Clinical Exam Research Articles

Implementation of a clinical breast exam and referral program in a rural district of Pakistan

BackgroundThe role of clinical breast examination (CBE) for early detection of breast cancer is extremely important in lower-middle-income countries (LMICs) where access to breast imaging is limited. Our study aimed to describe the outcomes of a community outreach breast education, home CBE and referral program for early recognition of breast abnormalities and improvement of breast cancer awareness in a rural district of Pakistan.MethodsEight health care workers (HCW) and a gynecologist were educated on basic breast cancer knowledge and trained to create breast cancer awareness and conduct CBE in the community. They were then deployed in the Dadu district of Pakistan where they carried out home visits to perform CBE in the community. Breast cancer awareness was assessed in the community using a standardized questionnaire and standard educational intervention was performed. Clinically detectable breast lesions were identified during home CBE and women were referred to the study gynecologist to confirm the presence of clinical abnormalities. Those confirmed to have clinical abnormalities were referred for imaging. Follow-up home visits were carried out to assess reasons for non-compliance in patients who did not follow-through with the gynecologist appointment or prescribed imaging and re-enforce the need for follow-up.ResultsBasic breast cancer knowledge of HCWs and study gynecologist improved post-intervention. HCWs conducted home CBE in 8757 women. Of these, 149 were warranted a CBE by a physician (to avoid missing an abnormality), while 20 were found to have a definitive lump by HCWs, all were referred to the study gynecologist (CBE checkpoint). Only 50% (10/20) of those with a suspected lump complied with the referral to the gynecologist, where 90% concordance was found between their CBEs. Follow-up home visits were conducted in 119/169 non-compliant patients. Major reasons for non-compliance were a lack of understanding of the risks and financial constraints. A significant improvement was observed in the community’s breast cancer knowledge at the follow-up visits using the standardized post-test.ConclusionsBasic and focused education of HCWs can increase their knowledge and dispel myths. Hand-on structured training can enable HCWs to perform CBE. Community awareness is essential for patient compliance and for early-detection, diagnosis, and treatment.

Bringing a Structural Competency Framework to the (Simulated) Bedside: The Premature Discharge Objective Structured Clinical Exam.

Structural competency is increasingly valued as a framework to address health equity within undergraduate medical education. As of academic year 2023-2024, the Liaison Committee on Medical Education (LCME) requires that medical schools have content regarding basic principles of structurally competent health care. Despite encouraging data about the effectiveness of structural competency curricula, most occur within the walls of a classroom and do not enter the authentic or simulated clinical space. From 2022 to 2023, an objective structured clinical exam (OSCE) focused on premature discharge, previously known as discharge against medical advice, was integrated into the required fourth-year Health Policy course at Weill Cornell Medical College, which uses the framework of structural competency. After a simulated clinical encounter, students completed a reflection assignment and participated in group debriefing to reflect on how policy coursework affected their simulated clinical experience. Students completed an evaluation about their OSCE experience, and OSCE checklist performance was analyzed. Of 82 students who participated in the curriculum, 68 completed a curricular evaluation, and 62 consented to have their OSCE performance evaluated for research. Mean overall OSCE checklist performance evaluating students' patient-centered communication skills, harm reduction skills, and discharge planning and counseling was 14.3/16 (89.6%; standard deviation, 9.8%). Students reported it was valuable to focus on structural factors affecting care within the simulated clinical encounter by using the structural competency framework. To the authors' knowledge, this is the first OSCE for medical students designed to deepen their understanding of structural competency by embedding the experience into an existing course using the framework. Future work should explore how this curriculum affects students' attitudes toward structurally vulnerable patients. With structural competency as an LCME requirement, the use of OSCEs may give educators a means to teach and assess fundamental concepts.

Vulvar oedema secondary to exogenous oestrogen exposure in a paediatric canine patient

AbstractA 12‐week‐old, female, entire miniature dachshund presented with a 3‐week history of progressive vulval enlargement with an associated clear serous sanguinolent discharge. Vulval oedema was noted on clinical exam. Further investigations included a complete cell count, computer tomography and a guarded vaginal swab, which revealed vaginal epithelial cell keratinisation. After thorough anamnesis, the clinical signs were concluded to be a result of exogenous oestrogen exposure.

