AimTo compare the psychometric properties, pragmatic screening cut‐offs, and feasibility of two Clock Drawing Test (CDT) formats in older psychiatric outpatients.MethodsWe retrospectively analyzed 447 outpatients aged ≥65 years who completed the Mini‐Mental State Examination (MMSE), the Hasegawa Dementia Scale‐Revised (HDS‐R), and two CDT formats scored using the Freedman method: a free‐drawn clock (CDT1) and an examiner‐provided clock face (CDT2). Pearson correlations, forced‐entry multiple regression models, exploratory factor analyses, and receiver operating characteristic (ROC) analyses were used. Possible cognitive impairment was operationally defined as MMSE ≤ 23 and/or HDS‐R ≤ 20. Administration time was summarized in a convenience subsample (n = 20).ResultsMean (SD) age was 80.20 (5.15) years, and mean education was 11.74 (2.36) years. CDT totals correlated positively with MMSE and HDS‐R totals (r = 0.47–0.58, all p < 0.01). Education, functional disability, CDT1, and CDT2 predicted MMSE total, while age additionally predicted HDS‐R total. Both CDT formats showed interpretable two‐factor structures with good internal consistency (Cronbach's α 0.82–0.90). ROC analyses identified the same pragmatic cut‐off (10/11) for both formats (CDT1 area under the curve [AUC] 0.72, 95% CI 0.67–0.77; CDT2 AUC 0.71, 95% CI 0.66–0.76). Mean CDT administration time was 2.13 min.ConclusionBoth CDT formats showed clinically useful psychometric properties and similar pragmatic cut‐offs in older psychiatric outpatients. CDT1 favored sensitivity, and CDT2 favored specificity at the same threshold. The CDT was highly feasible in routine practice, requiring approximately 2 min to administer.

To establish an assessment method for safe acetabular screw placement based on three-dimensional CT reconstruction and the acetabular "clock-face" coordinate system; to quantify the vascular safety length and effective intraosseous length at each screw hole position of the acetabular prosthesis; and to provide a reference basis for individualized acetabular screw placement in total hip arthroplasty (THA). The CT angiographic data of both lower extremities of 64 patients hospitalized for non-orthopedic diseases between January 2022 and December 2024 who met the selection criteria was retrospectively analyzed. There were 32 males and 32 females. Three-dimensional reconstruction was performed using Mimics21.0 software. With the anterior pelvic plane as the reference plane, the acetabular opening was conceptualized as a "clock face". The intersection of the anterior superior iliac spine-to-acetabular center line (or its projection) with the inferior acetabular rim was defined as the "6 o'clock" reference point. Based on this reference point, the central hole of the prosthesis was aligned toward the 12 o'clock direction to simulate acetabular cup implantation, achieving positional correspondence between the prosthesis screw holes and the clock-face coordinates, with the anterior hole aligned to 1 o'clock and the posterior hole aligned to 11 o'clock. Acetabular prosthesis implantation was simulated at fixed angles (abduction angle 40°, anteversion angle 20°). Cylindrical models matching the diameter of actual screws were used to simulate screw insertion, with axial extension perpendicular to each screw hole. The safe length of the blood vessel or effective intraosseous length at each hole site and the coverage of three commonly used screw lengths (20, 25, 30 mm) at each hole site were measured. Pearson correlation was used to analyze the correlation of each measurement with age and body mass index. The safe length from the anterior hole to the external iliac artery and the effective intraosseous length of the middle hole were significantly longer in males than in females ( P<0.05). There was no significant difference in the safe length from the posterior hole to the superior gluteal artery between males and females ( P>0.05). Pearson correlation analysis showed that only the effective length of the middle hole was negatively correlated with age ( P<0.05), while the safe length of the anterior hole to the external iliac artery and the safe length of the posterior hole to the superior gluteal artery were not correlated with age and body mass index ( P>0.05). In terms of screw selection, the coverage rate of 20 mm screws in the anterior, middle, and posterior holes of acetabular prosthesis was 100.00% in both males and females, and the safety was good. The coverage rate of 25 mm screws in anterior and posterior holes was 100.00% in both males and females, and the safe length was sufficient; the coverage rate of middle hole was 96.86% in males and 71.86% in females. When the length of screw was further increased to 30 mm, the coverage rate of anterior hole was still 100.00% in males and 68.97% in females, the coverage rate of middle hole was 71.86% in males and 34.36% in females, and the coverage rate of posterior hole was still at a high level, 92.86% in males and 100.00% in females. The decrease in coverage was more pronounced in males when longer screws were used in the anterior and middle hole areas. Significant sex-related differences exist in the safety parameters of acetabular screws in THA. In females, the anterior screw hole is associated with a higher vascular risk, and the effective intraosseous length at the middle hole is shorter; therefore, a middle-hole plus posterior-hole combination is recommended. In males, an anterior-hole plus posterior-hole combination may be considered the preferred reference strategy. In the absence of navigation assistance, a conservative screw placement strategy is recommended to reduce vascular complications and improve the initial stability of the prosthesis.

