was a cross sectional study conducted at the Department of Paediatrics, Dhaka Medical College Hospital, Dhaka. The study was conducted during the period of Jan’2020 to July 2022. The total number of study patients was 92. Result: The most extensive prevalence of UGIB is found in children aged 5 to 10 years (71.4%), followed by those aged 1 to 12 years (26.8%). Varices accounted for 67 (72.8%) of the UGIB causes, followed by erosive gastritis (6.5%), stomach ulcers (3.3%), esophagitis (2.2%), and Mallory Weiss tears (1.1%), with 13 (14.1%) of them being judged to be normal. Pallor was the most common presenting symptom, making up 82 (89.1%), then hematemesis 61(66.3%) and melena 30.4%, splenomegaly 55(59.8%), hematemesis plus melena (30.4%), hepatomegaly (28.3%), jaundice (15.6%), and melena (3.3%). Conclusion: Hematemesis is the most common presenting symptom of upper GI haemorrhage, which is more common in kids between the ages of 5 and 10. Esophageal varices were the most common source of intestinal bleeding. J Dhaka Med Coll. 2022; 31(2) : 215-219

Pneumonectomy for non–small cell lung cancer. A National Cancer Database analysis of geographic and temporal trends, outcomes, and associated factors

BackgroundThe circumstances under which pneumonectomy should be performed are controversial. This study aims to investigate national trends in pneumonectomy use to determine which patients, in what geographic areas, and under what clinical circumstances pneumonectomy is performed in the United States. MethodsWe queried the National Cancer Database and included all patients undergoing anatomic surgical resection for non–small cell lung cancer (2015–2020). The association between demographic and clinical factors and the use of pneumonectomy were investigated. ResultsWho: A total of 128,421 patients were identified, of whom 738 (0.6%) underwent pneumonectomy. Those patients were younger (median 65 vs 68 years, P < .001), more often male (59.9% vs 44.9%, P < .001), more likely to be below median income level (44.2% vs 38.6%, P = .002), and more likely to have lower education indicators (53% vs 48.6%, P = .02) than those who underwent other anatomic resections. Notably, there was a decreasing trend in pneumonectomy use during the study period (0.9% down to 0.4%, P < .001). Where: Patients undergoing pneumonectomy were less likely to live in metropolitan areas (77.9% vs 81.7%, P = .008) and to live closer (<12 miles) to their treating facility (45% vs 49%, P = .02). Regional geographic differences also were identified (P < .001). Why: Patients who underwent pneumonectomy were more likely to have received neoadjuvant therapy (20.6% vs 5.3%, P < .001), to be clinically N (+) (39.3% vs 12.3%, P < .001), and to have more advanced tumors (cT3-4: 46.3% vs 11.3%, P < .001). ConclusionAlthough primarily driven by advanced oncologic features, socioeconomic and geographic factors also were associated independently with the use of pneumonectomy. Standardizing pneumonectomy indications nationwide is crucial to prevent widening outcome gaps for patients with lung cancer.

A Narrative Review of Pain in Pediatric Oncology: The Opioid Option.

Opioid therapy is the mainstay for managing pain in pediatric oncology. This narrative review describes the current literature regarding opioids for pediatric cancer pain. The review explores the multifaceted landscape of opioid utilization in this population, including the role of opioids in certain clinical circumstances, modalities of opioid delivery, unique opioids, outpatient and at-home pain management strategies, and other key concepts such as breakthrough pain. This review highlights the importance of individualized dosing and multimodal approaches to enhance efficacy and minimize adverse effects. Drawing from a wide range of evidence, this review offers insights to optimize pediatric oncology pain management.

Clinical use of CRT‐D devices with left ventricular sensing: Impact of the desynchronization‐detection algorithm

AbstractThe use of CRT‐D devices with left ventricular (LV) sensing has created controversy about programming various parameters especially the left ventricular T wave protection (LVTP) designed to prevent the delivery of a pacing stimulus into the LV vulnerable period. Such devices are available from two manufacturers. This review focuses only on those provided by Biotronik. As the LVTP controls LV sensing, some investigators have advocated turning off the LVTP to prevent episodic desynchronization known a CRT pacing interrupt. However, LVTP off reduces but does not eliminate this type of desynchronization if triggering of an LV stimulus upon right ventricular sensing (RVs) is programmed on. Deactivation of the LVTP incurs loss of diagnostic data provided by CRT pacing interrupt itself. By choice, the occurrence of CRT pacing interrupt can be totally eliminated by appropriate programming of the LV upper rate interval, LVTP and triggering of an LV pacing event upon RVs. Various programmability options are available according to clinical circumstances. As a rule, clinical judgement must weigh the potential diagnostic benefit of preserving the LVTP capable of recording of episodic CRT pacing interrupt against the loss of diagnostic benefit when LVTP is programmed off (with or without triggering of an LV stimulus upon RVs).