Experimental measurement of local noise power spectrum (NPS) in photon counting detector-CT (PCD-CT) using a single data acquisition.

Accurate noise power spectra (NPS) measurement in clinical X-ray CT exams is challenging due to the need for repeated scans, which expose patients to high radiation risks. A reliable method for single CT acquisition NPS estimation is thus highly desirable. To develop a method for estimating local NPS from a single photon counting detector-CT (PCD-CT)acquisition. A novel nearly statistical bias-free estimator was constructed from the raw counts data of PCD-CT scan to estimate the variance of sinogram projection data. An analytical algorithm is employed to reconstruct point-wise covariance between any two image pixel/voxel locations and . A Fourier transform is applied to obtain the desired point-wise NPS for any chosen location . The method was validated using experimental data acquired from a benchtop PCD-CT system with various physical phantoms, and the results were compared with the conventional local NPS measurement method using repeated scans and statistical ensembleaveraging. The experimental results demonstrate that (1) the proposed method can achieve pointwise/local NPS measurement for a region of interest (ROI) located at any chosen position, accurately characterizing the NPS with spatial structures resulting from image content heterogeneity; (2) the local NPS measured using the proposed method show a higher precision in the measured NPS compared to the conventional measurement method; (3) spatial averaging of the local NPS yields the conventional NPS for a given localROI. A new method was developed to enable local NPS from a single PCD-CTacquisition.

A realist evaluation of how, why and when objective structured clinical exams (OSCEs) are experienced as an authentic assessment of clinical preparedness

Introduction Whilst rarely researched, the authenticity with which Objective Structured Clinical Exams (OSCEs) simulate practice is arguably critical to making valid judgements about candidates’ preparedness to progress in their training. We studied how and why an OSCE gave rise to different experiences of authenticity for different participants under different circumstances. Methods We used Realist evaluation, collecting data through interviews/focus groups from participants across four UK medical schools who participated in an OSCE which aimed to enhance authenticity. Results Several features of OSCE stations (realistic, complex, complete cases, sufficient time, autonomy, props, guidelines, limited examiner interaction etc) combined to enable students to project into their future roles, judge and integrate information, consider their actions and act naturally. When this occurred, their performances felt like an authentic representation of their clinical practice. This didn’t work all the time: focusing on unavoidable differences with practice, incongruous features, anxiety and preoccupation with examiners’ expectations sometimes disrupted immersion, producing inauthenticity. Conclusions The perception of authenticity in OSCEs appears to originate from an interaction of station design with individual preferences and contextual expectations. Whilst tentatively suggesting ways to promote authenticity, more understanding is needed of candidates’ interaction with simulation and scenario immersion in summative assessment.

Abstract PO3-03-03: Prospective non-randomized study to compare accuracy of clinical examination under anesthesia, axillary ultrasound and histo-pathological evaluation for axillary nodal staging in women with clinically N0 early breast cancer