BackgroundAlthough multi-task handwriting analysis has the potential to improve early detection of Alzheimer's disease (AD), the educational bias inherent in its text-based tasks poses a significant obstacle to its widespread adoption across different regions.ObjectiveUsing the clock drawing test, we aim to design a deep neural network to extract features from static images and process signals to achieve high-precision recognition of early AD.MethodsEarly Detection of Alzheimer's Disease based on Leveraging Multimodal Features of the clock-drawing test (EDADLMF) is proposed. Firstly, to utilize the behavioral features inherent in the clock drawing test task, we propose a Dual Stream Clock Drawing Feature Extraction module,which employs a convolutional neural networks to capture the spatial features of static clock face images, while concurrently employing a multi-layer perceptron to map low-dimensional process signal into a high-dimensional feature space. Furthermore, we propose a Feature Fusion module with the Squeeze-and-Excitation attention mechanism to adaptively enhance key features and fuses complementary information from different modalities. Thirdly, to enhance the model's focus on hard-to-classify samples, a PolyLoss function is introduced to assign greater weights to difficult samples.ResultsComparative experiments on benchmark demonstrated that EDADLMF outperforms the compaired methods on accuracy (92.59%), precision (93.65%), recall (92.65%), and F1-score (92.59%), and the case study indicates that the developed prototype system has well effectiveness.ConclusionsThe clock drawing test, combined with process signals and image data, exhibits better screening accuracy and could serve as a practical alternative to initial MRI scans.

Bodily rhythms such as breathing and heartbeat influence perception and motor processes. Recent studies have indicated that breathing phases, particularly exhalation, synchronize with voluntary actions, potentially reflecting a general influence on motor intention. However, this effect might depend on the specific effector and movement direction. This study aimed to investigate (i) respiratory synchronization across different voluntary motor tasks, (ii) the interaction between stimulus-locked and action-locked respiratory coupling, and (iii) cardiac synchronization with voluntary actions. A total of 32 healthy participants performed two voluntary motor tasks: a modified Libet clock task and an elbow flexion-extension task. In the Libet clock task, the participants monitored a rotating dot on a clock face and either pressed a key at a self-chosen time (key-press condition) or released the key after holding it pressed (key-release condition). In the elbow flexion-extension task, the participants spontaneously pushed (elbow extension) or pulled (elbow flexion) a joystick. Across tasks, voluntary actions showed an overall tendency to occur during exhalation across multiple effectors (finger and elbow) and movement directions (extension and flexion). Furthermore, stimulus-locked respiratory phase was associated with subsequent action timing, suggesting that trial structure can shape respiration-action coupling. We found no robust evidence for systematic cardiac-phase modulation of voluntary action timing, although a weak condition-specific trend was observed. Collectively, these findings support respiration-action coupling across diverse actions and highlight a potential contribution of stimulus-locked respiratory dynamics to voluntary action timing.

Location and size of the glenoid defect in patients with traumatic posterior shoulder instability.

BackgroundThe digital clock drawing test (dCDT) is a cognitive screening tool employing a digital pen to capture high‐resolution pen movements. Traditional dCDT approaches to predict cognitive outcomes often rely on many summary features (e.g. time to completion, mean pressure, clock face area, etc.) which involve subjective decisions such as feature selection and imputation of missing data. To address these limitations, we introduce novel dCDT features, expressed as mathematical functions. These functional features include the G‐function (measuring spatial proximity of points), pressure density function (measuring variability in pressure exerted on the paper), and radius function (measuring circularity of the clock face). We compare the performance of these functional features to 45 commonly used summary features.MethodsWe included dCDTs from 3,415 stroke‐free participants from the Framingham Heart Study with at least one command or copy task. Random forest models with five‐fold cross‐validation were trained to distinguish participants with MCI or dementia from cognitively intact participants. Predictors included combinations of demographics, time‐based features, summary features, and functional features. Functional features underwent dimension reduction using functional principal components analysis. Area under the receiver operating curve (AUC), sensitivity, and specificity assessed model performance.ResultsAverage age was 63.6 years (SD: 13.9), with 1,546 (45%) males, 785 (23%) having at least one APOE‐e4 allele, and 1,957 (57%) having a college education. At the time of the dCDT, 122 (4%) had mild cognitive impairment and 74 (2%) had dementia. When combined with demographics and time‐based features, functional features from command and copy tests related to spatial proximity (AUC: 0.90; 95% CI: 0.88‐0.92) and circularity (AUC: 0.91; 95% CI: 0.89‐0.93) were as predictive as summary features (AUC: 0.90; 95% CI: 0.88‐0.92). Similar results were found when analyzing command and copy features separately.ConclusionsFunctional features of the dCDT offer several advantages such as robustness to missing data, decreased subjectivity in feature selection, and avoidance of reducing complex information into summary statistics. In addition, there is potential to make inferences about cognition based on the shape and behavior of the functions. Further research is required to better understand what these functional features reveal about cognition.