Safety of Progestogen Hormonal Contraceptive Methods during Lactation: An Overview.

Breastfeeding is a process for not only nourishing infants but also for building a unique emotional bond between mother and child. Therefore, the ideal contraception during lactation should not affect lactation (milk composition, milk volume) and offspring development. This study aims to analyze the literature on the safety of progestogen hormonal contraceptive methods during lactation. We conducted a thorough search across various databases, including the National Library of Medicine (PubMed), and the Cochrane Database, Drugs and Lactation Database (LactMed). Our search utilized specific phrases such as: "lactation" and "breastfeeding" and "oral contraception" with "drospirenone" or "desogestrel", with "subcutaneous etonogestrel implant" or "etonogestrel implant", with "levonorgestrel-releasing intrauterine system", and "emergency contraception", with "levonorgestrel" or "ulipristal acetate". Based on published scientific reports, progestogen hormonal contraceptives can be considered a relatively safe solution for women desiring to continue feeding their infant with their milk while using hormonal contraception. It is important to seek guidance on selecting the best contraception method based on the latest medical knowledge, tailored to the individual needs and clinical circumstances of each woman and place of residence. A woman should always be informed of the potential risks of such a treatment and then allowed to make her own decision based on the knowledge received from a specialist.

A Three-year Retrospective Study Looking at Preventing Hospital Acquired Thrombosis.

Hospital-acquired venous thromboembolism (HA-VTE) is defined as cases of venous thromboembolism (VTE) that occur in a hospital and within ninety days of a hospital admission. Deep vein thromboses (DVTs) most commonly occur within the deep veins of the pelvis and legs. If the thrombus dislodges and travels to the lungs, it can result in a pulmonary embolus (PE). VTE is associated with significant morbidity and mortality, accounting for almost 10% of all hospital deaths. If risk factors are correctly identified and VTE prophylaxis is prescribed, VTE can be a preventable condition. In 2010, NHS England launched The National Venous Thromboembolism Prevention Programme. This included NICE guidance, and a VTE risk assessment tool, which must be completed for at least 95% of patients on admission. The National Thrombosis Survey, published by Thrombosis UK, studied how this program was implemented locally, and audited HA-VTE prevention strategies nationally. Using the Thrombosis Survey and NICE guidance as an aide, this study collects data about hospital-acquired DVT (HA-DVT) at the Queen Elizabeth Hospital in Gateshead (QEH) and aims to: 1. Identify cases of HA-DVT and understand the clinical circumstances surrounding these cases 2. Assess the quality of VTE preventative measures at QEH 3. Outline potential improvement in reducing the incidence of HA-VTE at this hospital Methods: This retrospective cohort study used electronic records to identify all cases of DVT between April 2019 and April 2022 at QEH. Cases of HA-DVT were defined as: a positive ultrasound doppler report and either the case occurring in the 90 days following an inpatient stay, or beyond two days into an admission. For these cases of HA-DVT, we recorded the: reason for admission; admitting specialty; presence of an underlying active cancer and deaths occurring within 90 days of diagnosis. We assessed the quality of VTE preventative measures, by recording the: completion of VTE risk assessments; prescription of weight-adjusted pharmacological VTE prophylaxis and provision of VTE prophylaxis on discharge. For HA-DVT cases occurring within 90 days of an inpatient stay, the preventative measures were assessed on the original admission. Electronic records were used to record the completion rate of the National VTE risk assessment tool for all inpatients during this time frame. The VTE risk assessment tool was completed for 98.5% of all admissions. One hundred and thirty-five cases of HA-DVT were identified between April 2019 and April 2022. Sixteen patients with HA-DVT did not have VTE prophylaxis prescribed on admission. Eleven of these patients had a clearly documented reason why anticoagulation was avoided. In HA-DVT cases where pharmacological VTE prophylaxis was prescribed, 23% were prescribed an inappropriate dose for their weight. If anticoagulation was required on discharge, this was prescribed appropriately in 94% of cases. About 31% of the patients with HA-DVT had an underlying active malignancy. Thirty-nine patients died within 90 days of the DVT being diagnosed; in only 1 case was VTE thought to be a contributing factor to death. The hospital exceeded the national standard of VTE risk assessment completion on admission (greater than 95%). For almost a quarter of patients with HA-DVT, the dose of thromboprophylaxis prescribed was not appropriate for weight. In five cases of HA-DVT, thromboprophylaxis was omitted with no clear justification. HA-DVT often affects the most clinically vulnerable patients and is associated with a high mortality.