Abstract Introduction: Accurate assessment of axillary lymph nodes is crucial in the management of early breast cancer (EBC), especially in clinically node negative (cN0) axilla to avoid extensive axillary surgery. Clinical examination alone underestimates nodal disease in nearly 30% women with cN0 axilla. The current study compares, in cN0 axilla, the benefit of axillary ultrasonography (USG) and clinical axillary examination under anesthesia (EUA) to predict involvement of axillary lymph nodes. The gold standard in these patients however remains pathological evaluation after sentinel node biopsy/low axillary sampling (SNB/LAS) and a complete axillary lymph node dissection (ALND) if node positive. Methodology: Prospectively, 500 women with cN0 EBC were enrolled from Aug 2015 to April 2023 in a study approved by Institutional Ethics Committee. After informed consenting, a preoperative axillary USG was carried out in addition to standard breast imaging to determine number of axillary node(s) and its architecture. The USG assessment was labeled as suspicious or not and the result was blinded to the surgeons. A USG-guided FNAC was not performed as it would then be difficult to blind the surgeon and pathologist preoperatively. During surgery, an initial axillary EUA was performed before starting and any suspicious node was documented. This was followed by axillary staging by standard dual tracer SNB/LAS. A complete axillary dissection was done (level 1-3) if any node was positive on frozen section evaluation or final histopathology. Axillary node histopathology was the gold standard for comparison of effectiveness of clinical exam, USG, EUA, and SNB/LAS for prediction of axilla. Standard diagnostic tests such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were used. Results: Thirty-six patients were excluded in the final analysis (disease progression, chemotherapy first, or had a surgery elsewhere). Of the eligible 464 cN0 patients, 129 were detected to have axillary metastases (27.8%) in final histopathology. The 2 interventions namely USG axilla, EUA were compared to final axillary nodal histopathology. Axillary USG reported suspicious/indeterminate node(s) in 129 (27.8%) patients. USG had a low sensitivity of 46.5% and a low PPV of 46.5% to identify a positive node. However, the specificity and NPV both were 79.4%. Axillary USG was 70.2% accurate in predicting axillary nodal involvement. EUA also had sensitivity of 60% and low PPV of 14.8%. However, the specificity of EUA was 73.4%, NPV of 95.9%; higher than that of USG. EUA was 72.4% accurate. SNB/LAS had the sensitivity of 93.3%, specificity 79.2%, NPV 82.9%, PPV 91.6% and accuracy rate 89.2% in predicting a positive axilla. Conclusions: While the fallacy of clinical exam remains at 27.8%, both USG alone (without FNAC) and EUA failed in predicting a positive axillary node. EUA fared better at predicting a negative axilla. USG guided FNAC would perhaps improve the sensitivity of USG, however additional investigations are difficult in resource constraint and high-volume center, especially, when surgical interventions like SNB or LAS remain standard of care. Table 1 Citation Format: Vani Parmar, Zeal Sanghvi, Shalaka Joshi, Nita Nair, Palak Popat, Seema Kembhavi, Souwmyashree KN, Soujanya Mynalli, Purvi Thakkar, Garvit Chitkara, Sangeeta Desai, Tanuja Shet, Rajendra Badwe. Prospective non-randomized study to compare accuracy of clinical examination under anesthesia, axillary ultrasound and histo-pathological evaluation for axillary nodal staging in women with clinically N0 early breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-03.

Denervation procedure of the lateral epicondyle for refractory lateral epicondylitis

BackgroundLateral epicondylitis is the most common cause of lateral elbow pain in adults, and non-operative treatment is the first-line management modality of choice. Pain refractory to conservative management may improve with surgical interventions involving ECRB débridement or denervation. This investigation was conducted to evaluate the long-term analgesic efficacy, incidence of postoperative sensory deficits, and postoperative elbow functionality in patients who underwent a denervation surgery of the posterior branch of the posterior cutaneous nerve of the forearm (PBPCNF) for refractory lateral epicondylitis. MethodsThis investigation was an IRB-approved, single-center, single-surgeon case series of 22 patients who underwent denervation surgery with an average final follow-up of 4.7 years. Inclusion criteria for surgery were a minimum of 6 months symptom duration refractory to conservative therapies, a minimum of 2 years clinical follow-up, and significant (70-80%) pain relief from the nerve block test. Visual Analog Scale (VAS) pain and Single Assessment Numerical Evaluation (SANE) scores were used to assess pain and function, respectively. The incidence of postoperative sensory deficits was evaluated via clinical exam. ResultsCompared to the preoperative average, the cohort’s mean VAS pain was significantly decreased at all postoperative follow-up intervals, including 2 weeks, 1 year, and final average follow-up of 4.7 years. At the final follow-up, the mean SANE score was 98.8 ± 2.6, and one patient (4.5%), who reported the same sensory deficit preoperatively, reported postoperative sensory deficits. ConclusionsThe PBPCNF denervation procedure is a highly efficacious procedure for achieving long-term pain control in the treatment of refractory lateral epicondylitis. The PBPCNF denervation procedure affords patients a high level of postoperative functionality with a low incidence of sensory deficits.