Feeling of agency (FoA)—the experience of controlling one’s actions and their outcomes—has been widely studied for bodily movements. Here, we investigated if microsaccades—small ballistic eye movements—are equally characterized by FoA and if intention mediates this sense of control. We measured FoA via intentional binding, a perceived compression between an action and its effect. In our experiments, we presented a vertically oriented grating, rendered invisible during stable fixation by a rapid temporal phase shift (>60 Hz) that became visible when its retinal motion was slowed down by a microsaccade (active condition). The stimulus was embedded in a clock face and observers reported perceived stimulus timing in each trial. Perceived timing of microsaccade-contingent stimulus perception was compared to the replay of a previous microsaccade’s retinal consequence (replay condition). Trials without a stimulus were included as a control. To examine the role of intention, we tested this paradigm across two experiments in which observers were either instructed to saccade (intended microsaccades) or fixate (unintended microsaccades). In Experiment 2, no instruction was administered such that any microsaccades were considered spontaneous. Microsaccades—either actively generated or replayed—consistently rendered the stimulus highly visible compared to trials without such movements—provided microsaccade direction and peak velocity aligned with the stimulus’s motion. Temporal estimates did not differ between the active and replay conditions for any microsaccade type. This result suggests the absence of temporal binding between eye movements and their sensory consequences, and that intention does not facilitate FoA for small eye movements.Significance StatementEye movements reflect our decision to closer inspect an aspect of the environment—bodily actions that align our perception with a preceding intention. Here, we investigated if microsaccades—a ballistic, minuscule type of saccade—can be characterized by a feeling of agency: the faint experience of affecting change through intentional actions. In two experiments, we presented an identical stimulus whose visibility was either gaze-contingent (active condition) or independent of eye movements (replay condition). In Experiment 1, we directly compared intended and unintended microsaccades and contrasted them with spontaneous microsaccades in Experiment 2. We found no difference between the active and replay condition for either eye movement type. Our data, hence, does not support feeling of agency for microsaccades. While it remains an open question if large saccades are characterized by feeling of agency, our finding demonstrates that intention is not sufficient to elicit feeling of agency for minuscule motor acts.

BACKGROUND. Vascular age is considered as an additional criterion for the progression of cardiovascular disease and cardiovascular aging. Arterial hypertension contributes to the development of cognitive impairments that go beyond the age norm.OBJECTIVE. Evaluation of the correlation relationship between vascular age and manifestations of moderate cognitive impairment in patients with arterial hypertension.MATERIALS AND METHODS. The study included 30 patients with stage 1 and 2 arterial hypertension, 12 men, 18 women, aged 67 to 70 years. All patients underwent clinical, laboratory and instrumental examination in accordance with clinical recommendations. Based on the modified SCORE table, vascular age was calculated taking into account gender, age, smoking status, blood pressure and total serum cholesterol levels. The presence of manifestations of moderate cognitive impairment was assessed using the self-assessment questionnaire. A score of more than 45 points allowed us to suspect cognitive impairment. Moderate cognitive impairment was objectively assessed by conducting a minimal neuropsychological study on the ability to remember and repeat words before and after the Clock test.RESULTS. In all patients, the vascular age was higher than the chronological age. The average chronological age was (62.4 ± 11.6) year, the average vascular age was (68.7 ± 10.6) year. The predominance of vascular age over chronological age varied from 2 to 10 years and was directly proportional to the duration of arterial hypertension (r = 0.64). Cognitive impairment, according to the memory self-assessment test, was detected in 11 patients (36.6 %). The average score of the memory self-assessment test was 38.39. The indicator of this test correlated with the vascular age indicator (r = 0.65). Objective assessment confirmed moderate cognitive impairment in 7 patients (23.3 %). According to the minimal neuropsychological examination, they were unable to reproduce previously memorized words, and 4 of them had noticeable deviations in the position of the hands or numbers on the clock face in the drawing. In these patients, the vascular age exceeded the chronological age by 7–10 years.CONCLUSION. The obtained results showed that arterial hypertension can lead to the development of cognitive deficit. The influence of risk factors for arterial hypertension, which reflects the vascular age indicator, and an increase in the duration of arterial hypertension is associated with the likelihood of developing mild cognitive impairment.