Five-Year Results for Abdominal Aortic Aneurysm Repair with the GORE® EXCLUDER® Device: Insights from the Gore Global Registry for Endovascular Aortic Treatment (GREAT)

ObjectivesThe early postoperative benefits of EVAR have been well established but questions remain regarding its durability at mid and long-term timepoints. Long-term results in real-world use of EVAR outside of randomized trial data are limited. This study utilized the GREAT Registry to explore the 5-year outcomes with the GORE® EXCLUDER® device in real-world clinical circumstances. MethodsAll patients within the GREAT registry that underwent an infrarenal AAA repair with the GORE® EXCLUDER® device were included in this study. Baseline characteristics and demographic information of the cohort were collected. Endpoints included mortality (all-cause and aneurysm related), serious endoleaks, aneurysm sac diameter, endograft integrity (fracture, compression, migration), post-EVAR aortic rupture, device-related reintervention, conversion to open repair, graft explantation, and major adverse cardiovascular events (MACE). ResultsA total of 3216 patients were included in this analysis. The cohort reflected a significantly comorbid population with 46% of patients reaching a Charlson comorbidity index score of ≥ 5. Follow-up at 5 years was 60% of eligible participants. The freedom from aortic-related mortality was at 98.8% and overall survival was 71.2%. Post-operative MACE occurred in 49 (1.5%) patients. Device-related intervention through 5 years was 7.2% and the overall serious endoleak rate was 6.8%. Less than 1% of patients required an open conversion/revision and aortic rupture following device placement occurred in 15 (0.5%) patients. Aneurysm sac regression was achieved in 58.1% of patients at 5 years, and stability/absence of growth was observed in 83.6% at 5 years. ConclusionsThis study supports the durability of the GORE® EXCLUDER® device though 5 years with negligible incidence of graft integrity compromise and low aortic/device-related reintervention rates. Furthermore, the efficacy of the device is highlighted with low aortic-related mortality and high sac regression/stability diameter though 5 years.

A Deep Learning Model for Detecting Diabetic Retinopathy Stages with Discrete Wavelet Transform

Diabetic retinopathy (DR) is the primary factor leading to vision impairment and blindness in diabetics. Uncontrolled diabetes can damage the retinal blood vessels. Initial detection and prompt medical intervention are vital in preventing progressive vision impairment. Today’s growing medical field presents a more significant workload and diagnostic demands on medical professionals. In the proposed study, a convolutional neural network (CNN) is employed to detect the stages of DR. This research is crucial for studying DR because of its innovative methodology incorporating two different public datasets. This strategy enhances the model’s capacity to generalize unseen DR images, as each dataset encompasses unique demographics and clinical circumstances. The network can learn and capture complicated hierarchical image features with asymmetric weights. Each image is preprocessed using contrast-limited adaptive histogram equalization and the discrete wavelet transform. The model is trained and validated using the combined datasets of Dataset for Diabetic Retinopathy and the Asia-Pacific Tele-Ophthalmology Society. The CNN model is tuned in with different learning rates and optimizers. An accuracy of 72% and an area under curve score of 0.90 was achieved by the CNN model with the Adam optimizer. The recommended study results may reduce diabetes-related vision impairment by early identification of DR severity.

Experimental Model of Ligature-Induced Peri-Implantitis in Mice.