Late metastasis of a clear-cell renal cell carcinoma in the gallbladder as a possible cause of acute cholecystitis: a case report

Background: Gallbladder metastasis from renal cell carcinoma (RCC) is extremely rare. Case Presentation: We present a case of metastasis of clear cell carcinoma to the gallbladder, mimicking acute cholecystitis on clinical exam, in an 80-year-old man 24 years after radical nephrectomy. Ultrasound showed an image compatible with acute cholecystitis with sludge in the gallbladder. An elective cholecystectomy was performed with an uneventful postoperative course. Histopathologic examination revealed a metastasis of clear-cell renal cell carcinoma. The clinical presentation of acute cholecystitis can mask an RCC metastasis to the gallbladder, even several years after initial nephrectomy. This makes qualitative anatomopathological examination essential, especially with a neoplasia in the medical history. Gallbladder metastasis from RCC is not necessarily linked to a poor outcome. A cholecystectomy is recommended whenever possible. Conclusion: This case highlights the importance of considering metastatic disease in the differential diagnosis of gallbladder masses and acute cholecystitis, even in patients with a history of treated primary tumors.

Most Patients Older Than 40 Years of Age Who Underwent Meniscal Root Repair Presented With an Effusion, a Positive McMurray Test, and a Positive Hyperflexion Test

PurposeThe purpose of this study is to analyze the presenting symptoms and clinical exam findings of patients undergoing meniscal root repairs to aid physicians in diagnosing this injury. MethodsAll patients undergoing isolated arthroscopic meniscal root repair from 1/1/2016-9/1/2021 were identified. Patients under the age of 40 years were excluded. Clinical notes were reviewed for presenting symptoms and physical exam findings. Pre-operative radiographs were graded using the Kellgren-Lawrence (KL) scale for osteoarthritis. Root tears were graded using the radiographic criteria of Chung et al. and articular cartilage injury was graded using a validated system, AMADEUS (mean total Area Measurement And Depth & Underlying Structures). Results221 patients met inclusion criteria. 65.6% of patients reported that their pain began following an acute injury, with 39.4% of patients reporting a “pop”. On exam, an effusion was present in 71% of knees. McMurray test was reported positive in 85.5% and a positive hyperflexion test in 53.8% of knees. 49.5% of knees were graded KL 1. 154 had medial root tears, 10 had lateral root tears, and 24 suffered both root tears. 44.1% of tears occurred at the midsubstance of the root, with 28.0% occurring at the enthesis and 28.0% occurring at the root-posterior horn junction. The mean AMADEUS score was 94.4 ± 11.4. ConclusionWhile a majority of patients reported pain began following acute injury, less than half reported hearing a “pop”. When evaluating patients, an effusion, positive McMurray test, and positive hyperflexion test was present in the majority of meniscal root tears. Level of EvidenceLevel IV Diagnostic case series

Single procedure tibialis anterior tendon shortening in combination with Achilles tendon lengthening in unilateral cerebral palsy improves swing phase dorsiflexion in gait.

Tibialis anterior tendon shortening combined with tendon Achilles lengthening showed satisfactory short- and long-term outcomes for pes equinus treatment. This retrospective study aimed to evaluate the effectiveness of a single tibialis anterior tendon shortening-tendon Achilles lengthening procedure for treating pes equinus, in a homogeneous unilateral cerebral palsy patient group. Gait analysis was conducted on 22 unilateral cerebral palsy patients (mean age at surgery = 13.3 years, standard deviation = 3 years) before and within 2.5 years (standard deviation = 0.61 years) after the tibialis anterior tendon shortening-tendon Achilles lengthening procedure. Primary outcome measures included foot drop occurrence in swing, foot dorsiflexion and the first ankle rocker presence compared to healthy reference data. Movement analysis profile and gait profile score were also calculated for the entire gait cycle. The clinical exam and the A2 peak ankle power were analyzed. Statistical analysis used the paired Wilcoxon's sign rank test (p < 0.05). Post-operatively, significant improvements were observed in ankle dorsiflexion during swing (p = 0.0006) and reduced foot drop in swing (p = 0.0107). The occurrence of a first ankle rocker did not significantly change (p = 0.1489). Significant improvements in gait profile score and movement analysis profile for all joints and planes indicate overall gait quality improvement. The foot progression changed significantly (p = 0.0285), with a greater external orientation. Nineteen out of 22 patients were able to quit wearing their ankle foot orthoses. Tibialis anterior tendon shortening and tendon Achilles lengthening combination yielded positive outcomes, showing increased foot dorsiflexion, first ankle rocker presence, and overall improved gait quality. These findings support the effectiveness of this surgical approach for treating pes equinus in children with unilateral spastic cerebral palsy.