Significant variability exists in the use of corticosteroids for treating adverse radiation effects (ARE) after stereotactic radiosurgery (SRS) of brain metastasis (BM). Here, we determine the diagnostic utility of a quadrant-based, visual assessment of magnetic resonance (MR) FLAIR as an imaging biomarker for steroid-dependent ARE. FLAIR was assessed at four axial levels along the rostral-caudal axis of the cerebrum, defined by standard landmarks of superior temporal line, third ventricle, temporal horn, and fourth ventricle. Each axial level was divided into four quadrants, defined by 12, 3, 6, and 9 on a clock face. New, post-SRS FLAIR hyperintensity extending beyond any quadrant was defined as FEQ+. FEQ+ was then correlated with corticosteroid treatment instituted within a month of the MRI. To establish intra- and inter-rater reliability of FEQ, MR images from 20 patients (10 FEQ+ and 10 FEQ-) were assessed by three clinicians (a radiation oncologist and two neurosurgeons) for FEQ positivity. These results showed an > 85% intra- and inter-rater reliability (Cohen's Kappa and Fleiss' Kappa of 0.970 and 0.785, respectively, both p < 0.001). We tested the hypothesis that FEQ+ is associated with corticosteroid use post-SRS in an initial cohort of 40 patients. The sensitivity, specificity, positive predictive value, and negative predictive value of FEQ for corticosteroid treatment were 75.0%, 96.4%, 75.0%, and 90.0%, respectively. To validate these findings, we examined the association of FEQ and corticosteroid use in an independent cohort of 214 SRS-treated BM patients. The sensitivity, specificity, positive predictive value, and negative predictive value of FEQ for corticosteroid treatment in this validation cohort were 94.6%, 74.0%, 43.2%, and 98.5%, respectively. We conclude that FEQ is an imaging marker with high intra- and inter-rater reliability, with a high negative predictive value (90.0-98.5%) for steroid treatment in SRS-treated BM patients. These results lay the foundation for future studies of FEQ for research and clinical applications.

Objectives:It is estimated that up to 2% of the general population will experience a glenohumeral joint dislocation in their lifetime, with active adolescents and young adults making up a large proportion of those events. When encountered by an orthopaedic surgeon, patients with shoulder instability typically undergo MRa or MRI for diagnosis and to aid in surgical planning. Recently, MRa has been the advanced imaging of choice as it is considered superior to MRI in detecting labral pathology, although both are still used in clinical practice, and with limitations to accurately detect labral pathology. Thus, shoulder arthroscopy remains the gold standard for diagnosing labral pathology. In regards specifically to the pediatric population, relatively few studies exist in determining the sensitivity and specificity of MRa/MRI compared to arthroscopy in detecting anterior and SLAP lesions in cases of shoulder instability. To our knowledge, there are no studies that assess the ability of MRa/MRI in detecting posterior labral pathology in this specific cohort. The purpose of this study was to evaluate the effectiveness of MRa and MRI as diagnostic tools prior to shoulder stabilization surgery in the pediatric population.Methods:This is a retrospective review of data obtained between January 1, 2012 to June 30, 2022 from the IRB-approved Shoulder Stabilization Study. Query CPT codes to identify patients treated with shoulder stabilization surgery included both arthroscopy CPT codes (29806, 29807, and 29999) and open procedure CPT codes (23450, 23455, 23460, 23462, 23065, 23066, 23929). Inclusion criteria were any patient treated with shoulder stabilization surgery with an MRa or MRI obtained at a single institution. Exclusion criteria were greater than six months between imaging and surgery, MRa or MRI reports that were inconclusive due to motion, prior ipsilateral shoulder stabilization surgery, or charts with incomplete or insufficient data. Data collected and reviewed included description of the labral pathology identified from pertinent imaging reports from non-MSK focused radiologists and operative notes from one of three board certified orthopaedic surgeons at a single institution. Demographics and office notes were also analyzed. Lesion type was classified based on location of tear using conventional clock face nomenclature with lesions defined as follows regardless of laterality: Superior 10-2 o’clock, Anterior 3-6 o’clock, Posterior 6-10 o’clock. For patients that had two or more lesions, each lesion was counted separately. The use of the term fraying was classified as negative whereas the use of the terms “maybe” or “possible” was considered positive. A tear that partially extended into another region as defined by the clock face classification was considered positive only for the primary region. Outcome measures included sensitivity and specificity. For each imaging method, the sample size for sensitivity was the number of positives according to the arthroscopic findings which was considered the “gold standard” (TP + FN); for specificity, it was the number of negatives according to the “gold standard” (TN + FP).Results:340 cases met inclusion criteria (297 MRa, 43 MRI). Average age at surgery was 17 ±1.8 (10-25 years old). 350 lesions were identified on arthroscopy: 200 (57%) anterior; 90 (26%) posterior; 60 (17%) SLAP. See the attached table for a comparison of sensitivity and specificity of MRa versus MRI in identifying anterior, posterior, and SLAP lesions relative to the arthroscopic findings as the “gold standard” (Table I). When comparing between MRa versus MRI, the only statistically significant differences in sensitivity or specificity were for SLAP lesions. Sensitivity was greater for MRa compared to MRI (74% vs. 29%, respectively; p=0.028). However, the specificity for a SLAP lesion was greater for MRI compared to MRa (97% vs. 84%, respectively; p=0.039). When comparing all imaging reports to the “gold standard” arthroscopic findings, the imaging was correct in fully diagnosing the integrity of the glenoid labrum in all three regions only 60% of the time.Conclusions:The only statistically significant differences in sensitivity/specificity of MRa and MRI were for SLAP lesions- with MRa being more sensitive and MRI being more specific. In general, this study includes the largest pediatric cohort to date and is the first to assess the ability of MRa/MRI to detect posterior labral pathology in the pediatric patient. The results consistently demonstrated lower sensitivities and specificities for both MRa and MRI in identifying various labral pathologies compared to other publications which almost ubiquitously have used MSK focused radiologists as part of its methodology. Our findings may more accurately represent clinical practice as access to MSK focused radiologists is limited. Lastly, the imaging report was accurate in fully diagnosing the existing labral pathology only 60% of the time. This is critically important for patients, families, and providers to be aware of, as the imaging reports available in the electronic medical record may misdiagnose one or more regions of the glenoid labrum prior to definitive diagnostic arthroscopy.