Dental implants have a high success and survival rate. However, complications such as peri-implantitis (PI) are highly challenging to treat. PI is characterized by inflammation in the tissues around dental implants with progressive loss of supporting bone. To optimize dental implants' longevity in terms of health and functionality, it is crucial to understand the peri-implantitis pathophysiology. In this regard, using mouse models in research has proven clear benefits in recreating clinical circumstances. This study aimed to describe an experimental model of ligature-induced peri-implantitis in mice and determine whether there is effectiveness in inducing this disease, given the observed bone and tissue changes. The experimental peri-implantitis induction comprehends the following steps: teeth extraction, implant placement, and ligature-inducted PI. A sample of eighteen 3-week-old C57BL/6J male mice was divided into two groups, ligature (N=9) and control non-ligature (N=9). The evaluation of clinical, radiographical, and histological factors was performed. The ligature group showed significantly higher bone loss, increased soft tissue edema, and apical epithelial migration than the non-ligature group. It was concluded that this pre-clinical model can successfully induce peri-implantitis in mice.

Spinal Trauma Revealing a Metastatic Medullary Lesion: A Case Report

Introduction and Importance: Intramedullary spinal cord metastases (ISCM) are a rare and devastating complication of malignant disease with a poor prognosis. Prompt and accurate diagnosis is necessary for effective treatment, and magnetic resonance imaging (MRI) is the preferred imaging technique. In this article, a rare case of an ISCM presenting with motor weakness after trauma is described. Case Presentation: The patient showed progressive severe paraplegia and urinary retention, and a thoraco-abdomino-pelvic scan showed a mediastinal pulmonary process and mediastinal adenopathies with adrenal lesions. He was admitted and a total resection of the processus was performed. After surgery, the patient showed partial neurological improvement, but two weeks later, he had a consciousness impairment. A cerebral CT scan showed multiple round lesions, with perilesional edema, and the patient died one month later. Discussion: The article discusses the pathogenic mechanisms of ISCM and its diagnosis, treatment, and management, which are controversial due to the multitude of clinical circumstances and the lack of controlled studies on the efficacy of the different therapeutic approaches. Conclusion: In conclusion, this rare case of Intramedullary Spinal Cord Metastases (ISCM) offers several important take-away lessons for clinicians and researchers alike.

Ultrasound evaluation of portal venous gas and its mimics.

Portal venous gas on abdominal ultrasound classically represents an indirect indicator of bowel ischemia, a critical condition which poses a high patient mortality and therefore warrants emergent corrective action. While the classic appearance of portal venous gas on ultrasound is well-described in the literature, the characteristic descriptors are nonspecific and may actually represent other less emergent mimics. Therefore, while radiologists should remain vigilant for the detection of findings corresponding to portal venous gas, they should also be aware of similar-appearing entities in order to provide the most accurate diagnosis. This pictorial essay will open with imaging examples of true portal venous gas attributable to bowel ischemia and describe the classic features which should alert radiologists to this specific diagnosis. Subsequently, this pictorial essay will provide imaging examples of other various other clinical entities which on ultrasound may share similar imaging characteristics. An important objective of this pictorial essay is to highlight distinguishing imaging features along with specific clinical circumstances for each pathological entity which can direct radiologists into identifying the correct diagnosis.

Ultrasonography of the normal donkey tarsus (equus asinus)

Tarsal joint illness is a frequent source of hind limb lameness due to the complex anatomy of the region and the presence of numerous bony and soft tissue structures. Proper lameness diagnosis aims to discover the structure provoking lameness. Ultrasonography documents valuable information of soft tissues and characterizes soft tissue injuries that have heretofore been difficult to obtain either noninvasively or via radiography. The objectives of the current study were to develop and describe a standardized ultrasonographic protocol for investigation of the tarsal region in donkeys. The donkey tarsal anatomy was investigated in 5 cadavers and the tarsi of 11 healthy lameness free adult donkeys were echographically investigated. The dorsal, plantar, lateral and medial aspects of the tarsal region were substantially evaluated at four anatomical landmarks in both the longitudinal and horizontal planes using a multi-frequency 5–12 MHz linear transducer. Sonoanatomy of the extensor and flexor tarsal tendons, collateral and plantar ligaments, and synovial pouches was delineated and described. Systematic echography of the tarsal region allowed accurate localization and thorough exploration of various soft tissues of clinical interest in the donkey tarsus. Sonograms provided in this study should serve as a reference database for tarsal ultrasonography in clinical circumstances.