A comprehensive MRI investigation to identify potential biomarkers of Osgood Schlatter disease in adolescents: A cross sectional study comparing Osgood Schlatter disease with controls.

Osgood-Schlatter disease (OSD) is the most common knee pain complaintamong adolescents playing sports. Despite this, there remains controversy over the pathophysiology and whether specific anatomical characteristics are associated with OSD. This study aimed to systematically and comprehensively characterize adolescents with OSD using magnetic resonance imaging (MRI) compared to pain-free controls, including both tissue abnormalities that may be associated with OSD, as well as anatomical characteristics. A secondary objective was to identify potential imaging biomarkers associated with pain. Cross-sectional study. Adolescents with OSD and controls were recruited from 2020 to 2022. Following a clinical exam, demographics, pain, sports participation, and Tanner stage were collected. Knee MRI was conducted on the participants' most symptomatic knee (OSD) or the dominant leg (controls). Sixty-seven adolescents (46 with OSD and 30 controls) were included. 80% of participants with OSD had at least one tissue alteration compared to 54% of controls. Compared to controls, OSD had 36.3 (95%CI 4.5 to 289.7) higher odds of bony oedema at the tibial tuberosity, and 32.7 (95%CI 4.1 to 260.6) and 5.3 (95%CI 0.6 to 46.2) higher odds of bony oedema at the tibial epiphysis and metaphysis respectively. Participants with OSD also had higher odds of fluid/oedema at the patellar tendon (12.3 95%CI 3.3 to 46.6), and superficial infrapatellar bursitis (7.2). Participants with OSD had a more proximal tendon attachment (mean tibial attachment portion difference, -0.05, 95% CI: -0.1 to 0.0, p = 0.02), tendon thickness (proximal mean difference, -0.09, 95% CI: -0.4 to 0.2, p = 0.04; distal mean difference, -0.6, 95% CI: -0.9 to -0.2, p = 0.01). Those with bony/tendon oedema had 1.8 points (95% CI: 0.3 to 3.2) higher pain on palpation than those without (t = -2.5, df = 26.6, p = 0.019), but there was no difference between these groups in a functional single leg pain provocation. Adolescents with OSD present with tissue and structural abnormalities on MRI that differed from age-matched controls. The majority had findings in the patellar tendon and bone, which often co-occurred. However, a small proportion of OSD also presents without alterations. It appears these findings may be associated with clinical OSD-related pain on palpation of the tibial tuberosity. Our highlight the pathophysiology on imaging, which has implications for understanding the mechanism and treatment of OSD.

Do students' self-reflections of performance align with their graded performance in objective structured clinical exams?

IntroductionSelf-awareness of strengths and weaknesses through self-reflection are important for life-long learning and development. The aim of this study was to assess the alignment in third-year undergraduate pharmacy students' self-reflections of their objective structured clinical exam (OSCE) performance to their actual OSCE scores and explore the most common aspects students reflected on as markers of perceived performance. MethodsStudents completed a three-station OSCE and a written self-reflection about their performance. These reflections were coded using a latent pattern content analysis, with categories defined as “doing well (≥ 50% on exam)” and “not doing well (< 50% on exam)” and compared to their actual OSCE exam scores, to determine the degree of alignment. ResultsTwo hundred sixty-nine students completed the OSCE and reflection. Students had a low degree of alignment between their self-reflections and actual OSCE performance. Low alignment was overwhelmingly prevalent and significant in high-achieving students with OSCE scores of ≥90%. Most common aspects students reflected on as indicators of performance were finishing on time and communicating effectively. High-achieving students reflected on aspects such as empathy, systematic questioning, and patient teach-back as aspects of their performance. ConclusionsStudent reflections on exam performance do not align with their actual performance, particularly amongst the high-achieving students. High-achieving students were more aware of the different aspects that affected their performance. To ensure that high-achieving students are aware of their strengths, educators should provide more targeted feedback mechanisms and positive reassurances to help these students become more confident in their decision-making skills.