Detailed anatomy of the meniscotibial ligament and clock face position of meniscal attachments in the tibia.

Detailed Anatomy of the Meniscotibial Ligament and Clock Face Position of Meniscal Attachments in the Tibia

Avian ocular ultrasound is an important diagnostic procedure for ophthalmologists. When combined with other ophthalmological examinations, it allows for an accurate diagnosis and timely, appropriate treatment. In addition to scanning techniques, it’s important for the physician to be proficient in using the equipment and understand certain subtleties of the procedure. These will improve visualization quality and help the bird avoid discomfort during the ultrasound examination. The quality of the equipment used for the examination is also crucial. Expert-class ultrasound machines offer many useful features and excellent image quality. We currently use the Alpinion E-CUBE 8 DIAMOND, an expert-class equipment with a 3–12 MHz linear transducer. Prior to the procedure, if the bird experiences eye pain, a local anesthetic, Inocaine (0,4% oxybuprocaine), is applied to the conjunctival sac. If the bird experiences no eye pain, the ultrasound examination is performed without local anesthetic. The sensor can be placed on either the cornea or the eyelids. It is more convenient and easier to place the sensor directly on the cornea. Ocular ultrasound examination is performed in both vertical (vertical axial scanning) and horizontal (horizontal axial scanning) planes. In vertical axial scanning (the sensor mark is located dorsally), the area between 12:00 and 6:00 o’clock is best visualized, viewing the eye as a clock face. In horizontal axial scanning (the sensor mark is located nasally), the area between 3:00 and 9:00 o’clock is best visualized, viewing the eye as a clock face.

The publication features a funeral oration composed in 1683 by Joasaf Krokovskyi, then a professor of rhetoric, in honor of Inokentii Gizel, the deceased archimandrite of the Kyiv Cave Monastery. The work is included in the rhetoric course «Penarium Tullianae eloquentiae...», which was delivered at the Kyiv-Mohyla College during the 1683/1684 academic year. The introductory article is followed by the original text in Polish and its Ukrainian translation, accompanied by necessary comments.In the rhetoric course, Krokovskyi’s oration is used as an illustrative sample in the theoretical unit on rhetorical figures. In line with the traditions of Baroque literature, the author selects a recurring image that determines the sequence of the presentation: here, this role is played by the clock face as an allegory of human life. Another point shaping the work’s figurative system and serving as a source of rhetorical argumentation is the emblem depicting a crayfish dragging the world on its back. Most likely, it was borrowed from Joachim Camerarius’ emblematic collection «Symbolum et emblematum centuriae quatuor». It is noteworthy that Krokovskyi’s Polish text is not overloaded with Latin inclusions, which reflects his linguistic and stylistic preferences related to the use of Polish.Since the biography of the archimandrite of the Kyiv Cave Monastery and a prominent figure in the Mohylean circle, Inokentii Gizel, remains incomplete and includes hypothetical information, this oratorical piece is also important as a historical source. In particular, it is the first known text to name some of Gizel’s places of study. The work also indirectly confirms the fact of Vilnius origin of the future archimandrite and contains an indication of his two terms as a philosophy lecturer at the Kyiv-Mohyla College.