Comparison of Diagnostic Accuracy and Diagnostic Adequacy Between Endoscopic Ultrasound-Guided and Percutaneous Liver Biopsies: A Meta-Analysis of Randomized Controlled Trials and Observational Studies.

A liver biopsy (LB) is a crucial diagnostic tool for evaluating liver diseases and is traditionally performed percutaneously under ultrasound guidance (PC-LB). However, endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as an alternative approach, offering potential advantages over conventional techniques. This systematic review and meta-analysis aimed to compare the effectiveness and safety of EUS-LB using modern core biopsy needles with PC-LB. A comprehensive literature search identified nine studies involving 785 patients that met the inclusion criteria. The meta-analysis evaluated three primary endpoints: diagnostic adequacy, diagnostic accuracy, and adverse event rates. The results indicated no significant difference in overall diagnostic adequacy (odds ratio: 0.446, 95% CI: 0.192-1.031) or diagnostic accuracy (odds ratio: 1.646, 95% CI: 0.224-12.09) between EUS-LB and PC-LB. Furthermore, the combined occurrence of adverse events did not differ significantly between the two procedures (odds ratio: 0.653, 95% CI: 0.298-1.431). However, PC-LB demonstrated superiority in obtaining a higher number of complete portal tracts (mean difference: -0.985, 95% CI: -1.753 to -0.218), indicating better specimen quality. While both EUS-LB and PC-LB exhibited similar diagnostic performance and safety profiles, PC-LB provided higher-quality specimens, which may be advantageous in cases where accurate diagnosis and staging are critical, such as the evaluation of liver fibrosis. Clinicians should consider factors like specimen quality, procedural preferences, and local expertise when selecting the appropriate biopsy approach tailored to individual patient needs and clinical circumstances.

Automation improves the efficiency of weightbearing CT scan 3D volumetric assessments of the syndesmosis

BackgroundWeight-bearing CT (WBCT) 3D volumetric measurement has shown promising accuracy for the diagnosis of syndesmotic instability. However, these measurements are rather complex and time-consuming, rendering them a clinically unfavorable option. We hypothesized that automatized measurements would be more accurate and time-efficient than manual ones. MethodsThirty cases of intraoperatively confirmed syndesmotic instability along with thirty individuals with no injuries to the ankle joint were recruited as cases and controls, retrospectively. Two observers conducted the manual volumetric measurements two times, at a one-week interval. An automated algorithm for 3D WBCT measurements was developed to conduct the measurements on the axial images. The time spent on each method was recorded. Mann-Whitney U test was used to compare the values between human raters and computers. Inter- and intra-class reliability were calculated. ResultsThe intra-class correlation coefficient was found to be “excellent” for the automated measurements (0.97) and “good” for the observers (0.75). Similarly, the Cronbach’s alpha was shown to be higher for the computer (0.88) than the observers (0.60 and 0.62). The mean time spent on the measurements was different between human raters and the computer-assisted method (p < 0.001). ConclusionAutomated volumetric assessment of syndesmosis seems to be a faster and more reliable option than the manual one. We suggest future larger-scale prospective studies conducted under actual clinical circumstances for more definitive conclusions. Level of evidenceRetrospective case-control study - Level 3

Common Ground: We Can Comprehensively Treat Pediatric Epilepsy and Psychiatric Comorbidities

Epilepsy and psychiatric illness have been long studied and today are better accepted as co-occurring than as discrete illnesses that are independent even if associated. Common pathophysiology may not be easily explained, but clearly exists given the significant overrepresentation of psychiatric illness among individuals with epilepsy. Conditions like autism spectrum disorder, anxiety, depression, and attention deficit hyperactivity disorder are prevalent in pediatric epilepsy much more than expected, even in the context of chronic neurologic disease. The interplay between pediatric epilepsy and neuropsychiatric symptoms represents a complex clinical circumstance that is not well subtended by the chasm-like division of labor between psychiatrists and neurologists. The unfortunate result is that children and families often experience care that is fractured and at worst, counterproductive for their quality of life. A neuropsychiatric paradigm is essential to address epilepsy and its intrinsic psychiatric symptoms. Practical strategies will be discussed to address this challenge.