Regional variability in therapeutic hypothermia eligibility criteria for neonatal hypoxic-ischemic encephalopathy.

Early induced therapeutic hypothermia represents the cornerstone treatment in neonates with probable hypoxic-ischemic encephalopathy. The selection of patients for treatment usually involves meeting criteria indicating evidence of perinatal hypoxia-ischemia and the presence of moderate or severe encephalopathy. In this review, we highlight the variability that exists between some of the different regional and national eligibility guidelines. Determining the potential presence of perinatal hypoxia-ischemia may require either one, two or three signs amongst history of acute perinatal event, prolonged resuscitation at delivery, abnormal blood gases and low Apgar score, with a range of cutoff values. Clinical neurological exams often define the severity of encephalopathy differently, with varying number of domains required for determining eligibility and blurred interpretation of findings assigned to different severity grades in different systems. The role of early electrophysiological assessment is weighted differently. A clinical implication is that infants may receive different care depending on the location in which they are born. This could also impact epidemiological data, as inference of rates of moderate-severe encephalopathy based on therapeutic hypothermia rates are misleading and influenced by different eligibility methods used. We would advocate that a universally endorsed single severity staging of encephalopathy is vital for standardizing management and neonatal outcome. IMPACT: Variability exists between regional and national therapeutic hypothermia eligibility guidelines for neonates with probable hypoxic-ischemic encephalopathy. Differences are common in both criteria indicating perinatal hypoxia-ischemia and criteria defining moderate or severe encephalopathy. The role of early electrophysiological assessment is also weighted unequally. This reflects in different individual care and impacts research data. A universally endorsed single severity staging of encephalopathy would be crucial for standardizing management.

Incidence of lower limb tendinopathy: A 3-year prospective study of a youth elite athletes in a Brazilian sport club

IntroductionThe purpose of this study was to investigate lower limb tendinopathy incidence over 3 seasons in Brazilian youth elite athletes. DesignProspective epidemiological study. MethodsA prospective study was performed during 2015, 2016 and 2017 seasons, with a total of 1553 Brazilian youth athletes (1.195 male and 358 female) out of 6 sports (volleyball, basketball, judo, gymnastics, tennis and futsal). The mean age was 14.1 (11.2; 17.0) years, mean height was 1.75 (1.55; 1.95) meters and mean body mass was 59.4 (42.0; 76.4) kilograms. The diagnosis of lower limb tendinopathy (LLT) was made by an experienced sports physician based on a detailed history and clinical exam. The incidence of LLT was determined by number of injuries/total exposure hours x 1000. ResultsIn total, 100 LLT were recorded during the 3 seasons. The most frequent type of LLT was patellar (79%), adductor (12%) and Achilles (9%). The frequency of patellar tendinopathy was higher in male's volleyball, basketball and female volleyball (41%, 25%, 13%, respectively) and the frequency of Achilles tendinopathy was higher in basketball and female volleyball (33%,22%). The LLT incidence was 2.5/1000h in 2015, 4.2/1000h in 2016 and 2.1/1000h in 2017. ConclusionLower limb tendinopathies are relatively common in youth elite athletes. In 3-season, the most frequent type was patellar tendinopathy. A higher LLT incidence was observed in male volleyball athletes when compared to female volleyball athletes. Basketball athletes presented a higher frequency of patellar, adductor and Achilles tendinopathies in 3-seasons when compared to other sports.