Objective. To demonstrate a clinical case of combined surgical treatment of a patient with penetrating trauma of the eyeball. Methods. Patient G., 42 years old, applied to the Scientific and Technical Complex "Microsurgery of the Eye" in Moscow with complaints of a sharp decrease in visual acuity of the left eye. It is known from the anamnesis that 6 months before the application he received an injury to the left eye while mowing the grass with a trimmer without using protective glasses. He was examined by an ophthalmologist at the place of residence, referred to the Scientific and Technical Complex "Microsurgery of the Eye" with the diagnosis: OS "Hemophthalmos. Traumatic cataract". At the place of residence, there was no suspicion of the presence of an intraocular foreign body. According to the examination data at the Scientific and Technical Complex of the Moscow Eye Institute: visual acuity OS – pr.lucis certae (proectio lucis certae), intraocular pressure (IOP) (pneumotonometry) 9 mm Hg, B-scan: OS – membranes are adjacent, in the vitreous body there is an acoustic picture of hemophthalmos, in the posterior pole a foreign body of high echo density with an acoustic track, measuring 0.8 × 2.0 mm, is visualized. To confirm the diagnosis, the patient was referred for computed tomography of the orbits, which revealed the presence of a foreign body up to 2.5 mm in diameter in the posterior parts of the vitreous body of the left eye. Based on the studies conducted, a combined surgical intervention was planned, including phacoemulsification with implantation of an intraocular lens, followed by endovitreal intervention and removal of the foreign body. Due to the presence of total hemophthalmos, the surgical treatment tactics were determined intraoperatively. The features of the first stage of the operation (phacoemulsification) include the presence of a point scar in the peripheral part of the cornea at 10 o'clock on the conventional clock face (the entry point of the foreign body), the presence of iridocorneal synechiae separated by a Koch spatula. Intraoperatively, at the stage of removing the cortical masses, a peripheral defect of the posterior capsule of the lens was detected at 10 o'clock. During the second, endovitreal, stage of the intervention, anterior vitrectomy, layer-by-layer central and peripheral vitrectomy were performed. After removal of the organized heme clots, an intraocular foreign body was found, which was a metal fragment with sharp edges, localized upward and inward from the optic nerve head, on the surface of the posterior hyaloid membrane of the vitreous body, between the retinal vessels. It is noteworthy that the foreign body was not fixed to the internal membranes, therefore, in order to protect the macular area from trauma, a bubble of perfluoroorganic compound (PFOC) was introduced through the hole in the hyaloid membrane. Through the defect of the posterior capsule of the lens, the fragment was brought out into the anterior chamber using straight endovitreal forceps, where it was captured by a second endovitreal forceps and brought out through the main corneal incision. After removal of the foreign body, peripheral vitrectomy was performed. The place of contact of the foreign body with the retina was examined for the presence of retinal ruptures, blocked using endolaser coagulation. At the final stages of the operation, a three-part intraocular lens was implanted, PFOC was removed by passive aspiration, and the sclerotomy incisions were sealed with interrupted sutures. Results. On the 1st day of the postoperative period, a standard ophthalmological examination was performed: visometry OS = 1.0 without correction, IOP (pneumotonometry) 17 mm Hg, B-scan OS - avitria, membranes are adjacent. At the control examination 1 month after the operation: the patient's condition is stable, no complaints, visometry data correspond to those obtained earlier. Conclusions. The combined surgical treatment, including phacoemulsification with implantation of an intraocular nicking injury of the eyeball. Key words: hemophthalmos, intraocular foreign body, vitrectomy

Giant ophthalmic artery (OphA) aneurysms remain surgically challenging despite the progress in endovascular treatments. This study describes the contralateral interoptic corridor in select patients based on imaging criteria suitable for clipping. The aim of this study was to show that despite the growing use of novel endovascular techniques, such as coil embolization and flow diversion, for the treatment of OphA aneurysms, microsurgical clipping may still be preferred for giant ones under certain conditions. The authors retrospectively reviewed the records of the microsurgical treatment of unruptured and ruptured giant OphA aneurysms at the University Hospital Center "Mother Teresa," Tirana, from 2007 to 2016. Four patients were selected for microsurgery and the contralateral approach using ophthalmic evaluations and coronal imaging on computed tomography, magnetic resonance imaging, and digital subtraction angiography that demonstrated aneurysms with a small neck and an orientation between 11 and 13 on the coronal clock face. A prefixed chiasm was a contraindication to this approach. Giant OphA aneurysms can be safely clipped through a contralateral interoptic corridor without creating new visual deficits or a residual aneurysm. https://thejns.org/doi/10.3171/CASE2473.