Potential Prodromal Digital Postural Sway Markers for Fragile X-Associated Tremor/Ataxia Syndrome (FXTAS) Detected via Dual-Tasking and Sensory Manipulation.

FXTAS is a neurodegenerative disorder occurring in some Fragile X Messenger Ribonucleoprotein 1 (FMR1) gene premutation carriers (PMCs) and is characterized by cerebellar ataxia, tremor, and cognitive deficits that negatively impact balance and gait and increase fall risk. Dual-tasking (DT) cognitive-motor paradigms and challenging balance conditions may have the capacity to reveal markers of FXTAS onset. Our objectives were to determine the impact of dual-tasking and sensory and stance manipulation on balance in FXTAS and potentially detect subtle postural sway deficits in FMR1 PMCs who are asymptomatic for signs of FXTAS on clinical exam. Participants with FXTAS, PMCs without FXTAS, and controls underwent balance testing using an inertial sensor system. Stance, vision, surface stability, and cognitive demand were manipulated in 30 s trials. FXTAS participants had significantly greater total sway area, jerk, and RMS sway than controls under almost all balance conditions but were most impaired in those requiring vestibular control. PMCs without FXTAS had significantly greater RMS sway compared with controls in the feet apart, firm, single task conditions both with eyes open and closed (EC) and the feet together, firm, EC, DT condition. Postural sway deficits in the RMS postural sway variability domain in asymptomatic PMCs might represent prodromal signs of FXTAS. This information may be useful in providing sensitive biomarkers of FXTAS onset and as quantitative balance measures in future interventional trials and longitudinal natural history studies.

Cracked tooth and endodontic-periodontal lesion: 2-years follow up of a conservative treatment

This study report diagnosis and management of an endodontic-periodontal lesion in a cracked mandibular tooth after a cyclist’s fall. A 34-year-old female patient with a chief complaint of pain and edema in the region of the mandibular right first molar was evaluated and treated. Patient presented excellent oral health. After clinical, radiographical and tomographic exams, it was diagnosed an acute periapical abscess in stage II combined with tooth cracks and a periodontal involvement (endodontic-periodontal lesion). After emergency dental care it was performed subgingival scaling and root planing, definitive endodontic treatment, indirect definitive restoration (overlay) combined with a reinforcement of the tooth structure with a high-resistance polyethylene tape. Patient was periodically followed up until 24 months and treatment was successful. It can be concluded that a correct diagnosis and a conservative and well-planned and -executed treatment of a compromised tooth by cracks can have good results even endodontic-periodontal lesion is present.

Compare the Effectiveness of Objective Structured Clinical Evaluation (OSCE) versus Checklist in Demonstration of Antenatal Abdominal Examination among Final Year G.N.M. students.

The OSCE is an approach to the assessment of clinical competence in which the components of competence are assessed in a planned or structured way with attention being paid to the objectivity of the evaluation” Harden, 1988 .The Objective Structured Clinical Exam (OSCE) is a performance- based exam. During the exam, trainees are observed and evaluated as theygo through a series of stations where they interview, examine and treat standardized patients presenting with some type of problem. An OSCE is: • Objectivity, because examiners use a checklist for evaluating the trainees. • Structured, because every trainee sees the same problem and performs same tasks in the same time frame. • Clinical based, because the tasks are representative of those faced in real clinical situations • An evaluation method II – Materials and Methods Comparative research design was used with group I &amp; group II to assess the effectiveness of objective structured clinical evaluation (OSCE) versus checklist in demonstration of antenatal abdominal examination among final year G.N.M students. The study conducted on 30 samples in each group. Data was collected using Objective Structured Clinical Evaluation and checklist for assessing performance of G.N.M final year students on abdominal examination. III – Results The overall mean and S.D. of OSCE was 11.03 with a percentage mean of 91.39% and 16.59 whereas the overall mean and S.D. of Checklist was 55.73 with a percentage mean of 79.62% and 11.24. The calculated ‘t’ value was higher than the table value (t58 = , P&lt; 0.01). Hence, the null hypothesis was rejected and research hypothesis was accepted and it was inferred that in the present study there was significant difference between the effectiveness of demonstration on antenatal abdominal examination during pregnancy assessed by Objective Structured Clinical Evaluation (OSCE) &amp; checklist among G.N.M final year students. Comparing the mean percentage of OSCE and Checklist 91.39% and 79.62%, it is inferred that the mean percentage of OSCE i.e. 91.39% is higher than the mean percentage of Checklist i.e. 79.62%. Therefore, it can be concluded that the OSCE is more effective than the checklist for evaluating the demonstration of abdominal examination during pregnancy. IV – Conclusion This study concluded that in comparison to, OSCE was found to be a more effective assessment tool than traditional method checklist. Use of OSCE as formative tool will help in modifying teaching- learning strategies so that both, the teachers as well as the students can derive maximum benefit

A portable system to measure knee extensor spasticity after spinal cord injury

BackgroundThe pendulum test is a quantitative method used to assess knee extensor spasticity in humans with spinal cord injury (SCI). Yet, the clinical implementation of this method remains limited. The goal of our study was to develop an objective and portable system to assess knee extensor spasticity during the pendulum test using inertial measurement units (IMU).MethodsSpasticity was quantified by measuring the first swing angle (FSA) using a 3-dimensional optical tracking system (with external markers over the iliotibial band, lateral knee epicondyle, and lateral malleolus) and two wireless IMUs (positioned over the iliotibial band and mid-part of the lower leg) as well as a clinical exam (Modified Ashworth Scale, MAS).ResultsMeasurements were taken on separate days to assess test–retest reliability and device agreement in humans with and without SCI. We found no differences between FSA values obtained with the optical tracking system and the IMU-based system in control subjects and individuals with SCI. FSA values from the IMU-based system showed excellent agreement with the optical tracking system in individuals with SCI (ICC > 0.98) and good agreement in controls (ICC > 0.82), excellent test–retest reliability across days in SCI (ICC = 0.93) and good in controls (ICC = 0.87). Notably, FSA values measured by both systems showed a strong association with MAS scores (ρ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\uprho$$\\end{document} ~ −0.8) being decreased in individuals with SCI with higher MAS scores, reflecting the presence of spasticity.ConclusionsThese findings suggest that our new portable IMU-based system provides a robust and flexible alternative to a camera-based optical tracking system to quantify knee extensor spasticity following SCI.

A Qualitative Analysis of Communication-focused Feedback Provided to Child Neurology Residents During an Objective Structured Clinical Exam (OSCE) (P4-7.003)

A Qualitative Analysis of Communication-focused Feedback Provided to Child Neurology Residents During an Objective Structured Clinical Exam (OSCE) (P4-7.003)

SORDD: mutation frequency and phenotype in predominantly axonal Charcot-Marie-Tooth disease of undefined genetic cause

Pathogenic, biallelic variants in SORD were identified in 2020 as a novel cause for autosomal-recessive Charcot-Marie-Tooth disease (CMT) type 2, an inherited neuropathy. SORD codes for the enzyme sorbitol dehydrogenase. Loss of this enzyme‘s activity leads to an increase of sorbitol in serum. We retrospectively screened 166 patients with axonal neuropathy (predominantly CMT type 2, but including intermediate form of CMT and distal hereditary motor neuropathy (dHMN)) without identified genetic etiology for SORD mutations at a single large German neuromuscular center. Clinical and electrophysiology exam findings were analyzed for genotype–phenotype correlation. Five patients of the total cohort of 166 patients harbored pathogenic variants in SORD (3%). The homozygous frameshift variant c.757delG (p.Ala253Glnfs*27) was the most common (4/5). One additional case carried this variant on one allele only and an additional pathogenic missense variant c.458C > A (p.Ala153Asp) on the other allele. Age of onset ranged from early infancy to mid-twenties, and phenotypes comprised axonal CMT (4) and dHMN (1). Our findings strengthen the importance of screening for pathogenic variants in SORD, especially in patients with genetically unconfirmed axonal neuropathy, especially CMT type 2 and dHMN.