Quantifying the Use of Space in the Clock Drawing Test: Validity in Hemispatial Neglect.

Anterior shoulder dislocations are a common injury, especially in the young, active, male population1. Soft-tissue treatment options for shoulder instability include arthroscopic or open Bankart repair, with open Bankart repair historically having lower rates of recurrence and reoperation, faster return to activity2-4, and a similar quality of life compared with arthroscopic repair5. More recent literature has suggested similar recurrence rates between arthroscopic and open procedures6. However, open Bankart repair may be indicated in cases of recurrent instability, especially if the patient participates in high-risk sports, because open repair can provide more capsular shift through the use of extra-capsular knots7. Performing a subscapularis split decreases the likelihood of subscapularis tendon avulsion following subscapularis tendon tenotomy and subsequent repair, as has been described in the literature8. Indications for open Bankart repair include failure of arthroscopic Bankart repair, multiple dislocations, with subcritical bone loss. This surgical technique is performed via the deltopectoral approach. The subscapularis tendon is exposed and "spared" by splitting the fibers with use of a longitudinal incision between the upper 2/3 and lower 1/3 of the subscapularis. We begin the split medially near the myotendinous junction. Because the subscapularis becomes increasingly difficult to separate from the capsule as it tracks laterally, a RAY-TEC sponge is utilized to bluntly dissect. A T-shaped laterally based capsulotomy is made to expose the glenohumeral joint. The vertical aspect is made first, followed by the horizontal aspect from lateral to medial, extending to the labrum. A Fukuda retractor is placed through the split to hold the humeral head laterally. The labrum is elevated, and the glenoid is prepared with rasp. Then labrum is repaired with knotted suture anchors until it is secure. One anchor is utilized for each "hour" of the clock face, with a minimum of 3 anchors. The anchors are placed on the articular margin of the glenoid. Sutures are passed from the anchor through the capsule and tied outside the capsule. The capsulotomy is then repaired with use of a suture. The suture is utilized to pull the inferior portion superiorly. The inferior portion is taken superiorly, and the superior leaflet is imbricated over the top. Finally, an examination is performed to ensure that the humeral head can be translated to but not over the anterior and posterior glenoid rims. No repair of the subscapularis tendon insertion is required. The incision is closed with deep dermal and subcuticular suture. Nonoperative treatment options include rotator cuff and periscapular strengthening or immobilization. Operative treatment options include open Bankart repair with subscapularis tenotomy and repair, arthroscopic Bankart repair, or bone block augmentation procedures. This procedure is different from the alternative treatments in that it is an open procedure, which allows for a more robust repair because the capsule can be shifted and doubled over, leading to the described decreased recurrence and reoperation rates. Open Bankart repair is better suited for large lesions that would be difficult to repair via arthroscopy. This procedure differs from other open Bankart techniques because the subscapularis is split rather than tenotomized, which removes the need to repair the tendon and decreases the rate of avulsion of the subscapularis tendon repair. Finally, this procedure is less invasive than the Latarjet procedure because it does not require osseous osteotomies and fixation. This procedure provides adequate capsular shift and visualization of the Bankart lesion without the increased risk of postoperative subscapularis tendon injury. If the subscapularis split alone does not provide adequate visualization, portions of the subscapularis tendon can be released from the lesser tuberosity.The location and origin of the upper and lower subscapular nerves can have variable courses, which could theoretically put them at risk for iatrogenic injury; however, studies have shown this subscapularis split technique to be safe from and prevent denervation of the muscle. GBL = glenoid bone lossEUA = examination under anesthesiaMRI = magnetic resonance imagingHSL = Hill-Sachs lesionAHCA = anterior humeral circumflex artery.

Objectives: Posterior shoulder instability is an uncommon injury, accounting for 2-12% of shoulder instability patients. Magnetic resonance imaging (MRI) is often utilized to non-invasively evaluate the joint for labral, cartilage, and bony injury. MR arthrography (MRA) may improve the evaluation of these intra-articular structures, but requires additional cost, time, and an invasive procedure. Moreover, its benefits for patients with posterior shoulder instability are unclear. Accurate imaging is critical in patients undergoing surgery because certain findings may influence the surgical approach. Thus, the purpose of this study is to compare the accuracy of MRA and non-enhanced MRI in detecting labral, chondral, and osseous lesions in patients with posterior shoulder instability. Methods: There were 291 patients with unilateral posterior shoulder instability who had preoperative MRA or MRI between 2006 and 2021 in the MOON database. Images were reviewed by a fellowship-trained musculoskeletal radiologist with 10+ years of experience and an orthopaedic surgeon. Evaluators were blinded to age, gender, medical history, MR report, and arthroscopic findings, but were aware of the patient's history of posterior shoulder instability. Examinations were evaluated for presence, location, morphology, and length of glenoid labral tears. Tear length and localization were noted using a standard clock face. The presence and size of humeral/glenoid osseous and cartilage lesions was also noted.Intraoperative findings from arthroscopic evaluation were documented by the surgeon using a standard response questionnaire. Diagnostic performance of standard MRA and MRI were evaluated using sensitivity and specificity with arthroscopic evaluation as the gold-standard. Chi-squared or Fisher’s exact tests were used to compare the sensitivities and specificities of MRA and MRI. Significance was defined as P &lt; 0.05. Results: 200 patients (69%) had MRA, while 91 patients had non-contrast MRIs of the shoulder. On imaging evaluation, 273 (94%) patients had labral tears with a mean tear size of 156º. 39 (13%) patients had humeral cartilage lesions, whereas 40 (14%) patients had glenoid cartilage lesions. 34 (12%) patients had glenoid bone loss greater than 5%. The mean glenoid bone loss was 12% (range, 5% - 26%). A reverse Hill-Sachs lesion was present in 35 (12%) patients. 16 (6%) patients had bipolar bone loss. The sensitivity for detection of labral tears was high for both MRA (0.95) and standard MRI (0.98) (Tables 1 and 2), though the specificity was low for both modalities (0.25 and 0.40, respectively). There was no difference in the sensitivities or specificities of the two imaging modalities in the detection of labral tears. MRA had a lower sensitivity than MRI in the detection of glenoid cartilage lesions (0.31 vs 0.88, p &lt; 0.001), but no difference was observed for specificity. There was no difference in the sensitivities and specificities of MRA and MRI for humeral cartilage lesions (p = 0.354).MRA had a higher sensitivity than MRI in assessing glenoid bone loss (0.78 vs 0.50, p &lt; 0.001), though there was no difference in specificity. There was no difference between imaging modalities in the evaluation of humeral bone loss (p = 1.000). Conclusions: In this multicenter study, MRA was the most commonly utilized preoperative advanced imaging study for patients with posterior shoulder instability. MRA had a higher sensitivity in detecting glenoid bone loss but lower sensitivity in detecting glenoid cartilage lesions compared to standard non-contrast MRI. There was no difference in diagnostic performance between MRA and MRI in the diagnosis of labral tears and humeral chondral and osseous lesions. MRA may provide an advantage over standard MRI in the evaluation of glenoid bone loss, which can influence the treatment plan for patients undergoing surgical management of posterior shoulder instability.

BackgroundIn patients with traumatic posterior shoulder instability, little is known about the precise location and size of the reverse Hill-Sachs lesion. MethodsForty-nine shoulders of 47 patients with traumatic posterior instability were included in this study based on the following inclusion criteria: 1) a primary or recurrent traumatic posterior shoulder dislocation, and 2) the initial event was caused by trauma. Patients were excluded if they had: 1) no history of trauma, 2) prior shoulder surgery, 3) no CT examination, or 4) seizure cases. Three-dimensional images of the humerus reconstructed from CT images were reviewed using an image analysis software. The location and size of the reverse Hill-Sachs lesion were measured and described on a clock face on the humeral head. ResultsThe reverse Hill-Sachs lesion was observed in 25 of 49 shoulders (51%). The reverse Hill-Sachs lesions were located between 1:37 and 2:48. The depth of the reverse Hill-Sachs lesion (mean ± SD) was 5.8 ± 2.2 mm. The extent of the reverse Hill-Sachs lesion was 35° ± 12°. The average orientation of the reverse Hill-Sachs lesion, represented by an angle measured from the 12 o'clock position, was 64° ± 12° and pointing towards 2:09 on a clock face. Length and width of reverse Hill-Sachs lesions were 9.7 ± 4.7 mm, 11.1 ± 3.6 mm, respectively. ConclusionThe reverse Hill-Sachs lesion was a semicircular compression fracture located on the anteromedial aspect of the humeral head. Compared with shoulders with anterior shoulder instability, the humeral defect was smaller and located more inferiorly in shoulders with posterior instability.